Takuya Kotani

Detection of citrullinated proteins in synovial fluids derived from patients with rheumatoid arthritis by proteomics-based analysis

Abstract Background Rheumatoid arthritis (RA) is the most common inflammatory joint disease. The aetiology of RA remains unknown, but autoimmune responses are considered to play an important role in the disease pathophysiology. Currently available data suggests that the process of diagnosing RA may benefit from testing for anticyclic citrullinated peptides. Identification of the presence of citrullinated proteins in rheumatoid synovial fluids is important for the elucidation of the aetiology of RA as well as in the differential diagnosis of rheumatic-related diseases. Methods A proteomics-based approach using electrophoresis/mass spectrometry was applied to identify the citrullinated proteins in synovial fluids from patients with RA. Synovial fluids from patients with RA were subjected to sodium dodecyl sulfate–polyacrylamide gel electrophoresis and Western blot analysis to detect the citrullinated proteins. Identification bands were then subjected to mass spectrometry. Results Three proteins – citrullinated fibrinogen, citrullinated fibronectin and citrullinated vimentin – in synovial fluids from RA patients were identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Conclusions Proteomics-based analysis can be used to detect citrullinated proteins in synovial fluids from RA patients.

Successful treatment of cold agglutinin disease with anti-CD20 antibody (rituximab) in a patient with systemic lupus erythematosus.

Cold agglutinin disease (CAD) is a rare cause of anaemia in patients with systemic lupus erythematosus (SLE). CAD is usually refractory to glucocorticosteroid, and other immunosuppressive and/or cytotoxic therapies. We report the case of a 55-years old woman with SLE and CAD that did not respond to high-dose methylprednisolone, cyclosporin A, and double filtration plasma pheresis. Because several recent case reports and studies have indicated promising results of rituximab treatment for CAD and for SLE, rituximab was given weekly at 375 mg/m2 in two doses. The rituximab was well tolerated, and there were no adverse effects. The hemolysis and SLE improved markedly, and the patient remained disease free eight months later. This is the first report of successful rituximab treatment of CAD in a patient with SLE. We conclude that rituximab is worth trying in such patients if they fail to respond to conventional treatment.

Differentiation between Polymyalgia Rheumatica (PMR) and Elderly-Onset Rheumatoid Arthritis Using 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: Is Enthesitis a New Pathological Lesion in PMR?

Background It is difficult to differentiate polymyalgia rheumatica (PMR) from elderly-onset rheumatoid arthritis (EORA) in clinical practice. We compared FDG-PET/CT findings between patients with PMR and those with EORA and extracted factors useful for differentiating the two disorders. Methods We compared abnormal FDG accumulation sites and maximum standardized uptake value (SUVmax) between 15 patients with PMR and 7 with EORA in whom FDG-PET/CT was performed. Results The proportion of patients in the PMR group with abnormal FDG accumulation at the following 9 sites on FDG-PET/CT was significantly higher than that in the EORA group: periarticular region of the scapulohumeral joint, enthesis of the pectineus muscle, vicinity of the enthesis of the rectus femoris muscle, lateral side of the greater trochanter, ischial tuberosity, hip joint, spinous process of the lower cervical vertebra, intervertebral joint of the lumbar vertebra, and spinous process of the lumbar vertebra. The PET/CT score was evaluated at 9 sites consisting of the abovementioned sites. The median score in the PMR group was 8, which was significantly higher than that of 0 in the EORA group (P = 0.0003). ROC curve analysis was performed with the PET/CT scores, and a score of 5 was shown to maximize the area under the ROC curve (sensitivity: 86.7%, specificity: 86.7%). Conclusions FDG-PET/CT is useful for differentiating PMR from EORA. In patients with PMR, abnormal FDG accumulation was observed at the entheses, suggesting the presence of enthesitis in addition to bursitis and synovitis.

Pre-Treatment Ferritin Level and Alveolar-Arterial Oxygen Gradient Can Predict Mortality Rate Due to Acute/Subacute Interstitial Pneumonia in Dermatomyositis Treated by Cyclosporine A/Glucocorticosteroid Combination Therapy: A Case Control Study

Background Acute/subacute interstitial pneumonia in dermatomyositis (DM-A/SIP) is a disease associated with a poor prognosis that resists treatment with glucocorticosteroids (GC) and progresses rapidly in a period of weeks to months to death. We retrospectively studied outcomes, prognostic factors, and their relations with survival rate in patients with DM-A/SIP treated with early cyclosporine A (CSA)/GC combination therapy and 2-hour postdose blood concentration monitoring. Methods This study comprised 32 DM-A/SIP patients who were simultaneously treated with CSA and prednisolone. Clinical and laboratory findings were compared between those who died due to DM-A/SIP and those surviving 24 weeks after beginning of therapy. Prognostic factors were extracted, and their relations with the survival rate were evaluated. Results Of the 32 DM-A/SIP patients, 25 survived, 5 died of DM-A/SIP, and 2 died of infections. In those who died due to DM-A/SIP, ferritin level and the alveolar-arterial oxygen gradient were significantly increased compared with the survivors (P<0.001 and P = 0.002, respectively). Multivariate analyses showed that ferritin and alveolar-arterial oxygen gradient were independent prognostic factors of poor outcome. The survival rate 24 weeks after beginning of treatment was significantly lower in those with a ferritin level of ≥600 ng/ml and alveolar-arterial oxygen gradient of ≥45 Torr (P<0.001 and P<0.001, respectively). All patients with both prognostic factors died, and the outcome was significantly poorer in these patients than in those with one or neither of the prognostic factors (P<0.001). Conclusions We identified pre-treatment high serum ferritin level and high alveolar-arterial oxygen gradient as poor prognostic factors in DM-A/SIP patients undergoing early CSA/GC combination therapy and showed that the outcomes were poor in patients with both factors.

Evaluation of clinical prognostic factors for interstitial pneumonia in anti-MDA5 antibody-positive dermatomyositis patients.

Abstract Objectives: We retrospectively investigated clinical prognostic factors for interstitial pneumonia (IP) in anti-melanoma differentiation-associated gene 5 (MDA5) antibody (Ab)-positive dermatomyositis (DM) patients. Methods: Subjects comprised 18 patients with anti-MDA5 Ab-positive DM-IP (9 survivors; 9 deaths). Results: Initial serum albumin levels, ferritin levels, and ground-glass opacity (GGO) scores in the right middle lobes were significantly higher in the death group than in the survivor group (p = .033, .013, and .005, respectively). Initial alveolar-arterial oxygen gradient (P[A-a]O2) was also higher in the death group than in the survivor group (p = .064). Initial serum ferritin, P[A-a]O2, and right middle lobe GGO score were found to significantly relate to death. Survival rates after 24 weeks were significantly lower among patients with an initial ferritin level of ≥450 ng/mL (25%), P[A-a]O2 of ≥30 mmHg (31%), and a right middle lobe GGO score of ≥2 (11%) than each of the others (p = .006, .020, and .002, respectively). Conclusions: An initial serum ferritin level of ≥450 ng/mL, P[A-a]O2 of ≥30 mmHg, and right middle lobe GGO score of ≥2 (GGO ≥5% of the lobe) were identified as poor prognostic factors for anti-MDA5 Ab-positive DM-IP patients.

Pulmonary Toxicity After Initiation of Azathioprine for Treatment of Interstitial Pneumonia in a Patient with Rheumatoid Arthritis

To the Editor: Pulmonary involvement of rheumatoid arthritis (RA) includes drug-induced pulmonary toxicity, interstitial pneumonia (IP) due to RA itself, airway lesions, pleural lesions, and pulmonary infections due to the use of immunosuppressants. It is sometimes difficult to differentiate between these conditions. Pulmonary toxicity has been reported to be often induced by methotrexate and leflunomide but rarely by azathioprine (AZA). We describe a patient with RA and IP, in whom AZA induced pulmonary toxicity. The patient was a 72-year-old man diagnosed with RA (Steinbrocker stage III, class 2), treated with 5 mg/day prednisolone (PSL) and with clinically low disease activity. He developed a nonproductive cough 2 years ago. Chest radiograph and high-resolution computed tomography (HRCT) of the chest at that time revealed ground-glass opacities (GGO) in the bilateral peripheral lung fields and honeycomb-like cysts in the dorsal side of both lower lung fields, leading to a diagnosis of IP. Pulmonary function tests showed a vital capacity (VC) of 99.3%, and DLCO 54.2%. After he developed exertional dyspnea (Hugh-Jones Grade II) in March 2006, he was referred to our hospital and was admitted on June 20, 2006. Fine crackles were audible in both lower lung fields. Blood tests showed a white blood cell … Address correspondence to Dr. Ishida; E-mail: t-takeuchi{at}poh.osaka-med.ac.jp

Initial limited three-level thin-section computed tomography scorings predict the prognosis of acute/subacute interstitial pneumonia in patients with dermatomyositis

Abstract Objectives: We investigated the prediction of outcomes of patients with dermatomyositis with acute/subacute interstitial pneumonia (DM-A/SIP) on the basis of chest computed tomography (CT) images. Methods: In 20 patients with DM-A/SIP (13 survivors; seven deaths), the relationships between prognostic outcomes and chest high-resolution CT (HRCT) findings or limited three-level thin-section CT scoring on the first examination were retrospectively investigated. Results: No significant difference was noted in chest HRCT findings between the survivor group and death group. The ground-glass opacity (GGO) scores of the right upper and middle lobes and left upper lobe, and the fibrosis score of the right middle lobe were significantly higher in the death group than in the survivor group (p = 0.01, 0.001, 0.02, and 0.02, respectively). The influence of the GGO score of the right middle lobe on death from IP was the strongest among the items examined, and it was independently significant (p = 0.01). A right middle lobe GGO score of ≥3 (GGO ≥ 25% of the lobe) was determined to be the best cut-off value for a poor prognosis (sensitivity: 85.7%, specificity: 85.7%), and the survival rate after 24 weeks was significantly lower in patients with a right middle lobe GGO score of ≥3 (survival rate: 0.0%) than in those with a score of< 3 (92.9%) (p < 0.0001). Conclusions: The prognosis of patients with DM-A/SIP was poor when the range of right middle lobe GGO was 25% or higher on limited three-level thin-section CT.

Successful treatment with intravenous high‐dose immunoglobulin for cardiomyopathy in dermatomyositis complicated with rapid progressive interstitial pneumonia

Cardiomyopathy and rapid progressive interstitial pneumonia (IP) are potentially fatal complications in polymyositis/dermatomyositis. We experienced a dermatomyositis patient with multiple adverse prognostic factors, complicating rapid progressive IP, macrophage activation syndrome (MAS), and cardiomyopathy. IP and MAS improved with strong immunosuppressive therapy, despite which cardiomyopathy developed. Therefore, we applied intravenous high‐dose immunoglobulin therapy (IVIg), and cardiac function improved dramatically. This is the first report to present the effectiveness of IVIg for cardiomyopathy in dermatomyositis.

Successful multi-target therapy including rituximab and mycophenolate mofetil in anti-melanoma differentiation-associated gene 5 antibody-positive rapidly progressive interstitial lung disease with clinically amyopathic dermatomyositis

Dear Editor, Interstitial lung disease (ILD) in dermatomyositis (DM) is a serious complication that affects patient prognosis. ILD associated with clinically amyopathic DM (CADM) is more refractory and rapidly progressive than classical DM. Sato et al. identified anti-melanoma differentiation-associated gene 5 (MDA5) antibody and reported that about half of the patients with CADM positive for this antibody developed rapidly progressive ILD (RP-ILD). The cumulative 6month survival rate is reported to be approximately 50% for RP-ILD with anti-MDA5 antibody. In classic DM patients, ILD can progress rapidly when they are anti-MDA5 antibody positive. Here, we present a case of worsening RP-ILD despite treatment with high-dose prednisolone (PSL) combined with cyclosporine (CSA) and intravenous cyclophosphamide (IVCY) in a patient with anti-MDA5 antibody-positive CADM. The addition of polymyxin-B direct hemoperfusion (PMXDHP), mycophenolate mofetil (MMF), intravenous immunoglobulin (IVIG), and rituximab (RTX) led to remission of the disease.

Therapeutic drug monitoring of cyclosporine microemulsion in patients with corticosteroid-resistant systemic lupus erythematosus.

Abstract Objectives. We retrospectively examined how the cyclosporine-A (CSA) microemulsion administration mode affected blood CSA levels, as well as how the dose and blood levels of CSA affected its therapeutic effect against systemic lupus erythematosus (SLE). Methods. We calculated the area under the blood concentration time curve (AUC) of CSA in 16 patients with corticosteroid-resistant SLE, and analyzed its correlation with CSA levels at the blood sampling time points to investigate the optimum monitoring and dosing regimen. Results. The blood CSA level peaked at 2 h after administration (C2) in all patients. AUC0-6, which most markedly reflects the immunosuppressive effect, significantly correlated with C2 (R2 = 0.905), but not with the trough (C0). In concentration/dose ratio (C/D) of CSA, C2/D level was significantly higher when administered once daily before breakfast than when administered in the divided dose after meals (R2 = 0.355, P = 0.015), but not C0/D. During the 6-month follow-up, the CSA C2 tended to correlate with improvement in SLE disease activity index 2000 (R2 = 0.633, P = 0.067). Conclusions. The treatment with a single dose of CSA before breakfast, followed by monitoring of C2, may be useful for improving the therapeutic effect in patients with corticosteroid-resistant SLE.