Tu-Anh Tran

Critical role of IL-21 in modulating TH17 and regulatory T cells in Behçet disease

BACKGROUND Behçet disease (BD) is a chronic systemic inflammatory disorder of unknown etiology. OBJECTIVE To determine the nature of T cells driving inflammatory lesions in BD. METHODS T cell homeostasis and cytokines production were analyzed in peripheral blood and brain inflammatory lesions from 45 adult patients with BD (active and untreated BD [n = 25] and patients in remission [n = 20]) and 20 healthy donors, using Luminex, flow cytometry, immunohistochemistry, and immunofluorescence analysis. RESULTS We found a marked increase in T(H)17 cells and a decrease in the frequency of CD4(+) forkhead box P3(+) regulatory T cells (Tregs) in peripheral blood that were induced by IL-21 production and that correlate with BD activity. The addition of serum from patients with active BD in a sorted CD4(+) T cells culture of healthy donors induced a significant and dose-dependent production of IL-17A and a decrease in forkhead box P3 expression. We demonstrated the presence of IL-21- and IL-17A-producing T cells within the cerebrospinal fluid, brain parenchyma inflammatory infiltrates, and intracerebral blood vessels from patients with active BD and central nervous system involvement. The stimulation of CD4(+) T cells with IL-21 increased T(H)17 and T(H)1 differentiation and decreased the frequency of Treg cells. Conversely, IL-21 blockade with an IL-21R-Fc restored the T(H)17 and Treg homeostasis in patients with BD. CONCLUSION We provided here the first evidence of the critical role of IL-21 in driving inflammatory lesions in BD by promoting T(H)17 effectors and suppressing Treg cells. IL-21 represents a promising target for novel therapy in BD.

Two-year results from an open-label, multicentre, phase III study evaluating the safety and efficacy of canakinumab in patients with cryopyrin-associated periodic syndrome across different severity phenotypes

Objective Longer-term effects of prolonged selective interleukin-1β blockade with canakinumab were evaluated in the largest cohort of cryopyrin-associated periodic syndrome (CAPS) patients studied to date. Methods Adult and paediatric CAPS patients (n=166, including canakinumab-naive and pretreated patients from previous studies) received canakinumab subcutaneously 150 mg or 2 mg/kg (≤40 kg) every 8 weeks for up to 2 years. Response and relapse was assessed using scores for disease activity, skin rash and C-reactive protein (CRP) and/or serum amyloid A (SAA) levels. Results Complete response was achieved in 85 of 109 canakinumab-naive patients (78%; 79/85 patients within 8 days, and five patients between days 10 and 21). Of 141 patients with an available relapse assessment, 90% did not relapse, their CRP/SAA levels normalised (<10 mg/l) by day 8, and remained in the normal range thereafter. Median treatment duration was 414 days (29–687 days). Upward adjustments of dose or frequency were needed in 24.1% patients; mostly children and those with severe CAPS. Predominant adverse events (AE) were infections (65.7%) of mostly mild-to-moderate severity. Serious AE reported in 18 patients (10.8%) were mainly infections and were responsive to standard treatment. The majority of patients (92%) reported having no injection-site reactions and only 8% patients reported mild-to-moderate reactions. Patients receiving vaccination (15%) showed normal immune response. Conclusions Subcutaneous canakinumab 150 mg every 8 weeks was well tolerated and provided substantial disease control in children and adults across all CAPS phenotypes. Higher canakinumab doses in younger patients and more severe CAPS disease were efficacious in achieving complete responses without evidence of increased AE. Trial registration number: NCT00685373 (clinicaltrials.gov)

TNF alpha antagonist therapy and safety monitoring

OBJECTIVES To develop and/or update fact sheets about TNFα antagonists treatments, in order to assist physicians in the management of patients with inflammatory joint disease. METHODS 1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable; 2. identification and review of publications relevant to each topic; 3. development and/or update of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The experts were rheumatologists and invited specialists in other fields, and they had extensive experience with the management of chronic inflammatory diseases, such as rheumatoid. They were members of the CRI (Club Rhumatismes et Inflammation), a section of the Société Francaise de Rhumatologie. Each fact sheet was revised by several experts and the overall process was coordinated by three experts. RESULTS Several topics of major interest were selected: contraindications of TNFα antagonists treatments, the management of adverse effects and concomitant diseases that may develop during these therapies, and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA and SpA, initiation and monitoring of TNFα antagonists treatments, management of patients with specific past histories, and specific clinical situations such as pregnancy; 2. diseases other than RA, such as juvenile idiopathic arthritis; 3. models of letters for informing the rheumatologist and general practitioner; 4. and patient information. CONCLUSION These TNFα antagonists treatments fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on these therapies. They will be available continuously at www.cri-net.com and updated at appropriate intervals.

The clinical spectrum of 94 patients carrying a single mutated MEFV allele

OBJECTIVE To assess the clinical characteristics of patients living in France and carrying a single MEFV mutation. METHOD A retrospective chart review of patients referred to us for recurrent fevers. Genetic testing: systematic screening of exons 2 and 10 was performed in the MEFV gene. A subset of patients was also investigated for other auto-inflammatory genes. RESULTS We analysed 94 patients (sex ratio:1). Forty-two percent of them were Jews and 17% were Arabs. The median age of onset was 2 years (3 months-47 years). Fever was >39 degrees C in 80% of them, while the duration and frequency of an attack varied (<24 h: 8%; 1-3 days: 56%; >3 days: 36%; >2 months: 15%; 1-2 months: 48%; and <1 month: 37%, respectively). Peritonitis occurred in 97%, pleuritis in 25%, arthralgia in 53%; skin rashes in 20%, aphthosis in 18% and lymphadenopathy in 9%. MEFV mutations were M694V (60%) and M694I (7%). The R92Q TRAPS mutation was retrieved in 3/21 patients tested and the V377I MKD mutation in 1/6. Associated diseases in these patients were periodic fever, aphthosis pharyngitis and adenitis syndrome (4), AS (5), Crohns disease (2) and Castlemans disease (1). CONCLUSION The clinical picture of French heterozygote patients with recurrent fevers resembles that of homozygote patients. Most of them required colchicine treatment.

IL-1RA agonist (anakinra) in the treatment of multifocal castleman disease: case report.

Multicentric Castleman disease (MCD), or multicentric angiofollicular lymph node hyperplasia, is an idiopathic lymphoproliferative disorder that is only seldom reported in children. The clinical and laboratory findings that characterize this peculiar disorder are thought to result from increased interleukin (IL)-6 production. We report herein the case of a 13-year-old boy with a long history of hectic fevers and abdominal pain, accompanied by stunted growth and elevated biologic markers of inflammation. Surgical biopsies of a pancreatico-splenic mass and of mesenteric lymph nodes revealed mixed-type MCD, which was diagnosed 6 years after the first clinical symptoms appeared. He received combination chemotherapy (cyclophosphamide, vinblastine) associated with a monoclonal B-cell antibody (Rituximab). This treatment was well tolerated but ineffective. Given the reported success of IL-1 blocking agents for treating Still disease, another IL-6 linked disorder, we attempted to treat him with anakinra, an IL-1RA agonist. His overall state normalized and both his clinical and biologic signs dramatically improved. This is the first report of anakinra treatment for MCD. We conclude that anti-IL-1 blocking agents could be an interesting treatment alternative for MCD, a chronic debilitating disease, which still carries a poor prognosis.

Registries in rheumatological and musculoskeletal conditions. Paediatric Behçet’s disease: an international cohort study of 110 patients. One-year follow-up data

OBJECTIVE To set-up an international cohort of patients suspected with Behçets disease (BD). The cohort is aimed at defining an algorithm for definition of the disease in children. METHODS International experts have defined the inclusion criteria as follows: recurrent oral aphthosis (ROA) plus one of following-genital ulceration, erythema nodosum, folliculitis, pustulous/acneiform lesions, positive pathergy test, uveitis, venous/arterial thrombosis and family history of BD. Onset of disease is <16 years, disease duration is ≤3 years, future follow-up duration is ≥4 years and informed consent is obtained. The expert committee has classified the included patients into: definite paediatric BD (PED-BD), probable PED-BD and no PED-BD. Statistical analysis is performed to compare the three groups of patients. Centres document their patients into a single database. RESULTS At January 2010, 110 patients (56 males/54 females) have been included. Mean age at first symptom: 8.1 years (median 8.2 years). At inclusion, 38% had only one symptom associated with ROA, 31% had two and 31% had three or more symptoms. A total of 106 first evaluations have been done. Seventeen patients underwent the first-year evaluation, and 36 had no new symptoms, 12 had one and 9 had two. Experts have examined 48 files and classified 30 as definite and 18 as probable. Twenty-six patients classified as definite fulfilled the International Study Group criteria. Seventeen patients classified as probable did not meet the international criteria. CONCLUSION The expert committee has classified the majority of patients in the BD group although they presented with few symptoms independently of BD classification criteria.

Comparative study of complete versus incomplete Kawasaki disease in 59 pediatric patients

OBJECTIVES To compare the clinical and laboratory features and the rate of echocardiographic coronary artery abnormalities in patients with complete and incomplete forms of Kawasaki disease (KD) and to determine which additional clinical criteria might support a suspicion of KD. METHODS We retrospectively reviewed the medical records of patients with KD who were admitted to the general pediatrics department of the Kremlin Bicêtre Teaching Hospital, France, between January 1995 and May 2006. We compared patients with a fever and four or five of the principal criteria (complete KD) to the other patients (incomplete KD). Clinical and laboratory features were abstracted from the records. RESULTS We identified 63 patients with a mean age of 33 months (+/-31). The male-to-female ratio was 2.47. Four patients were excluded. Of the remaining 59 patients, 39 had complete KD and 20 incomplete KD. The group with complete KD had significantly higher rates of changes in the extremities, conjunctival injection, exanthem, and enanthem; and a significantly lower rate of coronary artery dilation (48.7% vs. 90% in the incomplete KD group, P=0.002). Serum levels of alanine aminotransferase and gamma glutamyl transferase were significantly higher in the complete KD group. No significant differences were found between the two groups regarding age, sex, blood cell counts, or laboratory markers for inflammation. Pyuria was found in 45.4% of patients with complete KD and in 30.8% of those with incomplete KD (P=0.17). Of 14 patients who underwent ophthalmological evaluation, two had uveitis; both of them had complete KD. CONCLUSION Incomplete KD shares with complete KD a risk of coronary artery disease. The diagnosis of incomplete KD is challenging but can be supported by the presence of features other than the principal criteria, such as acute anterior uveitis or unexplained pyuria.

Treatment of pediatric Erdheim‐Chester disease with interleukin‐1–targeting drugs

Erdheim-Chester disease (ECD) is a rare nonLangerhans systemic histiocytosis of unknown origin. ECD typically involves bilateral symmetric cortical osteosclerosis of the diaphyseal and metaphyseal regions in the long bones and infiltration of other organs (1). The diagnosis is based on typical histologic findings, with xanthogranulomatous infiltration of tissue by foamy CD68-positive and CD1a-negative histiocytes. Published data on therapeutic approaches, including surgery, corticosteroids, cytotoxic drugs, stem cell transplantation, and others, are limited to case reports and small series and show generally incomplete and/or transient remission and frequent toxicity (2–4). More recently, interferon(IFN ) has been suggested as a treatment option; it has demonstrated variable efficacy and sometimes limited tolerance (5–7). Herein we report on a child with ECD who was treated with anakinra, a recombinant, nonglycosylated homolog of the human interleukin-1 (IL-1) receptor antagonist, and we describe a rationale for this treatment. The patient, a 10-year-old girl, presented with recurrent fever, elevated erythrocyte sedimentation rate (ESR) and increased C-reactive protein (CRP) levels, bone pain, and failure to thrive, and was diagnosed as having ECD. Bone radiography revealed multiple osteolytic and osteosclerotic lesions in the femurs, tibia, and pelvis. Whole-body magnetic resonance imaging (MRI) showed high-intensity signal of the skeletal bone marrow on fat-suppressed T2-weighted images, retroperitoneal infiltration, and diffuse low-intensity signal in the metadiaphyses (Figure 1C). Histologic findings on bone biopsy confirmed the diagnosis of ECD (Figure 2). Treatment with subcutaneous IFN alfa-2a (3 10 units 3 times per week) resulted in normalization of clinical symptoms, ESR and CRP values, and liver and spleen volumes, significant regression of retroperitoneal infiltration, and improvement of bone marrow signal intensity within 4 months. However, after 10 months of treatment the patient experienced relapse, manifested by fever, bone pain, and increased ESR and CRP levels. Treatment with vinblastine (6 mg/m/ week) and prednisone (2 mg/kg/day) for 6 weeks showed no efficacy. The patient was then treated with PEGylated IFN alfa-2a (1.5 g/kg/week) (8), with good efficacy. However, after 12 months of treatment, another relapse occurred. To obtain a rationale for a potential alternative treatment option targeting specific cytokines, IL-1 , IL-6, and tumor necrosis factor (TNF ) levels in unstimulated and lipopolysaccharide (LPS; 1 g/ml)–stimulated peripheral blood mononuclear cells (PBMCs), which had been isolated from whole blood samples with Ficoll-Paque and cultured in RPMI, were measured by enzyme-linked immunosorbent assay. Data on the patient were compared with data from 15 healthy controls. As shown in Figure 1A, the unstimulated PBMCs from the patient displayed increased levels of IL-1 (40.3fold), IL-6 (23.9-fold), and TNF (5.6-fold). Following LPS stimulation, levels of IL-1 , IL-6, and TNF were comparable to those in controls. These findings suggested that high basal levels of IL-1 and IL-6 may participate in the pathophysiology of ECD. Serum levels of IL-1 were within the normal range. We therefore hypothesized that targeting of IL-1 might have a beneficial effect on the disease course, and consequently, treatment with anakinra (2 mg/kg/day) was instituted. Within 1 week, fever and bone pain resolved, and 1 month later, the ESR and CRP normalized (Figure 1B). During the subsequent 10 months the patient gained weight (8 kg) and height (6 cm). However, no significant changes in the bone lesions or retroperitoneal infiltration were seen on MRI 7 months after initiation of this treatment (Figure 1C). During Figure 1. A, Production of cytokines (interleukin-1 [IL-1 ], IL-6, and tumor necrosis factor [TNF ]) by peripheral blood mononuclear cells from the patient and from 15 healthy controls, with or without lipopolysaccharide (LPS) stimulation. B, Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels before and after initiation of treatment with anakinra. IFN2a interferon alfa-2a. C, Comparative magnetic resonance imaging findings before (left) and 6 months after (right) initiation of treatment with anakinra. Frontal view whole-body images (T2-weighted with fat suppression) show no evidence of change in retroperitoneal infiltration (arrows).

Interferon-alpha triggers B cell effector 1 (Be1) commitment.

B-cells can contribute to the pathogenesis of autoimmune diseases not only through auto-antibody secretion but also via cytokine production. Therapeutic depletion of B-cells influences the functions and maintenance of various T-cell subsets. The mechanisms governing the functional heterogeneity of B-cell subsets as cytokine-producing cells are poorly understood. B-cells can differentiate into two functionally polarized effectors, one (B-effector-1-cells) producing a Th-1-like cytokine pattern and the other (Be2) producing a Th-2-like pattern. IL-12 and IFN-γ play a key role in Be1 polarization, but the initial trigger of Be1 commitment is unclear. Type-I-interferons are produced early in the immune response and prime several processes involved in innate and adaptive responses. Here, we report that IFN-α triggers a signaling cascade in resting human naive B-cells, involving STAT4 and T-bet, two key IFN-γ gene imprinting factors. IFN-α primed naive B-cells for IFN-γ production and increased IFN-γ gene responsiveness to IL-12. IFN-γ continues this polarization by re-inducing T-bet and up-regulating IL-12Rβ2 expression. IFN-α and IFN-γ therefore pave the way for the action of IL-12. These results point to a coordinated action of IFN-α, IFN-γ and IL-12 in Be1 polarization of naive B-cells, and may provide new insights into the mechanisms by which type-I-interferons favor autoimmunity.

Muckle-Wells syndrome and male hypofertility: a case series.

OBJECTIVES Muckle-Wells syndrome (MWS) is a rare autoinflammatory disorder associated with NLRP3 gene mutations, which cause excessive caspase-1 activation and processing of interleukin (IL)-1β and IL-18. Here we investigated whether MWS disease may be associated with impaired fertility in male patients. METHODS Medical records of all male MWS patients with NLRP3 mutations followed in our tertiary center for inherited autoinflammatory diseases were reviewed retrospectively for data indicating fertility problems. RESULTS Six of 9 patients were unable to have children despite regular sexual activity during at least 2 years; 3 succeeded in having children through in vitro fertilization. Infertility was the main reason for divorce in 1 patient. Spermiogram analyses were available in 8 of the 9 patients. Oligozoospermia was observed in 5 patients and azoospermia in 3 patients. In 2 patients, treatment with IL-1-targeting drugs for 6 and 12 months, respectively, had a moderate or no effect on spermatozoa counts. In 2 patients testosterone levels were low and testosterone treatment significantly increased spermatozoa counts in 1 of them. CONCLUSIONS MWS may be associated with subfertility and infertility in male patients. Consequently, sexual health and fertility should be assessed systematically in adolescent and adult male patients. Additional studies are required to establish the frequency of subfertility in male MWS patients, to understand when subfertility occurs in the disease natural history, and, finally, to investigate whether early management with IL-1-targeting drugs, or testosterone treatment or early sperm cryo-conservation may help to allow procreation.