Won-Tae Chung

Endothelial nitric oxide synthase gene polymorphisms in Behçet’s disease and rheumatic diseases with vasculitis

Objective: To assess potential associations between Korean Behçet’s disease (BD) or other rheumatic diseases with vasculitis and two polymorphisms of the endothelial nitric oxide synthase (eNOS) gene, which include the Glu298Asp polymorphism in exon 7 and a variable number of tandem repeats (VNTR) polymorphism in intron 4. Methods: 65 patients with BD, 27 with rheumatic diseases with vasculitis, and 80 controls were studied. Analyses of the Glu298Asp polymorphism in exon 7 and VNTR polymorphism in intron 4 of the eNOS gene were made by the polymerase chain reaction (PCR)-restriction fragment length polymorphism technique and PCR genotyping, respectively. Additionally, HLA-B51 typing was performed in the BD group and controls by a two step PCR sequence-specific primers method. Results: Significant differences in Glu298Asp genotype frequencies were found between the BD or vasculitis groups and the controls (BD group v controls: pcorr=0.006; vasculitis group v controls: p<0.001). The Asp298 frequency was much higher in the BD and vasculitis groups than in the controls. Even after stratification of the BD group based on the results of HLA-B51 testing, a significant association of the Glu298Asp polymorphism was still found (p=0.002, Mantel-Haenszel weighted odds ratio 4.3, 95% confidence interval 1.7 to 10.9). Distribution of the genotype frequencies in two eNOS gene polymorphisms was similar in connective tissue diseases-associated vasculitis and primary vasculitic syndromes. In contrast, distribution of alleles and genotypes of VNTR polymorphism did not differ between BD or vasculitis groups and the controls. Conclusion: The Glu298Asp polymorphism in exon 7 of the eNOS gene seems to be a susceptibility gene for Korean BD and other rheumatic diseases.

Adalimumab treatment for life threatening pulmonary artery aneurysm in Behçet disease: a case report

Behςet’s disease (BD) is a multisystem disorder characterized by vasculitis. Pulmonary vascular problems such as pulmonary artery aneurysms (PAA) are reported to indicate poor prognosis and high mortality. We describe a 43-year-old man who presented with life threatening bilateral PAA and thromboembolic disease due to BD. He was treated with prednisone and pulse cyclophosphamide and was poorly responsive to the conventional immunosuppression. The introduction of adalimumab therapy stabilized his PAA. We report that the inhibition of TNF-α using the neutralizing monoclonal antibody adalimumab has the potential to induce rapid, complete, and long-lasting remission in a life-threatening manifestation of BD.

Serial Interferon-gamma Release Assays for the Diagnosis of Latent Tuberculosis Infection in Patients Treated with Immunosuppressive Agents

Background We assessed the efficacy of serial interferon-gamma release assays (IGRAs) for the diagnosis of latent tuberculosis infection (LTBI) in patients receiving immunosuppressive agents for treatment of rheumatic diseases in Korea. Methods Of 276 patients who underwent consecutive screening with one of two IGRAs [QuantiFERON-TB Gold or QuantiFERON-TB Gold In-Tube], 66 patients were evaluated by the serial IGRA for detection of LTBI during therapy with immunosuppressive agents. Information on clinical diagnosis, medication, previous TB, blood cell count, tuberculin skin test, and interferon-gamma (IFN-γ) level measured by IGRA was collected. Results Of the 66 patients, the initial IGRA was positive in 24.2%, negative in 65.2%, and indeterminate in 10.6%. Forty-six patients (69.7%) showed consistent IGRA results during follow-up, and 13 patients (19.7%) had consistently positive results. IGRA conversion rate was 12.1% (8/66) and reversion rate was 4.5% (3/66). Conversion of IGRA results was only observed in ankylosing spondylitis patients, and the median interval between the two tests in patients with conversion was 8.5 months. The mean IFN-γ level in the group of patients with consistently positive IGRA results was higher than that in the group with inconsistently positive results, although this trend was not statistically significant (P=0.293). Indeterminate results were observed most frequently in patients with systemic lupus erythematosus. Conclusions In patients receiving immunosuppressive agents, both IGRA conversions and reversions were observed. Serial IGRA testing may not be needed in patients with a positive initial IGRA result showing high IFN-γ levels, because of high consistency in the test results.

Prevalence and clinical associations of lupus anticoagulant, anticardiolipin antibodies, and anti-beta2-glycoprotein I antibodies in patients with systemic lupus erythematosus.

BACKGROUND The presence of antiphospholipid antibodies (aPLs) is associated with the clinical features of antiphospholipid syndrome (APS), which comprises venous and arterial thrombosis and pregnancy loss, and systemic lupus erythematosus (SLE). The prevalence of aPLs has been reported to be different in patient populations affected by either of these conditions. We performed a retrospective study to evaluate the prevalence and clinical associations of aPLs, including lupus anticoagulant (LAC), anticardiolipin (aCL), and anti-beta2-glycoprotein I antibodies (anti-beta2-GPI) in a cohort of Korean patients with SLE. METHODS This study included samples from 88 SLE patients for whom aPL testing had been advised between June 2006 and July 2009 at the Dong-A University Hospital. Serum and plasma samples were tested for LAC, aCL (IgG, IgM), and anti-beta2-GPI (IgG, IgM) antibodies. Clinical data from patients were obtained from a review of medical records. RESULTS LAC was the most common (34.1% of total patients, 30/88) antibody, followed by IgM aCL (31.8%, 28/88), IgG aCL (18.2%, 16/88), and IgM and IgG anti-beta2-GPI (both 5.7%, 5/88 each). Positivity for LAC was strongly associated with venous/arterial thrombosis (P=0.002). CONCLUSIONS LAC was the most common antibody detected in Korean SLE patients and is shown to have a significant association with the presence of venous/arterial thrombosis. The measurement of LAC may be clinically useful in identifying patients with SLE who are at a high risk for venous/arterial thrombosis.

Simultaneous intrahepatic and subgaleal hemorrhage in antiphospholipid syndrome following anticoagulation therapy

Warfarin is a widely used anticoagulant. Interindividual differences in drug response, a narrow therapeutic range and the risk of bleeding render warfarin difficult to use clinically. An 18-year-old woman with antiphospholipid syndrome received long-term warfarin therapy for a recurrent deep vein thrombosis. Six years later, she developed right flank pain. We diagnosed intrahepatic and subgaleal hemorrhages secondary to anticoagulation therapy. After stopping oral anticoagulation, a follow-up computed tomography showed improvement in the hemorrhage. After restarting warfarin because of a recurrent thrombosis, the intrahepatic hemorrhage recurred. We decided to start clopidogrel and hydroxychloroquine instead of warfarin. The patient has not developed further recurrent thrombotic or bleeding episodes. Intrahepatic hemorrhage is a very rare complication of warfarin, and our patient experienced intrahepatic and subgaleal hemorrhage although she did not have any risk factors for bleeding or instability of the international normalized ratio control.

THU0532 Genetic Analysis for P2x7R rs3751142 and CARD8 rs2043211 Polymorphisms for Susceptibility of Gout in Male Korean Population

Background The NLRP3 inflammasome, a member of the NLR family, is a key player in the production of uric acid-mediated IL-1β and is an important cytoplasmic protein complex involved in gouty inflammation. Recent single-nucleotide polymorphism (SNP) studies suggested that genetic alternations of several target molecules such as CARD8 and P2X7R contribute to the process of NLRP3 inflammasome activation. Objectives The aim of this study was to determine the association between P2X7R rs3751142 and CARD8 rs2043211 polymorphisms and gout susceptibility in male Korean subjects. Methods This study enrolled a total 242 male patients with gout and 280 healthy controls. The polymorphisms of two individual genes including rs3751142 (C>A) in the P2X7R gene and rs2043211 (A>T) in the CARD8 gene were assessed using Taq-Man analysis. Statistical analyses were performed using the Chi-square test, Kruskal-Wallis test, and logistic regression analyses. Results A difference in genotypic frequency of the P2X7R rs3751142 and CARD8 rs2043211 genes was not detected between gout and control patients. Clinical parameters including age, onset age, disease duration, body mass index, and serum uric acid levels were not different among the three genotypes for either P2X7R or CARD8 (p>0.05 for all). A pair-wise comparison of P2X7R rs3751142 and CARD8 rs2043211 genotype combinations revealed a protective effect of P2X7R/CARD8 AA/AA against gout susceptibility (OR=0.023, 95% CI 0.874–0.999). Conclusions This study revealed that genetic variability of the P2X7R rs3751142 and CARD8 rs2043211 genes might, in part, be associated with susceptibility for gout. References Martinon F, Pétrilli V, Mayor A, et al. Gout-associated uric acid crystals activate the NALP3 inflammasome. Nature 2006;440:237–41. Choe JY, Jung HY, Park KY, et al. Enhanced p62 expression through impaired proteasomal degradation is involved in caspase-1 activation in monosodium urate crystal-induced interleukin-1b expression. Rheumatology (Oxford) 2014;53:1043–53. Yang SK, Kim H, Hong M, et al. Association of CARD8 with inflammatory bowel disease in Koreans. J Hum Genet 2011;56:217–23. Chen Y, Ren X, Li C, et al. CARD8 rs2043211 polymorphism is associated with gout in a Chinese male population. Cell Physiol Biochem 2015;35:1394–400. Gu BJ, Zhang W, Worthington RA, et al. A Glu-496 to Ala polymorphism leads to loss of function of the human P2X7 receptor. J Biol Chem 2001;276:11135–42. Disclosure of Interest None declared

AB0107 Association Heterogeneity Mapping Identifies An Asian-Specific Association of The GTF2I Locus with Rheumatoid Arthritis

Background Genetic association studies using multiple ancestral cohorts have revealed a large overlap of rheumatoid arthritis (RA)-risk alleles among different ancestries, but there are some exceptional loci showing heterogenic association among populations. Objectives Here we investigated genetic variants with distinct effects on the development of RA in Asian and European populations. Methods Ancestry-related association heterogeneity was examined using the association data from large Korean (n=9,299) and European (n=45,790) rheumatoid arthritis cohorts with Immunochip and genome-wide SNP array data. Novel disease associations detected in Koreans were validated using two independent Asian cohorts (n=5,166) and a meta-analysis. Results We identified significant heterogeneity between the two ancestries for the common variants in the GTF2I locus and showed that this heterogeneity is due to an Asian-specific association effect (PHeterogeneity =9.6×10-9 at rs73366469 [ORMeta =1.37 and PMeta =4.2×10–13 in Asians; ORMeta =1.00 and PMeta =1.00 in Europeans]) in RA. Trans-ancestral comparison and bioinfomatics analysis revealed a plausibly causal SNP (rs117026326; linked to rs73366469), whose minor allele is common in Asians but rare in Europeans. Conclusions We identified the largest effect on Asian RA across human non-HLA regions at GTF2I by heterogeneity mapping followed by replication studies, and pinpointed a possible causal variant. References Okada, Y. et al. Genetics of rheumatoid arthritis contributes to biology and drug discovery. Nature 506, 376–81 (2014). Kim, K. et al. High-density genotyping of immune loci in Koreans and Europeans identifies eight new rheumatoid arthritis risk loci. Ann Rheum Dis 74, e13 (2015). Acknowledgement This study was supported by the Korea Healthcare Technology R&D Project of the Ministry for Health & Welfare (HI13C2124), the Japanese Ministry of Education, Culture, Sports, Science and Technology Grant-in-Aid for Scientific Research (15H04965) and the US National Institutes of Health (R01MD007909 and R01AR060366). *Drs. Kwangwoo Kim and So-Young Bang contributed equally to this work. Disclosure of Interest None declared

FRI0433 Mri in Neuropsychiatric Lupus: Correlations with the 1999 ACR CASE Definitions

Background Neurological manifestations in systemic lupus erythematosus (SLE) are diverse. Because of its varied manifestations and low prevalence, the ACR has developed nomenclature and case definitions for neuropsychiatric SLE (NPSLE) to facilitate clinical research. Brain MRI has been used for the evaluation of neurologic symptoms. Objectives The purpose of this study was to identify characteristic brain MRI findings in NPSLE and to investigate the association between brain MRI findings and NPSLE manifestations. Methods In total, 145 brain MRIs in 126 patients with NPSLE from 2002 to 2013 from three tertiary university hospitals were retrospectively reviewed. The images were evaluated for the presence of white matter hyperintensity (WMH), gray matter hyperintensity (GMH), parenchymal defects, atrophy, enhancement, and the abnormalities in diffusion-weighted image (DWI). The number, size and location of WMH,GMH and parenchymal defects were evaluated. The NPSLE manifestations of each patient were classified according to the 1999 ACR case definitions for NPSLE syndromes. The associations between MRI findings and manifestations of NPSLE were examined. Results In total, 103 MRIs (71.0%) exhibited abnormalities among the 145 MRIs reviewed. There were 172 NP events that encompassed 16 of 19 NP syndromes. The most common MRI abnormalities were WMHs. One or more WMHs were found in 84 MRIs (57.9%) among the total 145 MRIs. GMHs were observed in 42 MRIs (29.0%). GMHs tended to involve much larger areas than WMHs. Patients with cerebrovascular disease or seizures were more likely to have GMHs than patients with other NP manifestations. 33 MRIs among 42 MRIs which had GMHs also exhibited WMHs. Parenchymal defects were found in 35 MRIs (24.1%). Atrophy was detected in 26 MRIs (17.9%). Brain MRIs were enhanced in 21 of the 126 cases that had undergone enhancement. Patients who had seizures were more likely to demonstrate MRI enhancement than patients with other NP manifestations. DWIs were obtained in 102 MRIs and abnormal DWIs were obtained in 18 MRIs cases. Patients with cerebrovascular disease were more likely to have GMH, parenchymal defects and abnormal DWI than patients with other NP manifestations Number of MRIs (%) Abnormalities of MRI WMH GMH Parenchymal defect Atrophy Enhancement Acute confusion 13 (9.0%) 10 7 3 3 5 3 Anxiety disorder 1 (0.7%) 0 0 0 0 0 0 Aseptic meningitis 6 (4.1%) 4 3 0 1 0 2 Cerebrovascular disease 33 (22.7%) 33 27 15 15 5 4 Cognitive dysfunction 4 (2.7%) 3 3 0 1 3 0 Demyelinating disease 2 (1.4%) 2 2 1 1 0 1 Headache 33 (22.7% ) 17 12 6 2 4 2 Mood disorder 1 (0.7%) 0 0 0 0 0 0 Movement disorder 5 (3.4%) 4 4 0 1 1 0 Psychosis 4 (2.7%) 3 2 0 1 1 1 Seizure 23 (15.9%) 17 14 12 5 5 7 Autonomic disorder 3 (2.1%) 0 0 0 0 0 0 Cranial neuropathy 12 (8.3%) 7 7 2 2 0 0 Mononeuropathy 3 (2.1%) 1 1 1 1 0 0 Myasthenia gravis 0 (0%) 0 0 0 0 0 0 Polyneuropathy 2 (1.4%) 2 2 2 2 2 1 Total 145 (100%) 103 84 42 35 26 21 Conclusions Diverse brain MRI abnormalities were observed in the brain MRI of patients with NPSLE. In addition to WMHs, which were previously known as SLE findings, we also noted the presence of GMHs, parenchymal defects and abnormal DWI in a substantial portion of SLE patients, particularly in those with cerebrovascular disease or seizure. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2216

SAT0008 Microarray-based analysis of DNA methylation in peripheral whole blood of korean rheumatoid arthritis patients

Background In genetically susceptible individuals, we suspect that other environmental factors, which are yet to be determined, induce epigenetic changes that result in the development of rheumatoid arthritis (RA). However, to our knowledge, a genome-wide profile of DNA methylation changes in RA is not yet available. Objectives To investigate the possible epigenomic biomarker of RA pathogenesis, the CpG methylation profiles of peripheral whole blood were analyzed using microarray profiling. using methylated DNA isolation assay (MeDIA)-CpG promoter microarray, and compared it with peripheral whole blood of healthy controls. Methods Human peripheral whole blood samples were obtained from 16 RA and from 16 age, sex-matched healthy vontrols. Total genomic DNA extracted using the QIAamp DNA mini and blood kit protocol (Qiagen, Hilden, Germany). To discover novel hypermethylated genes in RA by genome-wide search, we introduce a MeDIA-coupled CpG microarray method for directly identifying differentially methylated regions of the genomes in each pooled whole blood between RA patients and healthy controls. A minimized methyl-DNA binding domain (MBD) tagged by histidine (MBD2bt) of human MBD2b was used, which provides high binding sensitivity to methylated DNA. Four independent CpG microarray analyses with human 244K CpG island microarrays (Agilent, Santa Clara, CA) were done for screening of candidate gene. Results In four CpG microarray, 16 genes were screened as 2 fold hypermethylated targets among 267 porbes. Through stepwise subtraction processes, we finally selected four candidate targets. Among of these targets, four genes, LBX2, HOXA5, HUS1B, INPP5A gene in the promoter region have shown so far a significant increase in the methylation frequency in RA when compared with healthy controls (see figure 1). The methylation status of promising candidates will be validated by quantitative pyrosequencing assay in each samples. Figure 1. Candidate genes selection-screening. Conclusions LBX2, HOXA5, HUS1B, INPP5A gene in peripheral blood of RA patients can possibliy be a epigenomic biomarker. Pathophysiologic correlation and their role as a diagnostic or prognostic marker should be investigated by quantitative pyrosequencing in a larger number of patients group hereafter. References Costenbader KH, Gay S, Riquelme ME, Iaccarino L, Doria A. Genes, epigenetic regulation and environmental factors: Which is the most relevant in developing autoimmune diseases? Autoimmun Rev 2011: epub Ballestar E. Epigenetic alterations in autoimmune rheumatic diseases. Nat Rev Rheumatol 2011:7:263-71. van Baarsen LG, Bos CL, van der Pouw Kraan TC, Verweij CL. Transcription profiling of rheumatic diseases. Arthritis Res Ther 2009;11:207. Disclosure of Interest S.-H. Park Grant/Research support from: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2011-0007659)., S.-K. Kim: None Declared, J.-Y. Choe: None Declared, J. H. Kim: None Declared, H.-J. Lee: None Declared, J. N. Chae: None Declared, W.-T. Chung: None Declared

TNF‐α polymorphisms in Korean adult‐onset Still's disease patients

Aim:  To investigate the role of TNF‐α promoter polymorphisms in the pathogenesis of Korean adult‐onset Stills disease (AOSD) patients.