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Objective.To evaluate the frequency of malignancies in Italian patients with systemic sclerosis (SSc) and anti-RNA polymerase III (RNAP III), antitopoisomerase I (topo I), or anticentromere antibodies (ACA); and to characterize the temporal relationship between the 2 diseases, in order to confirm data suggesting a close temporal relationship between the onset of SSc and malignancy in American patients with anti-RNAP III antibodies.Methods.From a cohort of 466 consecutive SSc patients, 360 Italians with isolated positivity for anti-RNAP III (n = 16), anti-topo I (n = 101), or ACA (n = 243) were identified. Malignancy cases were divided according to their relationship with SSc onset into 3 categories: preceding, synchronous with, or metachronous to the onset of SSc (diagnosed more than 6 months before; 6 months before to 12 months after; and more than 12 months after onset of SSc, respectively).Results.Malignancies were more frequent in the anti-RNAP III group (7/16 patients), than in the anti-topo I (11/101) and ACA groups (21/243) (p < 0.001). This difference was accounted for by the number of patients with cancer synchronous to the onset of SSc (3/16 in the anti-RNAP III group vs 0/101 in the anti-topo I and 1/243 in the ACA group; p < 0.001), whereas neither the number of malignancies preceding nor those metachronous to the onset of SSc was significantly different between the groups.Conclusion.In a cohort of Italian patients with SSc we observed a significant association between malignancies synchronous to SSc onset and positivity for anti-RNAP III antibodies, similar to that described in American patients with SSc.

BackgroundRecent evidence has highlighted a potential role of interleukin 1β (IL-1β) in systemic sclerosis (SSc). NLRP1 provides a scaffold for the assembly of the inflammasome that promotes the processing and maturation of pro-IL-1β. In addition, NLRP1 variants were found to confer susceptibility to autoimmune disorders.ObjectiveTo study a possible association of the NLRP1 rs6502867, rs2670660 and rs8182352, rs12150220 and rs4790797 with SSc in the European Caucasian population.MethodsNLRP1 single nucleotide polymorphisms were genotyped in 3227 individuals comprising a discovery set (870 SSc patients and 962 controls) and a replication set including individuals from Germany (532 SSc patients and 324 controls) and Italy (527 SSc patients and 301 controls), all individuals being of European Caucasian origin.ResultsConditional analyses revealed a significant association for the NLRP1 rs8182352 variant with both anti-topoisomerase-positive and SSc-related fibrosing alveolitis (FA) subsets under an additive model: p=0.0042, OR 1.23 (95% CI 1.07 to 1.41) and p=0.0065 OR 1.19 (95% CI 1.05 to 1.36), respectively. Logistic regression analysis showed an additive effect of IRF5 rs2004640, STAT4 rs7574865 and NLRP1 rs8182352 risk alleles on SSc-related FA.ConclusionsOur results establish NLRP1 as a new genetic susceptibility factor for SSc-related pulmonary fibrosis and anti-topoisomerase-positive SSc phenotypes. This provides new insights into the pathogenesis of SSc, underlining the potential role of innate immunity in particular in the FA-positive SSc subphenotype, which represents a severe subset of the disease.

International audience; Objective. The nonsynonymous polymorphism rs763361 of the CD226 gene, which encodes DNAX accessory molecule 1, which is involved in T cell co-stimulation pathways, has recently been identified as a genetic risk factor for autoimmunity. The purpose of this study was to test for association of the CD226 rs763361 polymorphism with systemic sclerosis (SSc) in European Caucasian populations. Methods. CD226 rs763361 was genotyped in 3,632 individuals, consisting of a discovery sample (991 SSc patients and 1,008 controls) and a replication sample (999 SSc patients and 634 controls). All study subjects were of European Caucasian origin. Expression of CD226 was assessed on peripheral blood mononuclear cells obtained from 21 healthy donors genotyped for CD226 rs763361. Results. The CD226 rs763361 T allele was found to be associated with SSc in both the discovery and the replication samples, showing the following results in the combined populations: odds ratio (OR) 1.22 (95% confidence interval [95% CI] 1.10-1.34), P = 5.69 x 10(-5). The CD226 T allele was also associated with various SSc subsets, highlighting a potential contribution to disease severity. The most remarkable associations of the CD226 TT risk genotype were observed with the diffuse cutaneous SSc subtype, the anti-topoisomerase I antibody-positive, and SSc-related fibrosing alveolitis subsets: OR 1.86 (95% CI 1.42-2.43), P = 5.15 x 10(-6), OR 1.82 (95% CI 1.38-2.40), P = 2.16 x 10(-5), and OR 1.61 (95% CI 1.25-2.08), P = 2.73 x 10(-4), respectively. CD226 expression was not significantly influenced by CD226 rs763361 genotypes whatever the T cell subtype investigated. Conclusion. Our results establish CD226 as a new SSc genetic susceptibility factor underlying the contribution of costimulation pathways in the pathogenesis of SSc. Further work is nevertheless needed to define the causal variant at the CD226 locus as well as the functional consequences.

Objectives: To validate the clinical significance of anti-IFI16 autoantibodies in SSc and assess their associations with serological markers of SSc. Methods: A semi-quantitative ELISA was used to detect anti-IFI16 autoantibodies in the sera of 344 SSc patients from seven Italian hospitals and 144 healthy controls. SSc-associated autoantibodies [anti-RNA polymerase III (anti-RNAP III) antibodies, anti-centromere, anti-topo I] and IF patterns were evaluated using commercial assays. Statistical analyses were performed to test clinical and serological associations. Results: The results of this study confirm a significant prevalence (29%) of anti-IFI16 antibodies in the SSc population (n = 344). Anti-IFI16 antibodies were also detected in 30% of the SSc patients who tested negative for both ACAs and anti-topo I (anti-Scl70) antibodies. In this subgroup of patients, anti-IFI16 antibodies were significantly associated with the limited cutaneous form of SSc with a sensitivity of 40% and a specificity of 81%. Moreover, analysis of the distribution of anti-RNAP III antibodies vs anti-IFI16 in the same SSc population showed that they were mutually exclusive. IIF revealed no association between anti-IFI16 and fluoroscopic patterns, due to a lack of IFI16 autoantigen in HEp-2 cells. Anti-IFI16 antibody levels were also significantly associated with heart involvement. Conclusions: Anti-IFI16 autoantibodies are frequently detected in SSc, displaying clinical and laboratory associations, and being particularly useful for diagnosis and disease classification in patients who are negative for other SSc serological markers. © The Author 2010. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved.

The study aims to obtain more information about the immune deficit of common variable immunodeficiency (CVID) patients.A new real-time PCR assay was used to quantify T and B lymphocyte mobilization from the production and maturation sites through the detection of T cell receptor excision circles (TRECs) and kappa-deleting recombination circles (KRECs) and to allow the estimation of the average number of B cell divisions. T and B lymphocyte subsets were analyzed by flow cytometry.The number of TREC(+) lymphocytes, which depends on age and gender, was significantly reduced in CVID patients. Similarly, KREC concentration was lower than in controls. Classification of patients according to the percentage of memory switched B cells showed that patients belonging to MB2 group and therefore with conserved B cell maturation have the lowest new B cell output but increased average peripheral divisions, leading to the highest B cell number.TREC and KREC quantification can be helpful for a more complete and informative understanding of a heterogeneous disease such as CVID.

ObjectiveTo identify a core set of preliminary items considered as important for the very early diagnosis of systemic sclerosis (SSc).MethodsA list of items provided by European League Against Rheumatism (EULAR) Scleroderma Trial and Research(EUSTAR) centres were subjected to a Delphi exercise among 110 experts in the field of SSc. In round 1, experts were asked to choose the items they considered as the most important for the very early diagnosis of SSc. In round 2, experts were asked to reconsider the items accepted after the first stage. In round 3, the clinical relevance of selected items and their importance as measures that would lead to an early referral process were rated using appropriateness scores.ResultsPhysicians from 85 EUSTAR centres participated in the study and provided an initial list of 121 items. After three Delphi rounds, the steering committee, with input from external experts, collapsed the 121 items into three domains containing seven items, developed as follows: skin domain (puffy fingers/puffy swollen digits turning into sclerodactily); vascular domain (Raynaud's phenomenon, abnormal capillaroscopy with scleroderma pattern) and laboratory domain (antinuclear, anticentromere and antitopoisomerase-I antibodies). Finally, the whole assembly of EUSTAR centres ratified with a majority vote the results in a final face-to-face meeting.ConclusionThe three Delphi rounds allowed us to identify the items considered by experts as necessary for the very early diagnosis of SSc. The validation of these items to establish diagnostic criteria is currently ongoing in a prospective observational cohort.

1 página.-- Póster presentado al 5º European Workshop on Immune-Mediated Inflammatory Diseases celebrado en Sitges (Barcelona, Españ) del 1 al 3 de Diciembre de 2010.-- et al.

Objective.To measure the prevalence of different types of pulmonary hypertension (PH) and to identify patients with systemic sclerosis (SSc) at highest risk in a multicenter European sample, with a metaanalysis of relevant studies.Methods.Consecutive patients with SSc recruited at 11 French and Italian centers underwent detailed evaluations, including Doppler echocardiography, chest computed tomography, pulmonary function tests, and right-heart catheterization (RHC), to detect the presence and causes of PH. A metaanalysis was performed, including data from 4 other studies.Results.Among 206 patients in whom it was suspected, PH was confirmed by RHC in 83 patients (7%). Precapillary PH was found in 64 patients (5%), of whom 42 had pulmonary arterial hypertension (PAH) and 22 had PH secondary to interstitial lung disease (ILD). RHC identified 17 patients (1%) with postcapillary PH secondary to left-heart disease. Patients with DLCO/alveolar volume < 70% were more likely to have precapillary PH (87.5% vs 42%; p < 0.0001). Precapillary and postcapillary PH were associated with advanced age (68 ± 14 vs 59 ± 12 yrs, p < 0.0001, and 74 ± 16 vs 61.5 ± 10 yrs, p < 0.0001, respectively). The metaanalysis of 3818 patients showed a prevalence of precapillary PH of 9% (95% CI 6%–12%) and identified advanced age, longer disease duration, and limited cutaneous disease subset as risk factors for this condition.Conclusion.The prevalence of precapillary PH in our multicenter study of SSc was 5%, and in the metaanalysis 9%. Our observations support use of RHC to confirm the presence of precapillary PH suspected by noninvasive testing. We also identified patients at high risk who should be carefully monitored.

Objective.Patients with scleroderma (systemic sclerosis; SSc) can be classified into subsets based on autoantibody profile and clinical features. Specificities such as anti-Th/To and anti-fibrillarin (U3RNP) are detectable mainly by immunoprecipitation (IP), which is not widely used in clinical laboratories. We examined the autoantibody profiles and clinical manifestations in a cohort of Italian patients with SSc, focusing on anti-Th/To and anticentromere (ACA) antibodies, associated with limited cutaneous SSc (lcSSc).Methods.Sera from 216 consecutive patients with SSc were tested for ACA (by indirect immunofluorescence), antitopoisomerase I (topo I; by counterimmunoelectrophoresis), and anti-RNA polymerase III (RNAPIII; by ELISA). Forty-one sera negative for these specificities were tested by IP analysis of proteins (35S-methionine labeled K562 cell extract) and RNA (silver staining).Results.Among 216 SSc patients analyzed, anti-topo I, ACA, and anti-RNAPIII were detected in 38% (81/216), 31% (67/216) and 7% (15/216), respectively. Among 41 sera negative for ACA, anti-topo I, and anti-RNAPIII and which were tested by IP, 14 were nucleolar stain-positive. Eight out of 14 (57%) showed anti-Th/To reactivity, but no anti-U3RNP was found. In comparison with ACA-positive patients, anti-Th/To-positive patients were younger (p = 0.0046) and more commonly were male (p = 0.0006). All 8 anti-Th/To-positive and all but one ACA-positive patients had lcSSc. Interstitial lung disease (ILD) and pericarditis were more frequent in anti-Th/To-positive patients.Conclusion.Anti-Th/To are common in antinucleolar antibody-positive Italian patients with SSc. Anti-Th/To and ACA patients had lcSSc, with excellent prognosis. The anti-Th/To group had frequent pericarditis and ILD, although impairment of pulmonary function appeared mild.

Objective Pulmonary arterial hypertension (PAH) has emerged as a leading cause of death in systemic sclerosis (SSc). The genetic basis of PAH has been unraveled in recent years, with a major role played by transforming growth factor β receptors; however, some other candidate genes have also been advocated, including potassium voltage-gated channel, shaker-related subfamily, member 5 (KCNA5). We undertook this study to determine whether KCNA5 polymorphisms confer susceptibility to SSc and its vascular phenotype, including PAH. Methods Four KCNA5 single-nucleotide polymorphisms (SNPs), rs10744676, rs1860420, rs3741930, and rs2284136, were genotyped in a discovery set of 638 SSc patients and 469 controls. In addition, rs10744676 was genotyped in an independent replication sample (938 SSc patients and 564 controls) and in a cohort of 168 patients with different PAH subtypes. Results The KCNA5 rs10744676 variant was found to be associated with SSc in the discovery sample, with an odds ratio (OR) of 0.62 (95% confidence interval [95% CI] 0.48–0.79, adjusted P = 0.0003) in comparison with controls (C allele frequency 11.4% versus 17.2%). When subphenotypes were investigated, an association was found solely for PAH associated with SSc (OR 0.31 [95% CI 0.13–0.71], adjusted P = 0.04). The other KCNA5 SNPs tested were not associated with any SSc subset. The above association with PAH associated with SSc was replicated in the second set. In the combined population, rs10744676 was strongly associated with PAH associated with SSc in comparison with controls (OR 0.36 [95% CI 0.21–0.63], P = 0.0002). In the independent cohort of patients with PAH, after investigating PAH subtypes, only rs10744676 showed an association with PAH associated with SSc. Conclusion Our results provide the first evidence for an association between the KCNA5 rs10744676 variant and PAH associated with SSc.

To better understand the kinetics of the delayed reconstitution of peripheral CD4+ T-cells after depletion with a single administration of alemtuzumab (AL) for renal transplantation, we evaluated in these patients the percentage and absolute number of recent thymic emigrants (RTEs) CD4+ T cells, together with naive and memory subsets, defined by the analysis of CD31, CD45RA and CCR7 expression, and compared with patients treated with a nondepleting protocol based on basiliximab, and with healthy controls. In AL-treated patients, the number of circulating CD4+ T cells was greatly reduced 1 year after the infusion (P0.01), but the proportions of central memory, effector memory and terminally differentiated effector memory subsets among CD4+ cells were significantly increased. On the contrary, the proportion and the absolute number of naïve CD4+ T cells, although progressively increasing with time, were severely reduced. In particular, the absolute number of RTEs had only very slight increase with time (P = 0.049) and was dramatically low 1 year after the therapy (P0.01 vs. healthy controls; P0.05 vs. basiliximab-treated transplant recipients). These data suggest that a prolonged defective thymic output after AL therapy in renal transplant recipients is one of the main causes of the persistent CD4+ T-cell lymphopenia observed in these patients.

Objectives:To measure the prevalence of, and factors associated with, left ventricular (LV) dysfunction in systemic sclerosis (SSc).Methods:The EUSTAR database was first searched. A case-control study of a patient subset was then performed to further identify independent factors associated with LV dysfunction by simple and multiple regression.Results:Of 7073 patients, 383 (5.4%) had an LV ejection fraction (EF) of Conclusion:The prevalence of LV dysfunction in SSc is 5.4%. Age, male gender, digital ulcerations, myositis and lung involvement are independently associated with an increased prevalence of LV dysfunction. Conversely, the use of calcium channel blockers may be protective.

BackgroundTNFAIP3 encodes the ubiquitin-modifying enzyme, a key regulator of inflammatory signalling pathways. Convincing associations between TNFAIP3 variants and autoimmune diseases have been reported.ObjectiveTo investigate the association of TNFAIP3 polymorphisms with systemic sclerosis (SSc).MethodsThree single nucleotide polymorphisms (SNPs) in a set of 1018 patients with SSc and 1012 controls of French Caucasian origin were genotyped. Two intergenic SNPs, rs10499194 and rs6920220, and one located in TNFAIP3 intron 2, rs5029939, were selected. The TNFAIP3 rs5029939 found to be associated with SSc in this first set was then genotyped in a second set of 465 patients with SSc and 182 controls from Germany and 184 patients with SSc and 124 controls from Italy. Pooled odd ratios were calculated by Mantel–Haenszel meta-analysis.ResultsThe rs5029939 G allele was found to be significantly associated with SSc susceptibility (pooled OR=2.08 (95% CI 1.59 to 2.72); p=1.16×10−7), whereas the rs10499194 and rs6920220 variants displayed no association. Only one of the predicted haplotypes investigated in the French sample was significantly associated with SSc (p=8.91×10−8), and this haplotype was discriminating only in the presence of the rs5029939 risk allele, suggesting that this SNP tags the association signal. The strongest associations of rs5029939 with subphenotypes, having large magnitudes for complex genetic disorders, were observed for diffuse cutaneous SSc (pooled OR=2.71 (1.94 to 3.79), p=5.2×10−9), fibrosing alveolitis (pooled OR=2.26 (1.61 to 3.17), p=2.5×10−6) and pulmonary arterial hypertension (pooled OR=3.11 (1.86 to 5.17), p=1.3×10−5).ConclusionThese results suggest that TNFAIP3 is a genetic susceptibility factor for SSc.

4 páginas, 2 figuras, 2 tablas.-- Spanish Scleroderma Group., Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs that leads to profound disability and premature death. To identify new SSc susceptibility loci, we conducted the first genome-wide association study in a population of European ancestry including a total of 2,296 individuals with SSc and 5,171 controls. Analysis of 279,621 autosomal SNPs followed by replication testing in an independent case-control set of European ancestry (2,753 individuals with SSc (cases) and 4,569 controls) identified a new susceptibility locus for systemic sclerosis at CD247 (1q22–23, rs2056626, P = 2.09 × 10−7 in the discovery samples, P = 3.39 × 10−9 in the combined analysis). Additionally, we confirm and firmly establish the role of the MHC (P = 2.31 × 10−18), IRF5 (P = 1.86 × 10−13) and STAT4 (P = 3.37 × 10−9) gene regions as SSc genetic risk factors., This work was supported by the following grants: T.R.D.J.R. was funded by the VIDI laureate from the Dutch Association of Research (NWO) and Dutch Arthritis Foundation (National Reumafonds). J.M. was funded by GEN-FER from the Spanish Society of Rheumatology, SAF2009-11110 from the Spanish Ministry of Science, CTS-4977 from Junta de Andalucía, Spain and in part by Redes Temáticas de Investigación Cooperativa Sanitaria Program, RD08/0075 (RIER) from Instituto de Salud Carlos III (ISCIII), Spain (J.M.). R.B. is supported by the I3P Consejo Superior de Investigaciones Científicas program funded by the 'Fondo Social Europeo'. B.Z.A. is supported by the Netherlands Organization for Health Research and Development (ZonMW grant 016.096.121). B.K. is supported by the Dutch Diabetes Research Foundation (grant 2008.40.001) and the Dutch Arthritis Foundation (Reumafonds, grant NR 09-1-408). Genotyping of the Dutch control samples was sponsored by US National Insitutes of Mental Health funding, R01 MH078075 (R.O.A.). The German controls were from the PopGen biobank (to B.K.).

We retrospectively analysed the prevalence and clinical features associated to anti-Ku antibodies in patients affected by different autoimmune diseases. Anti-Ku antibodies are detected in 147 sera out of 7239 anti-ENA positive sera (2%). They are found in 2% of patients with systemic sclerosis (SSc) (8 out of 379), 1.8% of systemic lupus erythematosus (SLE) (7 out of 372) and 1.8% of undifferentiated connective tissue disease (UCTD) (9 out of 496) and more rarely in Sjögren Syndrome and rheumatoid arthritis. Most of anti-Ku positive patients were affected by UCTD and overlap syndromes, including polymyositis, SSc and SLE. Interstitial lung disease, myositis, articular symptoms, Raynaud’s phenomenon and sicca represents the main clinical features detected in our cohort. The rate and severity of pulmonary disease is similar to those found in other SSc patients. Isolated anti-Ku were detected in about 47% of sera. No clinical differences were observed between these patients and subjects with multiple anti-nuclear specificities. However, anti-Ku are usually detected in association with other serological markers in SLE and Sjögren Syndrome, while they occurred isolated in SSc and polymyositis.

Few data are available to assess the efficacy of rehabilitative interventions in systemic sclerosis (SSc). We refer here the results of an individualized rehabilitation program in 16 patients with SSc. In particular, when possible, the number of patients who achieved a minimal clinically important difference (MCID) was determined. Results were evaluated taking advantage of the development of validated questionnaires and tests to assess quality of life (QOL) and disability in SSc. At the end of a period of 4 months of observation, 69% and 62% of patients reported an improvement of the physical and mental components of the SF-36 higher than the MCID (as established in other rheumatic conditions). Analogously, an improvement of the impact of respiratory disease on patients’ QOL, as assessed by the Saint George’s Respiratory Questionnaire, was perceived by 67% of them. These results might be explained by better exercise tolerance, which was suggested by the significant reduction of the heart rate and of a visual analogue scale for dyspnoea at the end of the 6-min walking test. Finally, a statistically significant improvement of hand mobility, as assessed by the hand mobility in scleroderma test was obtained. This study suggests that a significant proportion of patients with SSc experience an improvement in their perception of QOL, a better exercise tolerance, and a better hand mobility after a rehabilitation program consisting by a 2-week period of daily individual 30-min sessions as outpatient, followed by at-home exercise program.

ObjectiveTo examine whether myxovirus-resistance protein A (MxA) mRNA expression, commonly considered a reliable marker of Type I interferon (IFN) bioactivity, is modified in patients with systemic sclerosis (SSc); if it is associated to specific clinical features; and if its modulation is accompanied by modulation of mRNA for the Type I IFN receptor (IFNAR).MethodsQuantification of mRNA for MxA and the subunit IFNAR1 and isoforms of IFNAR2 was performed by real-time polymerase chain reaction in 50 patients with SSc. Results were compared with those obtained from healthy controls and patients with another autoimmune disease such as multiple sclerosis.ResultsLevels of MxA mRNA above the 99th percentile of values found in healthy controls were observed in 9 out of 50 patients with SSc (p < 0.001). Induced MxA expression was significantly associated with some features of more severe disease, such as lower forced vital capacity and the presence of ischemic digital ulcers. No differences in the levels of IFNAR were found within MxA-induced and MxA-non-induced patients, but there was a direct correlation between levels of MxA and the soluble isoform of IFNAR2.ConclusionOur results show induction of MxA expression in some patients with SSc, which correlates with the presence of ischemic ulcers and other signs of worse disease, suggesting a potential role of Type I IFN in the pathogenesis of this disease and/or its complications.

To evaluate the safety and tolerability of lamivudine in patients with HBV infection needing immunosuppressive treatment for rheumatic diseases.Twenty patients with rheumatic diseases planned to receive immunosuppressive DMARDs or biological agents were screened for HBV markers. In all active carriers antiviral treatment was recommended. Inactive carriers (HBsAg positive, aminotrasferase and viremia persistently normal) were divided into two risk categories according to the type and the degree of immunosuppression, and antiviral prophylaxis was started only in patients of the high risk category. Antiviral treatment was recommended also in potential occult carriers (HBsAg negative, HBcAb positive) treated with rituximab. In twenty patients antiviral treatment was started: 1 was a potential occult carrier planned to receive rituximab; 9 were inactive carriers, in which prophylactic therapy was needed for a high risk of HBV reactivation (in 3, for the use of TNF blocking agents); 10 were treated for active viral replication. Prophylaxis and therapy were performed with lamivudine. In three patients adefovir was associated.Antiviral drugs were well tolerated. In all cases, immunosuppressive treatment was given for the planned duration of therapy, with good results on the rheumatic diseases. Median duration of antiviral treatment was 19 months (for a total of 386 month/person). No cases of viral reactivation were observed.Our experience demonstrates the feasibility of a prophylaxis and therapy of HBV infection in patients with rheumatic diseases. This approach reduces the risk of viral reactivation and allows the choice of the optimal immunosuppressive treatment in rheumatic patients.

To the Editor: Bone marrow transplantation (BMT) is the only curative treatment for children with (severe) combined immunodeficiency [(S)CID].[1][1] In the absence of HLA-identical siblings suitable as donors, alternative sources, such as HLA-identical marrow unrelated donors (MUD), should be used

The coexistence of systemic sclerosis (SSc) and multiple sclerosis (MS) in the same patient has been described in few cases. We refer here a further case of association between these diseases, which highlight the difficulty of treating such patients. A 57-year-old male with relapsing-remitting MS since 20 years, shortly after having received high-dose corticosteroids for a relapse of MS, suddenly developed SSc, with onset of Raynaud phenomenon simultaneous to that of scleroderma skin involvement, new appearance of accelerated arterial hypertension, and rapidly progressive oliguric renal failure, indicative of scleroderma renal crisis, that was controlled with ramipril, irbesartan and amlodipin. A further disabling relapse of MS was treated with interferon-beta, but 19 months later he developed multiple severe digital necrotic ulcers, that resolved with interferon discontinuation and therapy with iloprost. This case report shows that some form of treatment useful for MS might enhance the manifestations of SSc.

Interferons (IFNs) are now known to exert a multitude of immunological functions on both the innate and adaptive immunity. Given their pleiotropic effects on the immune system, it is conceivable that excess type I IFN or aberrant regulation of its signaling could contribute to autoimmunity. Several lines of evidence link IFNs to autoimmune disorders, in particular to systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). Expression of a spectrum of genes that constitutes an "IFN signature" is the most significant observation indicating that IFNs may be dominant among the pathogenic mediators involved in some autoimmune diseases. A family of IFN-inducible genes, designated HIN-200 in the human and IFI-200 in the murine species, encodes evolutionary related human (IFI16, MNDA, AIM2, IFIX) and murine proteins (Ifi202 a, Ifi202b, Ifi203, Ifi204, Ifi205/D3). Physiological IFI16 expression was found in cells of the immune system, in endothelial cells, and in stratified squamous epithelia, such as skin. The presence of anti-IFI16 antibodies was reported in SLE and primary/secondary Sjögren's syndrome. More recently, we reported that anti-IFI16 autoantibodies differentiate limited cutaneous systemic sclerosis (lcSSc) from diffuse systemic sclerosis (dcSSc). Molecular studies performed in primary endothelial cells overexpressing IFI16 demonstrated that it may be involved in the early steps of inflammation by modulating endothelial cell function, such as expression of adhesion molecules and chemokine production, cell growth, and apoptosis. Moreover, here we report that IFI16 expression is induced by proinflammatory cytokines. In this article the role of the IFI16 protein and its corresponding autoantibodies in the etiopathogenesis of systemic autoimmune diseases, in which chronic inflammation is involved, are discussed.

Background Articular involvement is reported to occur in up to 85% of patients with antisynthetase syndrome (ASSD) and it may be the only onset feature, although with frequencies and characteristics not still defined Objectives To determine in a large international cohort of anti Jo-1 positive ASSD the prevalence of isolated arthritis at disease onset. To describe the clinical, serological and radiological characteristics and evolution of these patients Methods We included all anti Jo-1 positive patients referring to participating centres and with an isolated arthritis at disease onset. The pattern of articular involvement, radiological and serological characteristics of patients were analysed. IgM-Rheumatoid factor (RF) was assessed by immunonephelometry; anti-cyclic citrullinated peptide antibodies (ACPA) by commercial second-generation ELISA kits; anti Jo-1 and anti-Ro positivity by commercially available ELISA kits Results An isolated arthritis was the first manifestation in 54 (41 females, 13 males) out of the 225 patients included (167 females, 58 males), with a prevalence of 24%. Main characteristics of arthritis and overal results has been completely reported in table 1. Conclusions We confirmed that an isolated polyarthritis is the first symptom of anti Jo-1 positive ASSD in up to a quarter of cases. Arthritis is mainly polyarticular and symmetrical, and the positivity for IgM RF or ACPA or both is not a rare finding, as well as the occurrence of marginal X-rays joint erosions. Anti-Ro positivity and RP occurrence may help clinician in the early identification of ASSD, even if the high rate of subsequent appearance of ILD and myositis clearly suggest that the screening for an underlying ASSD should be performed also in patients that may be undoubtedly diagnosed with RA. References Cavagna L, et al. Characterization of anti Jo-1 positive antisynthetase syndrome: results from an international multicentre study. Arthritis Rheum 2014;11:S550. Lefevre G, et al. Seronegative polyarthritis revealing antisynthetase syndrome: a multicentre study of 40 patients. Rheumatology (Oxford). 2014 Oct 27. pii:keu404. [Epub ahead of print] Disclosure of Interest None declared

Background Most data on the clinical associations of anti-RNA polymerase III (RNAP) antibodies in patients with Systemic Sclerosis (SSc) derive from single-center studies or relatively small positive case number reports. Objectives To analyse the clinical associations of anti-RNAP in a large cohort of patients with different geographic and ethnic origin using the multicenter EUSTAR database. Methods Patients from the EUSTAR database were included when the item anti-RNAP was fulfilled in at least one visit, and considered anti-RNAP+ when scored positive in at least one determination. In a second phase, EUSTAR centers were asked to participate to a case-control study, fulfilling a supplementary form dedicated to skin involvement progression, gastric antral vascular ectasia (GAVE), and malignancies. Malignancies diagnosed between 6 months before and 12 months after the onset of SSc were defined as “synchronous to the onset of SSc”. Centers were asked to match anti-RNAP+ cases with anti-RNAP- SSc controls, paired for sex, cutaneous subset, and disease duration. Univariate methods were used to compare patients with and without anti-RNAP. Results Among 11,399 SSc patients registered in the EUSTAR database, 4,986 had anti-RNAP antibodies status available including 223 anti-RNAP+ (4.5%) and 4,763 anti-RNAP-. The differences between the two groups are shown in Figure 1. There was no difference as far as ethnicity (Caucasians: 94.2% vs 95.0%), age at disease onset, disease duration, length of follow-up, and other parameters included in the database. Ten centers participated in the case-control study, collecting 126 anti-RNAP+ cases (23% male, 59% with diffuse cutaneous involvement), and 137 anti-RNAP- matched patients. A trend toward a higher peak of modified Rodnan Skin Score (RSS) in anti-RNAP+ patients was observed (p:0.07). Interval time between the first symptom of SSc other than Raynaud9s phenomenon and the peak of RSS was shorter in anti-RNAP+ cases than in controls (p:0.008; log-rank test). Other differences between the two groups are shown in Figure 1. Conclusions Analysis of a large, multicenter database and a dedicated case-control study confirm that anti-RNAP is one of the most useful markers available to stratify SSc patients in subsets with peculiar clinical features. These include rapid progression of skin involvement, GAVE, and an increased risk of diagnosis of cancer simultaneous to the onset of SSc. This information should guide monitoring and follow-up in anti-RNAP+ SSc patients. Disclosure of Interest None declared

Background Pulmonary arterial hypertension (PAH) is one of the leading causes of death in Systemic Sclerosis (SSc). World Health Organization (WHO) functional class at diagnosis is one of the most reliable outcome predictors of PAH. Moreover, patients starting in a poor functional class (eg. class III-IV) have a favorable long-term course if they achieve a better class (eg. class II) after initiation of PAH-targeted therapy. Therefore, current guidelines suggest a goal-oriented treatment aimed at obtaining a good functional class. Objectives To evaluate the proportions of patients with SSc-associated PAH in WHO functional class II at time of diagnosis and during follow-up. Methods In this retrospective single-center study all patients affected by SSc-associated pre-capillary PAH diagnosed between 2001 and 2014 were included, excluding those with clinically significant interstitial lung disease (ILD; Forced Vital Capacity Results PAH was diagnosed in 41 patients with SSc. Six of them (15%) were excluded because of associated ILD. Among 35 patients included, 11 (35%) were in WHO functional class II at the time of diagnosis, and 24 in class III-IV. Other main demographical and clinical characteristics of these patients were: limited cutaneous SSc: 35 (100%); female: 34 (97%); median age (IQR) 71.5 (64-75) years; time since Raynaud9s phenomenon (RP) onset: 21 (13-31) years; time since first non-RP symptom: 10 (2-15) years; ANA+ 34 (97%); anticentromere+: 27 (77%); anti-Topo I+: 0; anti-RNA polymerase III+: 1 (3%); sPAP estimated by echocardiography: 74 mmHg (58-88); TAPSE: 14 mm (12-19); FVC 115% (104-130); DLCO: 40% (36-52); 6 minutes walking test distance: 242 m (168-311); mean PAP on right heart catheterization: 38 mmHg (33-49); Cardiac Index: 2.9 l/min/m2 (2.1-3.5); PVR: 5.4 UW (3.5-6.4). Patients were divided in two groups according the time of diagnosis: 13 were diagnosed after 2010 and 22 before 2010. In patients with more recent diagnosis WHO functional class II was more frequent than in the others (7/13 (53%) vs. 4/22 (18%); p:0.03). There were trends toward better haemodynamic parameters in the first group, but these did not reach statistical significance. Twenty-one patients died; median survival from diagnosis of PAH was 49.5 months. Survival was better in patients diagnosed after 2010, as compared with those diagnosed before (log-rank test: p: 0.048; figure 1). At January, 2015, 14 patients were alive: in 8 of them the diagnosis was done in WHO functional class II, and all were still in this functional class; in 6 patients the diagnosis was done in WHO class III, and 3 of them were in WHO class II at the last evaluation. Therefore, the majority of patients in follow-up (11/14; 76%) had a good functional class at the moment of the last evaluation. Conclusions This retrospective evaluation of a real-life setting shows that diagnosis of SSc- associated PAH in a good functional class was rare before 2010, but it became more frequent in the last years. Moreover, the majority of patients can obtain a good functional class with PAH-targeted therapy. These data reflects better awareness of the problem and better strategies of diagnosis and of treatment, and may be linked to a better survival. Disclosure of Interest None declared

Background Systemic sclerosis (SSc) is classically dichotomized in limited or diffuse cutaneous subsets associated with different prognosis. However, it appears that SSc is a highly heterogeneous disease, with probably more subtle clinical phenotypes. Objectives The primary objective of our study was to identify and characterize homogeneous phenotypes in the EUSTAR SSc population using a cluster analysis. The secondary objective is to assess the survival in the different clusters. Methods The participants were SSc patients of the EUSTAR prospective cohort. Inclusion criteria were: age ≥18 years, fulfilled American College of Rheumatology criteria for SSc, and had a calculable follow up. Hierarchical clustering based on the Ward method was performed using 25 clinically meaningful variables. The clinical relevance of the clusters was analysed by their characteristics and survival outcomes. Survival curves were plotted by the Kaplan-Meier method. Crud and adjusted (on the age at diagnosis and gender) Cox models were performed. Results A total of 6.927 patients were analyzed. Cluster analysis identified 5 clusters (Table 1). The first cluster C1 (n=1,963) was mainly characterized by a low Rodnan skin score contrasting with a relatively similar percentage of anti topoisomerase 1 and anti-centromere Ab (28% and 40%) and a high percentage of lung fibrosis (48%); the second cluster C2 (n=1,186) by a large majority of limited SSc (89%) and anti-centromere (79%) and the lowest percentage of lung fibrosis (22%); the third cluster C3 (n=1,249) and the fourth cluster C4 (n=856) by a high percentage of diffuse SSc/anti topoisomerase 1 (72%/50% and 92%/77% respectively) and the highest proportion of male patients. Digital ulcers, renal crisis/anti RNA polymerase III antibodies, joint involvement were more frequently found in C4 than in the other clusters. Patients in the cluster C5 (n=1,673) were mainly female patients, older than in the other clusters, had a rather low mean Rodnan skin score, a high percentage of anti-topoisomerase 1 antibodies (46%) and a high percentage of lung fibrosis. Concerning survival, C2 had the best survival and C4 the worst. When compared to C1, C2 to C5 clusters had a significantly different prognosis (C2: adjusted hazard ratio [95% CI]: 0.70 [0.51-0.96]; C3: 2.27 [1.76-2.94]; C4: 4.52 [3.57-5.72]; and C5: 1.94 [1.51-2.44]. Conclusions This cluster analysis on the largest ever worldwide database of SSc patients showed 5 different clusters characterized by different sex ratio, maximum Rodnan skin scores, autoantibodies status, joint and organ involvement as well as by a different prognosis. Autoantibodies status seemed to play an important role for association with organ involvement. Although systemic sclerosis is a heterogeneous disease, this study shows that homogeneous groups beyond the classical limited/diffuse dichotomy can be delineated in this disease. Disclosure of Interest None declared

ObjectivesTo assess the effects of Rituximab (RTX) on skin and lung fibrosis in patients with systemic sclerosis (SSc) belonging to the European Scleroderma Trial and Research (EUSTAR) cohort and using a nested case-control design.MethodsInclusion criteria were fulfilment of American College of Rheumatology classification criteria for SSc, treatment with RTX and availability of follow-up data. RTX-treated patients were matched with control patients from the EUSTAR database not treated with RTX. Matching parameters for skin/lung fibrosis were the modified Rodnan Skin Score (mRSS), forced vital capacity (FVC), follow-up duration, scleroderma subtype, disease duration and immunosuppressive co-treatment. The primary analysis was mRSS change from baseline to follow-up in the RTX group compared with the control group. Secondary analyses included change of FVC and safety measures.Results63 patients treated with RTX were included in the analysis. The case-control analysis in patients with severe diffuse SSc showed that mRSS changes were larger in the RTX group versus matched controls (N=25; −24.0±5.2% vs −7.7±4.3%; p=0.03). Moreover, in RTX-treated patients, the mean mRSS was significantly reduced at follow-up compared with baseline (26.6±1.4 vs 20.3±1.8; p=0.0001). In addition, in patients with interstitial lung disease, RTX prevented significantly the further decline of FVC compared with matched controls (N=9; 0.4±4.4% vs −7.7±3.6%; p=0.02). Safety measures showed a good profile consistent with previous studies in autoimmune rheumatic diseases.ConclusionsThe comparison of RTX treated versus untreated matched-control SSc patients from the EUSTAR cohort demonstrated improvement of skin fibrosis and prevention of worsening lung fibrosis, supporting the therapeutic concept of B cell inhibition in SSc.

Background The treatment of ILD remains a challenge for the rheumatologist. Recent studies suggested a potential short-term benefit of rituximab (RTX) on connective tissue diseases developing ILD. Objectives To compare RTX effects on ILD in patients with systemic sclerosis (SSc), mixed connective tissue disorder (MCTD) and anti-synthetase (SYN). Methods Multicentre retrospective assessment of the effects of RTX on ILD comparing three patient populations: SSc (n=23), MCTD (n=6) and SYN (n=15). All underwent high-resolution computed tomography (HRCT) at baseline and lung function tests (LFTs) at baseline and at 1 and 2 years of follow-up. The primary outcomes were the mean change in predicted forced vital capacity (FVC) value and the percentage of responders defined by an increase in FVC of 10% or greater. Results In SYN patients, although the change of FVC from baseline to 2 years was not statistically significant, a trend of improvement was observed (table 1). In SSc, discrepancies were observed with a trend of improvement at 1 year but a decline at 2 years. In MCTD, FVC remained table at 1 and 2 years of follow-up. In SYN patients, the percentage of responders for FVC was greater than in SSc (33.3% vs 9.5%) (p=0.1) and than in MCTD patients (33.3% vs 16.7%) (p=0.15). At baseline, SSc and MCTD patients had a higher FVC when compared to SYN population (table 1) and this finding may partially explain the major percentage of responders in SYN than in SSc. The percentage of responders in DLCO (gain ≥15%) was similar in SYN and SSc populations (27.3% and 23.8% respectively). Some patients received DMARDs and/or immunosuppressive treatment previously or/and concurrently to RTX; although this did not influence our findings, these treatments may influence the effects of RTX. RTX showed a satisfactory safety profile. Conclusions Our data obtained in routine care provide for the first time outcomes in LFTs after 2 years of follow-up. The main results show a good safety profile supporting future development. We also observed a promising trend of improvement in the SYN group and indicate that the drug may provide a stabilization of the involvement of the lung in SSc and MCTD. Future trials on homogenous groups of patients are warranted to determine how rituximab may be positioned in the treatment of CTD-ILD, but the SYN group should be prioritized. Acknowledgements EULAR scintific travel bursary Disclosure of Interest G. Lepri: None declared, J. Avouac: None declared, P. Airo: None declared, F. Anguita Santos: None declared, S. Bellando Randone: None declared, J. Blagojevic: None declared, O. Distler Grant/research support from: received research funding from, 4D Science, Actelion, Active Biotec, Bayer-Schering, Biogen, Biovitrium, BMS, Boehringer Ingelheim Pharma, EpiPharm, Ergonex, GSK, Inventiva, Medac, Novartis, Pfizer, Pharmacyclics, Roche/Genentech, Sanofi/Genzyme, Serodapharm, Sinoxa and United BioSource Corporation., F. J. Garcia Hernandez: None declared, J. A. Gonzalez Nieto: None declared, S. Guiducci: None declared, S. Jordan: None declared, V. Limaye: None declared, B. Maurer: None declared, V. Riccieri: None declared, A. Selva-O9Calaghan: None declared, M. Matucci Cerinic: None declared, Y. Allanore Grant/research support from: received research funding in relationship with the treatment of systemic sclerosis from Actelion, Bayer, Biogen Idec, BMS, Genentech/Roche, Inventive, Medac, Pfizer, Sanofi/Genzyme, Servier and UCB

Background and objectives Rheumatoid arthritis (RA) is characterised by increased numbers of circulating CD28neg T-cells, a population displaying functional characteristic of cytotoxic memory cells, including expression of granzymes, a family of serine proteases playing key roles in the induction of target-cell death. Soluble granzymes (as granzyme B (GrB)) are elevated in sera from patients with RA, in which are associated with development of radiographic erosions. Abatacept (CTLA4-Ig; ABA) competing with the engagement of CD28 on T-cells, influences the subsequent T-cell activation. In patients treated with ABA, the number of circulating CD28neg T-cells decreases, suggesting that the drug can prevent the generation of CD28neg T-cell populations. Since CD28neg T-cells may be an important source of GrB, we have evaluated the effect of ABA therapy on GrB serum levels in patients with RA. Materials and methods Fifty-three RA patients, treated for at least 3 months with ABA were evaluated. Disease activity and response to the treatment were measured with DAS28 (based on CRP) and EULAR Criteria. T-cell counts were determined by flow cytometry. Serum GrB samples were collected before the first administration of ABA (T0) and then after 6 months (T6), and measured by an indirect solid-phase enzyme immunoassay with a sensitivity limit of 20 pg/ml. Results The percentage and the absolute number of circulating CD4 + CD28-neg T-cells decreased after ABA therapy (T0 vs. T6: p = 0.018; p = 0.018, respectively), as well as those of CD8 + CD28-neg T cells (T0 vs. T6: p = 0.005; p = 0.008, respectively). At T0, GrB serum levels were detectable in all RA patients, and were correlated with disease activity (p = 0.0022), and percentages of circulating CD4 + CD28- (p = 0.007) and CD8 + CD28- T-cells (p = 0.031). In 25 patients serum level of GrB were evaluated at T6: in 18 patients with a moderate or good clinical response to ABA the levels of GrB significantly decreased from T0 (median: 62.8 pg/mL[10th-90th percentile:45.8–116]) to T6 (53.8 [46.4–96.6]; p = 0.023), whereas no variation was observed in 7 non responders. The variation of GrB levels was directly correlated with that of DAS28-PCR (p = 0.040), but not with those of circulating CD28-neg T-cell subsets. Conclusions Costimulation blockade by ABA can decrease the serum levels of GrB in RA patients responding to the treatment, suggesting that this might be one of the mechanism by which ABA can prevent radiographic erosions. However, the lack of correlation of such decrease with the numbers of circulating CD28-neg T-cells suggests that these cells are not the main source of serum GrB.

Background CD28neg T cells, which display functional characteristic of oligoclonally expanded cytotoxic memory T lymphocytes, are believed to be pathologically relevant in rheumatoid arthritis manifestation. The CD28 co-stimulation blockade by abatacept can prevent the generation of CD28neg T-cell populations in these patients. Methods Samples were obtained before and after 12 months of abatacept therapy. T-cell phenotype and T-cell receptor diversity were evaluated by flow cytometry and complementarity-determining region-3 spectratyping, respectively, while telomerase reverse-transcriptase gene level was measured by real-time PCR. Results Abatacept induces a decrease of the percentage and number of CD4+CD28neg T cells and a reduction of T-cell repertoire restrictions; these features are directly correlated. Thymic output and telomerase activity are not modified by the therapy. Conclusions Abatacept-induced decrease of peripheral T-cell repertoire restrictions can due to a reduced generation of senescent, chronically stimulated CD4+CD28neg T cells. Electronic supplementary material The online version of this article (doi:10.1186/s12967-014-0363-2) contains supplementary material, which is available to authorized users.

Objective To investigate the presence and clinical significance of autoantibodies against the interferon-inducible gene IFI16 in systemic sclerosis (SSc), systemic lupus erythematosus (SLE), and other autoimmune diseases. Methods Immunohistochemical analysis was used to evaluate the expression of IFI16 in skin biopsy specimens obtained from patients with SSc and patients with SLE. Levels of antibodies against IFI16 in sera from 82 patients with SSc and 100 patients with SLE were determined by enzyme-linked immunosorbent assay. Other autoimmune diseases such as primary Sjogren's syndrome (SS), rheumatoid arthritis (RA), chronic urticaria, and hepatitis C virus (HCV) infection were also examined. Results Expression of IFI16 was greatly increased and was ubiquitous in all layers of the epidermis and in the dermal inflammatory infiltrates of lesional skin from both patients with SLE and patients with SSc. Patients with SLE, those with primary SS, and those with SSc exhibited significantly higher anti-IFI16 IgG antibody levels compared with normal controls (for SLE, P < 0.002; for primary SS, P < 0.001; for SSc, P < 0.0005). Anti-IFI16 titers above the ninety-fifth percentile for control subjects were observed in 26% of the patients with SLE, 50% of those with primary SS, and 21% of those with SSc (28% of patients with limited cutaneous SSc [lcSSc] versus 4% of patients with diffuse cutaneous SSc [dcSSc]). In contrast, the prevalence of anti-IFI16 was 4% in patients with RA, 5% in those with chronic urticaria, and 13% in those with HCV infection. Conclusion The results of this study provide evidence that an IFN-inducible gene, IFI16, may be involved in the pathophysiologic mechanisms of connective tissue disorders such as SSc. Moreover, a strict correlation with lcSSc was also demonstrated, thus providing a novel tool in the differential diagnosis of lcSSc from dcSSc.

The objectives of the study were to characterize the production, function and survival of T lymphocytes of children with prolonged fetal exposure to dexamethasone for anti-Ro/SS-A antibodies associated congenital complete heart block. The analysis of thymic function, studied by measuring the level of T-cell receptor excision circles, was performed by real time PCR, the composition of T-cell subpopulation was evaluated by flow cytometry and the T-cell diversity was assayed by heteroduplex analysis. T-cell competence was gauged at two functional levels by determining the proliferation and the number of T-cell divisions and by measuring γ-interferon production after mitogenic stimulation. We observed that the thymic output, distribution of T-cell subsets, thymidine incorporation, number of T-cell divisions, and γ-interferon production were comparable to those of age-matched control. On the contrary, heteroduplex analysis demonstrated the presence of both polyclonal and oligoclonal peripheral T-cell repertoires.In conclusion, the analysis of the T-cell compartment in children with prolonged intrauterine exposure to high dose dexamethasone did not disclose any relevant abnormality, except a restriction of T-cell receptor diversity in some patients.

A case of cutaneous T cell lymphoma associated with mild eosinophilia and rise of IgE levels is reported. A population of CD3-CD4+ cells was observed in the peripheral blood. After activation, these purified CD3-CD4+ cells showed a Th2 pattern of cytokine production, secreting higher levels of IL-5 and IL-4 and lower levels of IFN-gamma compared to the patient's and controls' CD3+CD4+ cells. Moreover, high levels of IL-5 and soluble CD30, a marker of Th2 cell activation, were detected in the patient's serum.

Objective: To analyse clinical efficacy, onset of new autoantibodies or symptoms of autoimmune disease in patients affected by rheumatoid arthritis with anti-Ro/SSA treated with anti-TNFa agents. Methods: Six anti-Ro/SSA positive subjects with RA were studied every six months until 24th month of treatment in order to detect ANA titer (IFI), anti-dsDNA (Farr), anti-cardiolipin and anti-beta2glycoprotein I (ELISA), anti-ENA (CIE). The titre of anti-Ro/SSA were analysed by ELISA. Four patients were diagnosed as overlap RA/SS. Results: Six female patients (mean age 58ys, SD 9.8ys), with long-standing RA (mean 7ys, range 5-22 ys) were treated with anti-TNFa agents for a mean of 31 months (SD: 20.4 m): 4 with Infliximab and 2 with Etanercept. All the patients showed a significant reduction of DAS until 24th month (p

The objective of this study was to analyse clinical and serological associations of anti-Ki antibodies. Thirty-five patients with anti-Ki antibodies, detected by CIE, selected from laboratory routine, were studied. All patients were affected by autoimmune diseases: SLE and pSS were the most frequent diagnoses. The cohort was constituted by 27 female and eight males. Main clinical features were skin involvement (60%), xerophtalmia (48.6%), Raynaud’s phenomenon (43%), photosensitivity (34%), xerostomia (31.4%). CNS involvement was present in four (11.4%) and renal disease in seven cases (20%). ANA, anti-dsDNA and RF were detected in 100%, 60% and 34.5%. In SLE, anti-Ki was detected in 6% of cases, more frequently in males compared to other SLE patients without anti-Ki ( P < 0.004). Nineteen anti-Ki positive patients affected by SLE showed more frequently malar rash and multiple autoantibody specificities compared to 16 anti-Ki positive patients with other diseases ( P = 0.044 and P = 0.0003, respectively). Our study confirms a preferential occurrence of anti-Ki antibodies in patients with sicca and skin involvement. Malar rash and multiple ANA specificities were significantly associated with SLE compared to other diseases in our study. Anti-Ki were detected in 6% of patients with SLE with a significant prevalence in males.

The aim of this study was to evaluate health-related quality of life (HR-QOL) in patients with systemic sclerosis (SSc), to compare it with that of patients with rheumatoid arthritis (RA), and to correlate it with other parameters. HR-QOL was evaluated by the Short Form 36 (SF-36), SSc disease activity and severity by preliminary indexes recently proposed, disability by the Health Assessment Questionnaire (HAQ), and depressive symptoms by the Beck Depression Inventory. HR-QOL perception was not statistically different in patients with SSc and RA, except that patients with diffuse cutaneous involvement had worse scores in the general health and mental health dimensions than patients with RA (p=0.03). Compared with RA, patients with SSc tended to perceive less bodily pain (p=0.06) and have less disability (p=0.04) but to report higher depressive symptom scores (p=0.05). SSc patients' HR-QOL was associated with some disease severity scales (general, kidney and, less significantly, heart), but it was poorly correlated with the other evaluated disease activity and severity indexes. A strong correlation with disability and with depressive symptoms was observed. In conclusion, patients with SSc perceived a reduced HR-QOL similar to that of patients with RA. SF-36 may provide useful information in their evaluation.

The objective of this study was to evaluate the oesophageal dysfunction in patients with "early" systemic sclerosis (SSc), as defined by LeRoy and Medsger, to compare it with that of patients with definite SSc, and to correlate it with other features of the disease. Oesophageal manometry results were retrospectively evaluated in 181 patients classified by the 2001 LeRoy and Medsger criteria and the 1980 American College of Rheumatology (ACR) criteria: group 1: limited SSc: Raynaud's phenomenon plus specific nailfold capillaroscopy abnormalities and/or autoantibodies; group 2: limited cutaneous SSc not satisfying the ACR criteria (lcSSc ACR-); group 3: lcSSc ACR+; group 4: diffuse cutaneous SSc. Peristaltic abnormalities in the oesophageal body were present in 73 of 125 patients with SSc ACR+ (groups 3 and 4) compared with 13 of 56 with SSc ACR- (groups 1 and 2) (p0.0001). They were more severe in patients with more advanced disease (1 vs 2; 1 vs 3; 1 vs 4; 2 vs 4; p0.05) and in patients anti-Scl-70+ than in patients anticentromere positive (p = 0.02). Abnormalities of the lower oesophageal sphincter (LES) were present in 35 of 125 patients with SSc ACR+ and 11 of 56 with SSc ACR- (not statistically different). They were correlated with forced vital capacity (FVC) (LES pressure: p = 0.0005; LES length: p = 0.0004). Abnormalities of the oesophageal body and of the LES were found in 21 and 16% of 46 patients without oesophageal symptoms. Oesophageal manometry can detect abnormalities in a sizeable proportion of patients with "early SSc" not fulfilling the ACR criteria, including asymptomatic patients. The correlation between LES abnormalities and FVC suggests a possible causal relationship between these disease manifestations.

Correlates of immune reconstitution after highly active antiretroviral therapy (HAART) are not completely understood, in particular as far as viro-immunological discordant responses are concerned. HIV-positive patients on stable HAART foror = 1 year were recruited. Viro-immunological responses were categorized according to positive or negative area under the curve (AUC) variations for HIV plasma viral load (pVL) and CD4+ T-cell counts measured at least every 4 months. The following parameters were evaluated: lymphocyte spontaneous apoptosis (LSA), intracellular Bcl-2 expression in both CD4-CD45RA+ and CD4-CD45R0+, IL-7 and IL-15 plasma concentrations, and lymphocyte TRECs levels. Sixty-one patients were enrolled. A significant inverse correlation was found between CD4+ T-cell count and pVL AUC (r = 0.45; p = 0.0003). Patients with pVL response had higher levels of Bcl-2 in CD4-CD45R0+ (mean 65,409 MESF vs. 54,018 MESF; p = 0.089) and higher IL-15 (mean 1.34 pg/mL vs. 1.05 pg/mL; p = 0.069, respectively). Higher LSA and lower TRECs levels were found in viro-immunological non-responder patients with respect to those who had viro-immunological response (mean 24.84% vs. 14.89%; p = 0.01, and mean 17,796 copies/10(6) cells vs. 29,251 copies/10(6) cells; p = 0.68, respectively). Virological suppression may allow Bcl-2 and IL-15 hyperexpression during incomplete immune-reconstitution phase, while more complete immune reconstitution appeared to be marked by both high TRECs and low LSA levels, possibly indicating both central and peripheral CD4+ T-cell repopulations at this stage.

Many of the immunosuppressive drugs that are used during pregnancy can cross the placental barrier and enter the foetal circulation, with a possible impact on the foetal immune system. We have evaluated the immune function of children born from mothers treated with immunosuppressants for connective tissue diseases. A total of nine babies, whose six mothers had been taking cyclosporine A (two), azathioprine (one) and dexamethasone (three) during pregnancy, together with 14 babies from mothers with similar diseases but who had not been treated (controls) were investigated. Complete blood count, IgA, IgG, IgM, IgG subclasses, and lymphocyte subpopulations were determined in all cases. Moreover, serum levels of anti-HBsAg and presence of autoantibodies (ANA, ENA) were also evaluated. Patients were tested at a mean age of 11 months (range, 1-17). Only a minor proportion of our patients displayed low values for age (mainly, IgA and IgG2), but none of the parameters tested resulted significantly different in patients than in controls. All children responded satisfactorily to hepatitis B vaccination. Although our results are preliminary, we conclude that prenatal exposure to immunosuppressive drugs does not have a profound effect to the developing immune system. More data and a longer follow-up are needed to confirm these results.

Rheumatic autoimmune diseases have a higher prevalence in women, particularly during their childbearing age. Due to improved management, an increasing number of patients plan and carry out one or more pregnancies. Therefore, a growing interest is being paid to the possible consequences of maternal disease and associated treatment on the fetus and newborn infant. If maternal disease is characterized by the presence of IgG isotype autoantibodies, these can cross the placenta with possible antibody-mediated damage to the fetus. This is typically the case of the so called neonatal lupus erythematosus (NLE); a similar mechanism has been shown in infants of patients with immune thrombocytopenic purpura (ITP) and, less frequently, in those from mothers with antiphospholipid syndrome (APS). Indeed, this last condition is often responsible for placental, rather than neonatal, pathology. In addition, immunosuppressive and other drugs administered to the mothers during pregnancy and lactation might affect the fetal and neonatal immune system development. Finally, mothers disease and/or treatment could be related to neuropsychological alteration reported in some of their children.

Interaction between the B cell glycoprotein CD40 and its ligand (CD40L), expressed by activated T cells, is of crucial importance in the generation of specific antibody response, which is impaired in HIV+ individuals. We studied the expression of CD40L by lymphocytes activated with PMA plus ionomycin in 17 HIV+ individuals and 12 healthy donors. In HIV+ individuals, the percentage of cells expressing CD40L was lower than that in the controls (22.6 ± 14.7 vs 40.1 ± 12.0; P < 0.002) and clearly correlated with that of CD4+ peripheral blood lymphocytes (r = 0.83; P < 0.001); therefore, the reduced CD40L expression might he explained by the decrease of the CD4+ cells. In fact, the expression of CD40L by purified CD4+ cells was comparable in individuals with and without HIV infection. These data indicate that the ability of CD4+ cells from HIV individuals to express CD40L is not impaired, at least after optimal stimulation in vitro.

To assess predictive factors of long-term immune restoration in patients who started protease inhibitor (PI)-based HAART and experienced virological rebound after initial complete success.A retrospective longitudinal analysis of all HIV-infected patients who started their first PI-based HAART and reached viral load below 500 copies/mL was carried out in a large academic center in Italy. Patients were classified either as complete virologic responder (CR) or rebounders (REB) when confirmed plasma viremia was detected thereafter. Immunological outcome was the area under the curve (AUC) of the absolute CD4+ cell count change since the 8th month after treatment initiation (CD4+ T-cell AUC). Association between baseline characteristics, virological outcome, and CD4+ T-cell AUC was assessed by univariate and multivariate analysis.There were 374 patients who were included in the study. Mean follow-up was 30.2 months. There were 226/374 patients (60.4%) who remained CR while 148/374 (39.6%) presented at least one rebound (REB). Among REB patients, complete viral suppression was regained in 15/42 (35.7%) and 50/106 (47.1%) patients who underwent therapy changes or not, respectively. When multiple linear regression was carried out, previous nucleoside reverse transcriptase inhibitor (NRTI) experience and baseline CD4+ cell count below 350 cells/muL did not impair long-term immune restoration. The occurrence of rebound, its duration (18 months), and its magnitude (peak of viral load10,000 copies/mL) were independent negative prognostic factors.The occurrence of viral rebound is independently associated with significantly impaired long-term immunological restoration. The magnitude of viral rebound (10,000 copies/mL) and its duration (18 months) may be useful to identify those rebounding patients who may still profit from maintaining the current failing therapy if a more aggressive approach may be expected to be deleterious for tolerability reasons or lack of options.

Patients with systemic sclerosis (SSc) may have arterial and venous thrombosis and, according to the limited and controversial data available, may have an increased incidence of pregnancy losses.1 These observations preceded the definition of antiphospholipid syndrome (APS) as the association of thrombosis and pregnancy loss with antiphospholipid antibodies (aPL), and did not focus on patients with SSc. However, the association of thrombosis and aPL, detected as lupus anticoagulant (LAC) and/or anticardiolipin antibodies (aCL), although rare, was described in SSc,2 supporting the possible existence of a “secondary” APS in SSc.3 In view of the fact that most aCL are directed to β2 glycoprotein I (aβ2GPI),4 the possibility that patients with APS may be negative for aCL, but positive for aβ2GPI,5 and considering the scarcity …

The case of a woman affected by an overlap syndrome systemic lupus erythematosus/polymyositis (PM), who presented with active myositis at the start of the pregnancy, is reported. Therapy with cyclosporin, corticosteroids, hydroxychloroquine and high-dose intravenous immunoglobulin induced a progressive remission of clinical and laboratory signs of myositis. At 33 weeks of gestation, after a premature pre-term rupture of membrane, a male child was delivered. Although premature, and small for gestational age, he had a normal growth, and did not show any clinical sign suggestive of immune deficiency. Lymphocyte phenotypical and functional studies, as well as response to vaccination, were also normal.

Iloprost is useful in the short-term treatment of severe Raynaud's phenomenon and ischaemic ulcers in patients with systemic sclerosis (SSc), but its long-term effects are largely unknown. The aim of this study was to report long-term outcome (median follow-up 36 months) in a prospective observational study of a cohort of 30 consecutive patients with SSc who received iloprost therapy with maintenance infusions every 3 weeks after an initial cycle of 5 consecutive days. At the end of the observation, compared to the pretreatment point, we observed complete healing of digital ulcers in 19/21 patients (90%), a decrease of the Raynaud's phenomenon visual analogue score from 10/10 (25th-75th percentile 7-10) to 5/10 (4-6.75) ( P0.001) and, in patients with diffuse cutaneous involvement, of the modified Rodnan skin thickness score from 25.5 (16.5-31.5) to 16 (13.5-20) ( P = 0.02), minimal improvement of the Health Assessment Questionnaire from 0.87 (0.68-1.37) to 0.75 (0.62-1.25), which was neither statistically nor clinically significant. The forced vital capacity was not significantly changed, but the diffusion capacity corrected for the alveolar volume decreased from 71% (54-76.7) of the expected value to 62% (51.5-71) ( P = 0.02). In one patient with limited SSc a positive effect on pulmonary hypertension was observed. Six patients, after a median of 25 months of treatment and healing of digital ulcers, discontinued the therapy; after a median of 10 months ulcers did not recur in five of these six. Other reasons for discontinuation were: tolerability (1), disease progression (normotensive renal crisis: 1), and death due to intracranial haemorrhage (1). This same patient had previously suffered a central retinal vein thrombosis. In conclusion, long-term therapy with iloprost in patients with SSc has a durable effectiveness on ischaemic ulcers and Raynaud's phenomenon, but it is not possible to conclude that the natural history of the disease was modified.

Background Through costimulation blockade, Abatacept (ABA) may down-modulate the immune responses of B lymphocytes in Rheumatoid Arthritis (RA). We previously showed that ABA reduces the serum levels of different classes of anti-cyclic citrullinated peptide (anti-CCP), and rheumatoid factor (RF), and limits the differentiation of B lymphocytes into post-switch memory cells (1). Free light chains (FLC) are produced by B cells, plasmablasts and plasmacells and raised levels correlate with disease activity in RA. Objectives To evaluate the effect of the ABA on serum levels of immunoglobulins (Ig) and FLC. To evaluate the baseline levels of these parameters as predictors of response to ABA. Methods 30 RA patients (pts) (26 female; median-age: 53 years [IQR: 44-60] treated for at least 6 months with ABA and 24 healthy controls (HC; 18 female; age: 39 [34-46]) were evaluated. Serum Ig levels were measured by a nephelometric-immunoassay (Siemens Healthcare Diagnostics Products GmbH). Reference ranges were derived by a consensus group based on the standardization against the calibrated reference material CRM 470. Serum FLC levels were measured by a latex-enhanced immunoassay (The Binding Site, Birmingham, UK). Reference ranges include 100% of a population of 282 HC. Clinical disease activity was evaluated with the DAS28 (based on CRP). Results At baseline (T0), RA pts had higher serum levels of IgM (p Conclusions ABA therapy induced a trend toward normalization of serum levels of total Ig of different classes and of FLC. FLC reduction was significant in pts achieving clinical remission after ABA therapy, but not in those who did not. In our evaluation, the decrease of serum free λ chains was correlated with clinical improvement, and their baseline levels appeared to be associated with clinical response to ABA. References Scarsi M et al; Ann Rheum Dis 2013;72(Suppl3):623 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5465

Background: UVA1 (340 to 400 nm) was found to be effective in the treatment of early-stage mycosis fungoides (MF). Objective: The purpose of this study was to assess the efficacy of UVA1 phototherapy for widespread plaque-type, nodular, and erythrodermic MF. Methods: Thirteen patients (8 with stage IB, 4 with IIB, and 1 with III MF) received 100 J/cm 2 UVA1 daily until remission. Four patients also had lesions inaccessible by UVA1 that were considered control lesions. Immunocytologic studies of skin infiltrates and circulating T cells were done before and after the therapy. Results: Eleven patients showed complete clinical and histologic responses. Two patients had a partial improvement. Unirradiated control lesions never improved. Serious short-term side effects were not recorded. Circulating CD4 + /CD45RO + and CD4 + /CD95 + lymphocytes were significantly reduced by the therapy. Conclusion: UVA1 therapy is an effective and well-tolerated treatment for advanced MF. The therapeutic relevance of the effects on circulating lymphocytes remains to be established because lesions in nonexposed cutaneous areas did not respond.

The mechanism causing the increasing number of peripheral T cells after highly active antiretroviral therapy (HAART) is still unclear. The bcl-2 oncogene prevents spontaneous apoptosis (SA) in lymphocytes. Spontaneous apoptosis could be a determinant of HIV immunodeficiency and can be reversed by HAART including protease inhibitors (PI-HAART). The aims of our study were to measure Bcl-2 protein expression in memory (CD45RO+) and naive (CD45RO-) CD4+ and CD8+ T lymphocytes of HIV+ patients and to correlate it with efficacy of PI-HAART. Forty-nine HIV+ patients (cases) and 26 HIV- individuals (controls) were evaluated. Patients receiving PI-HAART, and who had undetectable HIV plasma viral load (VL-, n = 21), had higher levels of Bcl-2 than did VL+ patients (n = 28), both in CD4+ cells (p0.0001) and in CD8+ cells (p0.001). VL+ patients had lower Bcl-2 levels than did controls in CD8+ cells (p = 0.02), but not in CD4+ cells (p0.05). Interestingly, VL- patients had higher Bcl-2 expression than did controls both in CD4+ cells (p0.0001) and in CD8+ cells (p = 0.03). In a subcohort of the same patients, Bcl-2 was significantly higher in VL- patients (n = 10) than in controls (n = 12), both in naive CD4+ cells (p0.0001) and in naive CD8+ cells (p = 0.01). Naive CD4+ cells had higher Bcl-2 expression in VL- than in VL+ patients (p = 0.01). In a subsequent longitudinal study of nine HIV patients, naive CD4+ cells increased after effective PI-HAART (p = 0.03), which paralleled an increase in Bcl-2 expression in the same cells (p = 0.02). In conclusion, upregulation of bcl-2 could be a mechanism of immune reconstitution of naive CD4+ T cells induced by PI-HAART.