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The complement system is composed of a set of plasma or membrane proteins. Complement protein deficiencies can be inherited or acquired, through the presence of autoantibodies or through consumption. We evaluated the analytical performance of the Optilite® analyser for the determination of the C3 and C4 levels and for the evaluation of the total complement activity. The intra- and inter-series CVs were evaluated and have showed satisfactory results, the concordances with analysers currently used in the laboratory (BNII® and BCT®, Siemens) are very good, as is the agreement between the serum and plasma samples. We also determined the reference values for the different parameters tested in view of a routine use of Optilite® analyser in the laboratory.

Background Down syndrome (DS) is the most common form of viable chromosomal abnormality. DS is associated with recurrent infections, auto-immunity and malignancies in children. Little is known about immunity and infections in DS at adulthood. Methods We studied two separate group of adults (> 18 years old) with DS in a single referral tertiary center (Strasbourg University Hospital). The first group included 37 ambulatory DS patients between November 2014 and May 2017. We analyzed exhaustive serological and immunobiological parameters, at one point, together with the prevalence of infections, autoimmune manifestations and malignancies. The second group included 64 hospitalized patients (138 stays) in the same center, between January 2005 and December 2016. Results One hundred and one adult patients with DS were included. Unlike children and despite a global lymphopenia, adults with DS underwent few infections in our ambulatory group. They did not experience any malignancy and, apart from hypothyroidism, they presented only occasional autoimmune manifestations. Hospitalized DS patients were older than ambulatory ones (median age 47 years (18–73) vs. 27 (18–52), p

Resume Objectif Decrire la signification clinique des anticorps anti-SG2NA egalement appeles anti-pseudo-PCNA de type 1 ( proliferating cell nuclear antigen auto-antibodies ) qui sont des anticorps antinucleaires (ANA) rares detectes par immunofluorescence indirecte (IFI) sur cellules proliferatives HEp-2 en phase S/G2. Par analogie avec les anticorps anti-PCNA, ils sont associes au lupus erythemateux systemique (LES), aux cancers ou aux pathologies virales. Methodes Entre mai 2006 et fevrier 2013, 16 827 patients ont eu une recherche d’ANA positive au laboratoire d’immunologie de Strasbourg (France). Nous avons analyse de facon retrospective les donnees cliniques et biologiques des 126 patients ayant un aspect de fluorescence de type anti-pseudo-PCNA de type 1. Resultats La prevalence des anticorps anti-pseudo-PCNA de type 1 etait de 0,75 % parmi les patients ayant une recherche d’ANA positive. L’âge median etait de 56,9 ans (deviation standard [DS] 13,4 ans), avec un sex-ratio de 1,9 en faveur des femmes. En comparaison avec les patients porteurs d’anticorps antinucleaires, significativement plus de patients etaient hospitalises dans le service d’oncologie et hematologie de l’hopital (23 % vs 6,3 %, p + ( p −6 ). Finalement, la presence de l’anticorps anti-pseudo-PCNA de type 1 etait associee dans 30 cas sur 126 avec d’autres auto-anticorps (en particulier diriges contre les proteines du cycle cellulaire), suggerant un mecanisme plus general de rupture de tolerance lymphocytaire B envers les auto-antigenes. Conclusion A la lumiere de nos resultats, l’exploration des tumeurs devrait etre recommandee pour les patients ayant des Ac anti-pseudo-PCNA de type 1. Aucune association de ces auto-anticorps avec le lupus n’a pu etre montree.

The most common cause of acute renal failure in systemic sclerosis patients is scleroderma renal crisis but other etiologies have to be considered such as another autoimmune disease. We report the case of a 60-year-old male admitted to our hospital with a renal failure. His medical history included a diagnosis of systemic sclerosis 6 months ago. Antinuclear antibodies were positive at a titer of 1:1280 with positive anti-Scl-70 and anti-myeloperoxidase (34 U/mL) antibodies. Scleroderma renal crisis was suspected. However, antineutrophil cytoplasmic antibody–associated vasculitis could not be excluded and a renal biopsy was performed. Histopathology revealed crescentic glomerulonephritis and rupture of Bowman’s capsule. Anti-glomerular basement membrane antibodies were detected in serum and the diagnosis of Goodpasture syndrome was confirmed by kidney’s immunofluorescence analysis showing typical deposits. Only three other cases of systemic sclerosis associated with Goodpasture syndrome have been reported in the literature. Also, rapidly progressive glomerulonephritis with positivity of both antineutrophil cytoplasmic antibody and anti-glomerular basement membrane antibodies has been described. Several studies have suggested that antineutrophil cytoplasmic antibody positivity occurs first leading to damages of the glomerular basement membrane, to the release of alpha-3 NC1 antigen, and ultimately to anti-glomerular basement membrane antibody production. Although rare, antineutrophil cytoplasmic antibody–associated vasculitis and Goodpasture syndrome should be searched for in systemic sclerosis patients with acute renal failure.

Greater accuracy in clinical descriptions combined with advances in muscle histology and immunology have established that inflammatory myopathies (IMs), similarly to inflammatory rheumatic diseases, constitute a highly heterogeneous group of conditions. The topographic distribution, severity, and tempo of onset of the myopathy vary widely, and the histological findings distinguish at least five different profiles, which may reflect different pathophysiological processes. Most IMs are connective tissue diseases that can affect multiple organs, among which the most common targets are the skin, joints, and lungs. The extramuscular manifestations may antedate the muscular involvement and should therefore suggest a diagnosis of IM even in the absence of obvious muscle disease. About 20 different autoantibodies have been identified in patients with IM. Some are mutually exclusive and associated with specific combinations of clinical manifestations. Following the model of antisynthetase syndrome, about 10 syndromes associated with autoantibodies specific of IM have been identified. Thus, polymyositis is now emerging as a rare entity that is often mistaken for more recently described patterns of IM. No consensus exists to date about the classification of IMs. Nevertheless, the clinical manifestations, autoantibody profile, and muscle histology can be used to distinguish patient subgroups with fairly homogeneous patterns of complications, treatment responses, and outcomes. These subgroups are also characterized by specific genetic and environmental factors. The advances made in the nosology of IMs have benefited the diagnosis, personalization of treatment strategies, and understanding of pathophysiological mechanisms. They can be expected to assist in the development of specific treatments.

International audience; Anti-signal recognition particle (SRP) antibodies are important serological markers for the diagnosis and the prognosis of idiopathic inflammatory myopathy (IIM), especially to distinguish immune-mediated necrotizing myopathy (IMNM). This study was set up to investigate the phenotype associated with anti-SRP antibodies and to evaluate the methods for detecting these antibodies. Clinical and biological data were retrospectively obtained from 60 adult patients with anti-SRP antibodies detected by a dot immunoassay from 12 centers. Thirty-six (60 %) out of these 60 patients suffered from an IIM, and among them, 21 patients were diagnosed as IMNM. Among patients with a definite IIM, proximal weakness and myalgia were prominent symptoms at the time of diagnosis. Only few patients displayed severe extra-muscular symptoms such as cardiac involvement or severe myositis. Mean creatine kinase levels were high for all patients except for two of them. When testing by indirect immunofluorescence (IIF) on HEp2 cells, the fraction of patients displaying the typical anti-SRP fine speckled staining of the cytoplasm was higher in patients with IIM (30/36) (83 %) than in patients with non-IIM (3/24) (12.5 %) (p

The inflammatory myopathies are a group of quite proteiform, systemic auto-immune diseases which include polymyositis, dermatomyositis and inclusion body myopathies. To facilitate the diagnosis, classification criteria (Bohan and Peter, 1975) have been proposed, based essentially on clinical criteria. In addition, over the past fifteen years, auto-antibodies characterizing certain forms of inflammatory myopathy have been identified. One distinguishes schematically: auto-antibodies specific for myositis and auto-antibodies sometimes associated with myositis. Concerning the myositis specific auto-antibodies (MSA), schematically there are a dozen specificities which are classed according to the cellular distribution of the auto-antigen. The most characteristic are certainly the auto-antibodies directed against cytoplasmic antigens: the anti-tRNA synthetases (anti-Jo-1 (PL-1), anti-PL-7, PL-12, EJ, OJ, JS, KS, ZO, YRS), anti-SRP (signal recognition particle), anti-Mas and anti-KJ, anti-Fer (eEF1), anti-Wa and anti-CADM p140. Other auto-antibodies are directed against nuclear auto-antigens: the anti-Mi-2, anti-PMS (PMS1, PMS2) and related antibodies (MLH1, DNA PKcs…), anti-56 kDa, anti-MJ (NXP-2), anti-SAE and anti-p155/p140 (TIF-1γ). Concerning the auto-antibodies sometimes associated with myositis (myositis associated auto-antibodies or MAA), they can also be observed in other auto-immune diseases. These auto-antibodies are directed against nuclear or nucleolar auto-antigens: the anti-PM-Scl, anti-Ku, anti-RNP (U1 RNP and U2 RNP, U4/U6 RNP and U5 RNP), anti-Ro 52 kDa and more rarely, anti-Ro 60 kDa and anti-La. The auto-antibodies related to myositis are biological tools which are of interest in two main ways. They have allowed us to sort out the nosology of these inflammatory myopathies, in particular by defining anti-tRNA synthetase syndrome. It now remains to determine how they might be employed to complement the classical clinico-biological diagnostic criteria. In this perspective, it will be indispensable first of all to diffuse and standardize the methods of detection. The latter are at the moment very heterogeneous as they use techniques and above all antigenic preparations which are extremely diverse. These antibodies are also very interesting "physiopathological" tools to try to better understand myositis. The example of anti-tRNA synthetases is a particularly original model of auto-immunization, which allows one to establish a link between an initial, probably poorly specific muscular lesion and the appearance of auto-antibodies which maintain and aggravate the muscular disease.

New treatment strategies require that rheumatoid arthritis (RA) be diagnosed as early as possible. New diagnostic markers were required, because rheumatoid factors (RF), until now criteria for classification of RA, are not sufficiently specific and sometimes appear late, thereby limiting their diagnostic usefulness. The objective of this review is to describe the current state of knowledge and more particularly to analyze the interest of new RA autoanti-bodies, called anti-peptide or anti-citrullinated protein anti-bodies (ACPA). Other autoanti-bodies have been described, including anti-Sa, anti-alpha enolase, and anti-calpastatin autoanti-bodies. Nonetheless, their diagnostic value remains limited compared to ACPA. Accordingly, in daily practice today, the only autoanti-bodies that must be tested for to diagnose RA are the ACPAs and RFs. The discovery of ACPA (initially called anti-keratin and anti-perinuclear anti-bodies) was a major step forward for the laboratory diagnosis of RA. The tests most often used routinely areenzyme-linked immunosorbent assays(ELISA) with cyclic citrullinated peptides, whence the name anti-CCP autoanti-bodies. Accordingly, the two terms ACPA and anti-CCP can both be used. The diagnostic value, in particular their specificity, is on the order of 95%, regardless of the method of identification. These markers are very useful and are often present earlier than RF. These ACPA also have prognostic value because they are associated with more aggressive forms of RA. On the other hand, their value over time, in particular, their fluctuation as a function of treatment, is more controversial. In practice, it is recommended to test for both RF and ACPA in a diagnostic work-up for early RA. During follow-up, the value of testing for these autoanti-bodies has not been demonstrated, but additional studies are still necessary with the anti-CCP autoanti-bodies and the new anti-citrullinated protein autoanti-bodies.

Our objective was to evaluate the prevalence of autoantibodies to cyclic citrullinated peptides (anti-CCP aAbs) in a cohort of patients with a variety of inflammatory or non-inflammatory rheumatic diseases other than rheumatoid arthritis (RA). Six hundred and nine serum samples were tested for anti-CCP aAbs and for rheumatoid factor (RF) using enzyme-linked immunosorbent assays and immunonephelometry. The prevalence of anti-CCP aAbs and RF reached 10% and 25%, respectively, using the positive cutoff value suggested by the manufacturers. Using a higher cutoff value (50 U/ml) for both aAbs, the prevalence was lower with 6% and 16%, respectively. The specificity of both markers for RA thus reached 94% and 84%, respectively. Anti-CCP aAbs were found to be elevated in inflammatory and also in non-inflammatory rheumatic diseases in the same proportion. Clinical data obtained for 36 positive patients showed that 17% developed RA within 5 years. In conclusion, anti-CCP aAbs are clearly more specific than RF for RA. Follow-up of anti-CCP aAbs-positive patients with inflammatory or non-inflammatory rheumatic diseases other than RA could be important considering the predictive value of these aAbs for the development of RA.

OBJECTIVE Describe the clinical significance of anti-SG2NA antibodies also called anti-pseudo-PCNA type 1 (proliferating cell nuclear antigen auto-antibodies) which are rare antinuclear antibodies (ANAs) staining distinctly S/G2 proliferative HEp-2 cells by indirect immunofluorescence. By analogy with anti-PCNA antibodies, they have been suspected to be associated with systemic lupus erythematosus (SLE), cancers or viral diseases. METHODS From May 2006 to February 2013, 16,827 patients were tested positive for ANAs in the Laboratory of Immunology, Strasbourg, France. We retrospectively analyzed clinical and biological data from 126 patients with anti-pseudo-PCNA type 1 antibodies. RESULTS There was a 0.75% prevalence of anti-pseudo-PCNA type 1 Abs among ANAs(+) patients. Median age was 56.9 years (standard deviation [SD] 13.4 years) with a sex ratio female/male of 1.9. Compared to ANAs(+) patients, many more patients have been hospitalized in the Oncology and Hematology Department (23% vs. 6.3%, P

The myositides are systemic autoimmune conditions of which the most important are polymyositis, dermatomyositis, and inclusion body myositis. In addition to the classic clinical diagnostic criteria, myositis-specific autoantibodies were identified about 15 years ago. Among the dozen or so myositis-specific autoantibodies reported to date, the most characteristic are directed against cytoplasmic antigens, such as tRNA synthetase (Jo-1 or PL-1, PL-7, PL-12, EJ, OJ, JS, and KS), signal-recognition particle (SRP), Mas, KJ, Fer (eEF1), and Wa. Antibodies to nuclear antigens include anti-Mi-2, anti-PMS (PMS1, and PMS2), and related antibodies (MLH1, DNA protein kinase catalytic subunit (DNA PKCS)...), and anti-56 kDa. Myositis-associated antibodies are not specific but may be found in patients with myositis. They are directed to nuclear or nucleolar antigens such as PM-Scl, Ku, RNP (U1-RNP and U2-RNP, U4/U6-RNP, and U5-RNP), Ro 52 kDa and, more rarely, Ro 60 kDa and La. Myositis-specific antibodies have proved useful on two fronts. They have improved the diagnosis of myositis by leading to the identification of characteristic clinical patterns, such as anti-synthetase syndrome. The place of autoantibodies alongside classic clinical and laboratory criteria remains to be determined, however. First, standardized assays will have to be developed to replace current detection methods, which use widely variable techniques and antigen preparations. Myositis-specific antibodies have also shed light on the pathogenesis of myositis. For instance, the development of antibodies to tRNA synthetases constitutes an original autoimmunity model that shows how muscle damage, probably of a nonspecific nature, can lead to the production of autoantibodies that perpetuate and aggravate the muscle lesions.

Resume Les myopathies inflammatoires sont un groupe de maladies systemiques auto-immunes qui comprennent les polymyosites, les dermatomyosites et les myopathies a inclusion. Pour faciliter le diagnostic, les criteres classiques sont fondes sur des criteres cliniques. En complement, depuis une quinzaine d'annees des autoanticorps caracterisant certaines formes de myopathies inflammatoires ont ete identifies. Les autoanticorps specifiques de ces myosites ont une douzaine de specificites que l'on classe en fonction de la repartition cellulaire de l'autoantigene ; les plus caracteristiques sont ceux diriges contre des antigenes cytoplasmiques : les anti-ARNt synthetases (anti-Jo-1 (PL-1), anti-PL-7, PL-12, EJ, OJ, JS, KS), les anti-SRP, les anti-Mas et les anti-KJ, anti-Fer (eEF1), anti-Wa ; d'autres autoanticorps sont diriges contre des autoantigenes nucleaires : les anti-Mi-2, les anti-PMS (PMS1, PMS2) et apparentes (MLH1, DNA PKcs…) et les anti-56 kDa. De facon specifique, les autoanticorps parfois associes a ces myosites observees aussi dans d'autres maladies auto-immunes. Ces autoanticorps sont diriges contre des autoantigenes nucleaires ou nucleolaires : les anti-PM-Scl, les anti-Ku, les anti-RNP (U1 RNP et U2 RNP, U4/U6 RNP et U5 RNP et les anti-Ro 52 kDa et plus rarement, anti-Ro 60 kDa et anti-La. Les autoanticorps associes aux myosites sont des outils biologiques avec deux interets majeurs. Ils ont permis de demembrer la nosologie de ces myopathies inflammatoires, en particulier en isolant le syndrome des anti-ARNt synthetases. Reste a savoir comment ils pourraient etre utilises en complement des criteres diagnostiques clinicobiologiques classiques. Dans cette perspective, il est indispensable, dans un premier temps de diffuser et standardiser les methodes de detection qui sont pour l'instant tres heterogenes car elles utilisent des techniques et surtout des preparations antigeniques extremement diverses. Ils sont aussi des outils pour essayer de mieux comprendre les myosites. L'exemple des anti-ARNt synthetases est un modele d'auto-immunisation particulierement original, permettant de faire le lien entre une lesion musculaire initiale probablement peu specifique et l'apparition d'autoanticorps venant entretenir et aggraver les lesions musculaires.

Introduction: Deficiencies in components of the classical pathway of complement activation are strong risk factors for lupus erythematosus (LE).Yet, it has not been addressed whether the conventional measurements of the serum hemolytic CH50 activity and antigenic concentrations of C3 and C4 are sufficient to asses a deficiency in C4A, C4B or C2 components, the most common deficiencies associated with LE. Patients and methods: In a retrospective series, we performed complement analyses in 35 patients with LE who were systematically screened for a complement deficiency. The majority of patients had cutaneous LE with mild systemic involvement and no complement consumption. Of 25 patients (72%) with complement deficiency we found 13 with a partial C4A deficiency, 2 with a complete C4A deficiency, 6 with a partial C4B deficiency, 2 with a complete C4B deficiency and 2 with a combined partial C2 and C4A deficiency. Results: The total complement activity (CH50) was decreased in only one out of two patients with complete C4B deficiency. CH50 level was found to be low–normal (35–38 U/ml− 1) in one patient with partial C4B deficiency, one patient with complete C4B deficiency and both patients with combined partial C4A and C2 deficiency. Total C4 levels were normal in 9 out of 13 the patients with a partial C4A deficiency and in 2 out of 6 patients with a complete C4B deficiency. The antigenic concentration of C3 was low in only 1 patients with a complete C4B deficiency and within the normal range in all the others patients. Overall, 50% of the patients had normal or elevated C3, C4, and CH50 levels. Discussion: This study emphasizes that the usual measurements of CH50, C3 and C4 levels are not adequate to detect a C4 and/or C2 deficiency in patients with LE. In epidemiologic or investigative studies addressing the prevalence of complement deficiency, more elaborated diagnostic tests, such as C4 protein allotyping, C2 level measurement and genetic screening for type I C2 deficiency should also be performed.

B cell activation may result in an increased secretion of immunoglobulin free light chains (FLCs) in autoimmune diseases.To analyse serum FLC levels in patients with rheumatoid arthritis and in those with primary Sjögren's syndrome (pSS).Blood samples were collected from 80 healthy blood donors, 50 patients with rheumatoid arthritis and 139 patients with pSS. Serum FLC level was measured using a new quantitative immunoassay.Mean (standard error (SE)) serum kappa and lambda FLC levels were significantly higher in patients with rheumatoid arthritis and in those with pSS than in controls (kappa : 18.9 (1.1) and 16.3 (1.4) v 10.5 (0.4) mg/l, p0.001 and p = 0.001, respectively; lambda: 16.7 (1.2) and 19.3 (1.5) v 11.6 (0.6) mg/l, p0.001 for both). 18 (36%) patients with rheumatoid arthritis and 31 (22.3%) patients with pSS had abnormal serum FLC levels (increased kappa or lambda levels and abnormal ratio of kappa:lambda). Serum kappa and lambda levels were correlated with other B cell activation markers in both diseases. FLC levels increased with disease activity, because, unlike total gammaglobulin and immunoglobulin G levels, they were significantly correlated with Disease Activity Score 28 in patients with rheumatoid arthritis (p = 0.004 for kappa, p = 0.05 for lambda) and with extraglandular involvement in pSS (p = 0.01 for kappa, p = 0.04 for lambda).FLC levels are increased and correlate with disease activity in patients with rheumatoid arthritis and in those with pSS, two diseases in which increased risk of lymphoma could result from persistent B cell activation and disease activity. Further studies are required to determine whether FLC assessment could represent a relevant biomarker for response to treatment (especially B cell depletion) and for the risk of lymphoma in autoimmune diseases.

Objective. There is no effective treatment for patients with primary Sjogren's syndrome (SS). Since tumor necrosis factor α (TNFα) could be a key element in the pathogenesis of primary SS, we conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate the effect of infliximab in primary SS. Methods. A total of 103 patients with primary SS were randomly assigned to receive infliximab infusions (5 mg/kg) or placebo at weeks 0, 2, and 6 and were followed up for 22 weeks. All patients fulfilled the new American-European Consensus Group criteria for SS and had active disease as assessed by values >50 mm on 2 of 3 visual analog scales (VAS) (0-100 mm) that evaluated joint pain, fatigue, and buccal, ocular, skin, vaginal, or bronchial dryness. A favorable overall response was defined as the patient having ≥30% improvement between weeks 0 and 10 in the values on 2 of the 3 VAS. Secondary end points were values on each VAS separately, the number of tender and swollen joints, the basal salivary flow rate, results of the Schirmer test for lacrimal gland function, the focus score on labial salivary gland biopsy, the level of C-reactive protein, and the erythrocyte sedimentation rate evaluated at weeks 0, 10, and 22, as well as quality of life evaluated by use of the generic Short Form 36 questionnaire administered at weeks 0, 10, and 22. Results. At week 10, 26.5% of patients receiving placebo and 27.8% of patients treated with infliximab had a favorable overall response (P = 0.89), and at week 22, 20.4% of the placebo group and 16.7% of the infliximab group had a favorable response (P = 0.62). In addition, the 2 groups did not differ in any of the secondary end points over the 22 weeks of the trial. Severe adverse events reported in the infliximab group did not differ from those observed in previous studies. Conclusion. This randomized, double-blind, placebo-controlled study of an anti-TNF agent did not show any evidence of efficacy of infliximab in primary SS.

Antisynthetase syndrome (ASS) is a rare systemic inflammatory disease associated with myositis, polyarthritis, interstitial lung disease, Raynaud’s phenomenon and the presence of auto-antibodies targeting aminoacyl-tRNA-synthetase enzymes [1]. We recently diagnosed amyloidosis in one patient with ASS. To better characterize this unusual association, we retrospectively assessed amyloidosis frequency in a monocentric cohort of 30 patients with ASS and performed a systematic review of the literature. The charts of the patients followed at Strasbourg University Hospital who serum tested positive for aminoacyltRNA-synthetase antibody using immunodot (Euroimmun, Germany and/or D-Tek, Belgium) between 1994 and 2011 were systematically reviewed. Patients were diagnosed with ASS if they had myositis according to Bohan and Peter criteria [2] and/or interstitial lung disease (ILD) diagnosed on chest computed tomography (CT). Diagnosis of amyloidosis was made if extracellular deposit stained with Congo Red was demonstrated in a biopsy. Monoclonal mouse antibodies against human AA protein, polyclonal rabbit antibodies against κ and λ light chains used for amyloidosis typing were purchased from Dako, Denmark. Thirty-three patients tested positive for aminoacyl-tRNAsynthetase antibodies. Charts were available for 30 patients who all had ASS. Patients tested positive for PL-7 (n = 4), PL-12 (n = 4), Jo-1 (n = 22) antibodies. Median follow-up was 6 years (range 1 month–16 years). Amyloidosis occurred in two patients with ASS.

The usefulness of immumoglobulin (Ig) A antibodies to gliadin (AGA-IgA) in addition to IgA anti-endomysium and tissue transglutaminase antibodies was evaluated in 4122 children younger than 2 years with a suspicion of coeliac disease (CD). Eight percent (312/4122) displayed IgA anti-endomysium and/or IgA anti-tissue transglutaminase, whereas 2.1% (85/4122) displayed only AGA-IgA. Clinical data were obtained for 62 of 85 children with isolated AGA-IgA, and 33 children underwent a duodenal biopsy. Histologically proven CD was established for 5 patients, whereas 57 children were diagnosed to experience other diseases. The systematic detection of AGA-IgA using native gliadin conferred no additional diagnostic benefit for the diagnosis of CD in children younger than 2 years of age, except for rare cases.

Pendant longtemps les analyses d’auto-immunite ont ete realisees de facon manuelle, en utilisant des techniques parfois artisanales. Plusieurs facteurs conduisent aujourd’hui les laboratoires a automatiser ces examens.

Background The presence of anti-Ku antibody is associated with a wide variety of clinical manifestations and various outcomes. Objectives We attended to refine anti-Ku associated disease by identifying subgroups of Ku-positive patients with similar clinico-biological features and prognosis. Methods We reviewed clinical, biological characteristics, diagnosis and management of 24 patients with anti-Ku antibody. A multidimensional analyze was performed to highlight homogeneous groups of patients. We search for features that most strongly match with each group. Results Anti-Ku positive patients had joint (n=19), muscle (n=10), lung (n=9), skin (n=9), renal (n=9), hematological (n=8), thrombotic (n=6), serous (n=6) and gastrointestinal (n=4) involvements. Associated antibodies were anti-DNA (n=7), -SSA (n=6), -RNP (n=4), -SSB (n=1), -Sm (n=1), rheumatoid factor (n=9) and ACPA (n=4). Diagnosis were overlap myositis (n=9), lupus erythematosus (n=8), Sjogren9s syndrome (n=7), rheumatoid arthritis (n=3), undifferentiated connective (n=2), and systemic sclerosis (n=2). Many patients had criteria for several connectivite tissue diseases. Managements were heterogeneous. Multidimensional analyze identified to groups that were mutually exclusive: (i) Patients characterized by scleroderma-like skin disease,myositis and ILD,frequently treated with high dose of corticosteroids, (ii) Patients with lupus like skin disease, haematological and renal involvements frequently receiving cyclophosphamide and mycophenolate mofetil. Anti-DNA antibody, absent in the first group and present in the second was the most powerful criteria to distinguish these two subsets of the anti-ku associated disease (sensibility 93% and a sensitivity of 86%). Conclusions Anti-DNA status distinguishes patients at risk of muscle and lung involvement (anti-DNA negative) from patients at risk of renal involvement (anti-DNA positive). These data significantly refine anti-Ku associated disease and help to personalize monitoring and care of the patients. Disclosure of Interest None declared

En pratique courante, le diagnostic immunologique des sclerodermies systemiques repose sur la recherche des anticorps anti-nucleaires par immunofluorescence indirecte sur cellules HEp2.

Leflunomide can have adverse effects, but cases of subacute cutaneous lupus have more rarely been described. This drug, through its immunomodulatory effect, can favor the appearance of a Th2 lymphocyte immune response inducing lupus. A recent study has suggested that Jessner–Kanof disease (JKD) could be a dermal form of lupus. We report a case of subacute cutaneous lupus induced by leflunomide with anti-Ro/SSA Ab and unusual histological presentation, identical to that of JKD. Leflunomide can induce cutaneous lupus characterized by exclusively dermal involvement and histologically comparable to JKD. This observation therefore suggests that JKD could be a dermal variant of lupus. This prompted a revision of the classification of cutaneous lupus, which has until now been divided into acute, subacute and chronic forms but could equally be classed as epidermal, dermal and hypodermal. The last point of interest in our observation is the efficacy of a combination of chloroquine and anakinra, which led to complete remission of the articular and cutaneous symptoms after the failure of corticotherapy.

The inflammatory myopathies are a group of quite proteiform, systemic auto-immune diseases which include polymyositis, dermatomyositis and inclusion body myopathies. To facilitate the diagnosis, classification criteria (Bohan and Peter, 1975) have been proposed, based essentially on clinical criteria. In addition, over the past fifteen years, auto-antibodies characterizing certain forms of inflammatory myopathy have been identified. One distinguishes schematically: auto-antibodies specific for myositis and auto-antibodies sometimes associated with myositis. Concerning the myositis specific auto-antibodies (MSA), schematically there are a dozen specificities which are classed according to the cellular distribution of the auto-antigen. The most characteristic are certainly the auto-antibodies directed against cytoplasmic antigens: the anti-tRNA synthetases (anti-Jo-1 (PL-1), anti-PL-7, PL-12, EJ, OJ, JS, KS, ZO, YRS), anti-SRP (signal recognition particle), anti-Mas and anti-KJ, anti-Fer (eEF1), anti-Wa and anti-CADM p140. Other auto-antibodies are directed against nuclear auto-antigens: the anti-Mi-2, anti-PMS (PMS1, PMS2) and related antibodies (MLH1, DNA PKcs…), anti-56 kDa, anti-MJ (NXP-2), anti-SAE and anti-p155/p140 (TIF-1γ). Concerning the auto-antibodies sometimes associated with myositis (myositis associated auto-antibodies or MAA), they can also be observed in other auto-immune diseases. These auto-antibodies are directed against nuclear or nucleolar auto-antigens: the anti-PM-Scl, anti-Ku, anti-RNP (U1 RNP and U2 RNP, U4/U6 RNP and U5 RNP), anti-Ro 52 kDa and more rarely, anti-Ro 60 kDa and anti-La. The auto-antibodies related to myositis are biological tools which are of interest in two main ways. They have allowed us to sort out the nosology of these inflammatory myopathies, in particular by defining anti-tRNA synthetase syndrome. It now remains to determine how they might be employed to complement the classical clinico-biological diagnostic criteria. In this perspective, it will be indispensable first of all to diffuse and standardize the methods of detection. The latter are at the moment very heterogeneous as they use techniques and above all antigenic preparations which are extremely diverse. These antibodies are also very interesting "physiopathological" tools to try to better understand myositis. The example of anti-tRNA synthetases is a particularly original model of auto-immunization, which allows one to establish a link between an initial, probably poorly specific muscular lesion and the appearance of auto-antibodies which maintain and aggravate the muscular disease.

New treatment strategies require that rheumatoid arthritis (RA) be diagnosed as early as possible. New diagnostic markers were required, because rheumatoid factors (RF), until now criteria for classification of RA, are not sufficiently specific and sometimes appear late, thereby limiting their diagnostic usefulness. The objective of this review is to describe the current state of knowledge and more particularly to analyze the interest of new RA autoanti-bodies, called anti-peptide or anti-citrullinated protein anti-bodies (ACPA). Other autoanti-bodies have been described, including anti-Sa, anti-alpha enolase, and anti-calpastatin autoanti-bodies. Nonetheless, their diagnostic value remains limited compared to ACPA. Accordingly, in daily practice today, the only autoanti-bodies that must be tested for to diagnose RA are the ACPAs and RFs. The discovery of ACPA (initially called anti-keratin and anti-perinuclear anti-bodies) was a major step forward for the laboratory diagnosis of RA. The tests most often used routinely areenzyme-linked immunosorbent assays(ELISA) with cyclic citrullinated peptides, whence the name anti-CCP autoanti-bodies. Accordingly, the two terms ACPA and anti-CCP can both be used. The diagnostic value, in particular their specificity, is on the order of 95%, regardless of the method of identification. These markers are very useful and are often present earlier than RF. These ACPA also have prognostic value because they are associated with more aggressive forms of RA. On the other hand, their value over time, in particular, their fluctuation as a function of treatment, is more controversial. In practice, it is recommended to test for both RF and ACPA in a diagnostic work-up for early RA. During follow-up, the value of testing for these autoanti-bodies has not been demonstrated, but additional studies are still necessary with the anti-CCP autoanti-bodies and the new anti-citrullinated protein autoanti-bodies.

Anti-Saccharomyces cerevisiae antibodies (ASCA), anti-nuclear associated anti-neutrophil antibodies (NANA) and antibodies to exocrine pancreas (PAB), are serological tools for discriminating Crohn's disease (CrD) and ulcerative colitis (UC). Like CrD, coeliac disease (CoD) is an inflammatory bowel disease (IBD) associated with (auto) antibodies. Performing a multicenter study we primarily aimed to determine the performance of ASCA, NANA and PAB tests for IBD diagnosis in children and adults, and secondarily to evaluate the prevalence of these markers in CoD.Sera of 109 patients with CrD, 78 with UC, 45 with CoD and 50 healthy blood donors were retrospectively included. ASCA, NANA and PAB were detected by indirect immunofluorescence (IIF).ASCA+/NANA- profile displayed a positive predictive value of 94.2% for CrD. Detection of ASCA was correlated with a more severe clinical profile of CrD and treatment of the disease did not influence their serum levels. ASCA positivity was found in 37.9% of active CoD. PAB were found in 36.7% CrD and 13.3% CoD patients and were not correlated with clinical features of CrD, except with an early onset of the disease. Fifteen CrD patients were ASCA negative and PAB positive.ASCA and PAB detected by IIF are specific markers for CrD although their presence does not rule out a possible active CoD. The combination of ASCA, NANA and PAB tests improves the sensitivity of immunological markers for CrD. Repeating ASCA, NANA, and PAB testing during the course of CrD has no clinical value.

Fodrin, an actin binding protein found in the cytoskeleton of most eukaryotic cells, would seem to be an important organ-specific autoantigen in Sjogren’s syndrome (SS). Fodrin is, moreover, detected in the salivary glands of patients with primary SS (pSS) but not in controls. It was thus recently claimed that antibodies against α-fodrin are a sensitive and specific serological marker for pSS.1 In this study we investigated the prevalence of autoantibodies against α-fodrin in patients with pSS, as compared with healthy subjects and patients with other autoimmune diseases. The study group included 107 patients with well defined pSS (mean age 57.5 years), 32 patients with systemic lupus erythematosus (SLE; mean age 40.1 years), 43 patients with rheumatoid arthritis (RA; mean age 59.0 years) with no signs of secondary SS, and 48 healthy blood donors (mean age 84.3 years). A diagnosis of SLE, RA, or pSS was …

According to international criteria, autoimmune hepatitis (AIH) type 1 is characterized by the presence of antinuclear or anti-smooth muscle antibodies (SMA) with F-actin specificity. SMA have been found in 85% of AIH patients, but are not specific to this disease, and anti-F-actin specificity is not always verified when SMA are detected. The objective of this study was to determine the diagnostic value of anti-F-actin antibodies in a large population. A multicenter study involving 12 clinical centers was performed. Patients were selected on the basis of the presence of F-actin SMA detected by indirect immunofluorescence (IIF) on rat liver-kidney-stomach sections and was confirmed by IIF on Hep2 cells treated with colchicine, or F-actin dot-blot. The clinical status of patients was determined from their medical records. One hundred sixty-eight patients were included: 76% women, 24% men; mean age of 45 years (range, 2-88 years), with a bimodal age distribution. Sixty percent had AIH type 1, and 40% had another disease. In the group of women younger than 25 years, 90% had AIH type 1. Other pathologies associated with antiactin were other liver diseases (19%), including viral hepatitis C (7%), and non-liver diseases (21%), including connective tissue diseases (12%). Antibody titers were higher in AIH than in other diseases. Antiactin antibodies are of major diagnostic value in AIH, especially in young women; they may be found in other disease settings, but mostly at low levels.

To investigate the prevalence of anti-cyclic citrullinated peptide (anti-CCP) and anti-keratin antibodies (AKA) in patients with primary Sjögren's syndrome.149 patients with a diagnosis of primary Sjögren's syndrome according to the European/American consensus criteria were recruited from three French medical centres. The presence of anti-CCP was determined by enzyme linked immunosorbent assay and of AKA antibodies by indirect immunofluorescence. Radiographs of hands and feet were evaluated at the time of anti-CCP analysis.Six patients with radiological erosions and nine patients with non-erosive arthritis fulfilling ACR criteria for rheumatoid arthritis were thought to have rheumatoid arthritis and secondary Sjögren's syndrome, while 134 were considered to have primary Sjögren's syndrome (mean (SD) disease duration, 11.1 (6.6) years). Of these, 80 tested positive for IgM rheumatoid factor (RF) (59%), 10 (7.5%) for anti-CCP, 7 (5.2%) for AKA, and 5 (3.7%) for both anti-CCP and AKA. There was no difference in clinical and biological features, including prevalence of RF, between anti-CCP positive and negative patients. The nine Sjögren patients with non-erosive arthritis, fulfilling ACR criteria for rheumatoid arthritis, were all CCP positive. Their response to disease modifying antirheumatic drugs could be different from classical rheumatoid patients.Most patients with primary Sjögren's syndrome are negative for AKA and anti-CCP, but positive test results should not rule out this diagnosis. Anti-CCP positive patients, who may be prone to developing rheumatoid arthritis, require cautious clinical and radiographic follow up.

Background: Anti-filaggrin antibodies (AFA) are among the most specific antibodies for rheumatoid arthritis, so procedures for their detection should be included in early biological diagnoses. AFA can be detected by indirect immunofluorescence (anti-keratin antibodies, AKA) or by new enzyme immunoassays (EIA). Their comparative performance needs to be established. Objective: To compare these technical procedures to optimise the serological diagnosis of rheumatoid arthritis. Methods: Results obtained using AKA and EIA were compared in 271 sera from 140 patients with rheumatoid arthritis at various stages, 98 patients with other autoimmune diseases, and 33 healthy subjects. EIA were successively undertaken with citrullinated linear filaggrin peptide (home made EIA) or cyclic citrullinated peptide (CCP2, commercial kits). Rheumatoid factor (RF) was assessed by EIA in all patients. Results: Anti-CCP2 kits showed the best sensitivity and specificity (65% and 96%, respectively). Among the 140 patients with rheumatoid arthritis, those with very recent disease (less than six months’ duration, n = 21) were studied as a separate group. In this group, the sensitivity of anti-CCP2 kits decreased to ~50%. Nevertheless this assay remained the most accurate when compared with AKA or home made EIA using linear filaggrin peptides. The combination of anti-CCP2 and RF only slightly increased the sensitivity of the diagnosis of very early rheumatoid arthritis. Conclusions: Kits using citrullinated cyclic peptides (CCP2) were more suitable than either AKA or EIA using linear filaggrin peptides for the diagnosis of early rheumatoid disease.

To report on an uncommon association of agranulocytosis in primary Sjögren's syndrome (SS).The clinical, haematological, and immunological features of seven patients with primary SS associated with a chronic (6 months) agranulocytosis, and the outcome of the patients, were analysed.Patients were white women with an unexplained agranulocytosis. They all had non-erosive arthritis and three had a thrombocytopenia or Evan's syndrome. In three patients, transient or durable expansion of T lymphocytes was present in the peripheral blood or in the bone marrow, but evolved independently from neutrophil counts. There was no paroxysmal nocturnal haemoglobinuria clone or antibodies to neutrophil surface antigens. In vitro bone marrow culture was normal (four patients) or showed a decrease in colony forming unit-granulocyte monocyte (CFU-GM) and colony forming unit-erythroblast (CFU-E) (one patient). Serum levels of soluble Fas ligand (sFasL) were normal, and granulocyte-colony stimulating factor (G-CSF) concentrations were either normal or raised. One patient was treated with steroids associated with intravenous immunoglobulins and achieved a lasting response. Two other patients were treated with steroids and methotrexate, with poor efficacy. Short courses of subcutaneous G-CSF produced a transient and mild response in all three patients. Complete recovery of the neutrophils occurred temporarily during pregnancy in two patients. After a mean follow up of 34.8 months (range 6-139) all patients were alive and none developed serious infections.A subset of patients with primary SS and non-destructive arthritis may develop a chronic but well tolerated agranulocytosis that is usually poorly responsive to steroids and oral methotrexate.

Revue du rhumatisme - In Press.Proof corrected by the author Available online since samedi 25 janvier 2014

Joint Bone Spine - In Press.Proof corrected by the author Available online since samedi 1 mars 2014

Background The nucleosome is considered as a major antigen in SLE and nucleosome-specific antibodies (Ab) seem to be the most specific and the earliest markers of SLE. Objectives To evaluate different methods of detecting anti-nucleosome Abs and determine the diagnostic value of these Abs in recently active SLE. Methods A 2 year (1998–99) prospective multicenter study in 13 European Immunopathology Centres (Groupe d’Etude de l’Auto-Immunite). Patients: (i) 55 cases of recently active SLE (evolution IgG anti-nucleosome Abs were detected by ELISA or immunodot using different nucleosome preparations. IgG anti-ds DNA Abs were detected by ELISA (calf thymus and human recombinant plasmid DNA). Results 34/55 SLE patients had anti-nucleosome Abs reacting with 4 kits. 16/55 SLE patients had anti-nucleosome Abs reacting with 1 to 3 kits. 5/55 SLE patients were negative for anti-nucleosome Abs. 5/50 patients with other autoimmune diseases had anti-nucleosome Abs. Conclusion 50/55 (91%) of patients with recently active SLE had anti-nucleosome Abs (by at least 1 method), 46/55 (84%) also had anti-ds DNA Abs (by ELISA). The sensitivity and the specificity of the anti-nucleosome Abs for SLE depend on the method and the nucleosome preparation.

Background The Ku autoantigen is a DNA binding factor consisting of 70 and 80 kDa protein which form a heterodimer involved in repair of ds DNA breaks. Since the original description of anti-Ku antibody in patients with polymyositis-scleroderma overlap syndrome, this antibody has been showed to be associated with several autoimmune diseases. Objectives To describe clinical features of 8 patients with anti-KU antibody. Methods Results Conclusion anti-Ku antibody is not specific of a connective tissu disease and can also be observed in patients without any autoimmune disease (n°7). In addition to previous described association, anti-Ku antibody can also be present in Wegener granulomatosis and idiopathic Raynaud’s phenomen. Two of our patients had an evaluative cancer (n°5 and 8) and one (n°7) presented a stomach neoplasm 3 years before the detection of anti-Ku antibody. This finding needs further investigations to assess if anti-Ku antibody can be associated with or predictive of a neoplasm.

Background & Aims: Despite extensive investigations of portal vein thrombosis, no underlying cause is identifiable in up to 30% of patients. A recently described mutation of the prothrombin gene at nucleotide position 20210 is associated with history of venous thrombosis and was assessed in this study. Methods: We compared the frequency of factor II G20210A and factor V G1691A (factor V Leiden) mutations in 10 patients with idiopathic portal vein thrombosis, 10 patients with nonidiopathic portal vein thrombosis, 60 patients with deep vein thrombosis of the legs, and 42 control subjects. Results: The frequency of factor II G20210A mutation was increased in patients with idiopathic portal vein thrombosis (40.0%; confidence interval, 3.1%–76.9%) compared with controls (4.8%; confidence interval, 0%–11.5%) or patients with nonidiopathic portal vein thrombosis or deep vein thrombosis ( P = 0.0001). In contrast, the frequency of the factor V G1691A mutation was similar in subjects with portal vein thrombosis and in controls but was increased in patients with deep vein thrombosis ( P = 0.0001). Conclusions: The factor II G20210A mutation is frequent in patients with idiopathic portal vein thrombosis and should therefore be assessed under this circumstance. GASTROENTEROLOGY 1999;116:144-148