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Wild-type amyloidogenic transthyretin (ATTR) amyloidosis, known as systemic senile amyloidosis (SSA), is an age-related nonhereditary amyloidosis, which is known to cause cardiomyopathy and carpal tunnel syndrome (CTS). Herein, we report a case of unilateral hydrarthrosis with arthritis of the right shoulder joint in an 82-year-old Japanese housewife who has a seven year history of polyneuropathy due to an unknown aetiology. At first, her joint pain was thought to be caused by overuse of her right upper arm. Despite treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and repeated arthrocentesis, her symptoms did not improve. She then visited our hospital, where magnetic resonance imaging (MRI) of her right shoulder suggested synovitis and hydrarthrosis. She also had an arthroscopic synovectomy of the right shoulder joint. The pathological testing revealed a diagnosis of non-specific arthritis with amyloidosis. After further pathological examination, wild-type ATTR was identified and she was diagnosed with senile amyloidosis.

A 57-year-old Japanese woman who had been diagnosed as having entero-Behcet's disease nine years earlier was admitted with a persistent high-grade fever. An Mediterranean fever (MEFV) gene analysis revealed the compound heterozygous P369S-R408Q variant. She was treated with colchicine, and her symptoms immediately improved. Prednisolone (PSL) was added to treat the punched-out ulcers in the terminal ileum, leading to remission. There has been no relapse since the PSL was discontinued. In Behcet's disease patients with MEFV variants, the use of colchicine should therefore be considered in such patients as well as immunosuppressive therapy.

We investigated clinical outcomes in patients with remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome.This is a retrospective multicenter study conducted in Nagasaki, Japan. We consecutively diagnosed a total of 41 patients with RS3PE syndrome between October 2003 and September 2012 and evaluated their outcomes from medical records from the first year of follow-up.Although an excellent initial response to corticosteroids was noted in all 41 patients, 34 (82.9%) were still receiving corticosteroids and 13 (31.7%) showed elevated C-reactive protein (CRP) at one year. Multivariate analysis demonstrated that male gender and high CRP level at entry were independent variables associated with patients' one-year CRP level being ≥0.5 mg/dL. Odds ratios were 17.05 ([95% CI 2.41-370.12], p 0.026) and 12.99 ([95% CI 1.78-269.62], p 0.0096), respectively. Twenty-four patients (58.5%) were still receiving prednisolone (PSL) ≥ 5 mg/day at one year. Disease-modifying anti-rheumatic drugs including methotrexate were required in three patients (10.3%). Neoplasms were found in 14 patients (34.1%) and 1 of these had died due to lung cancer at one year.RS3PE syndrome initially responds well to corticosteroids with remission of symptoms. However, outcomes of RS3PE syndrome appear to be worse than expected, and may be influenced by gender and initial CRP level.

Recently, it was reported that remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome could be complicated with solid tumors. In a retrospective, multicenter study between October, 2003 and September, 2010, we investigated the characteristics of patients with paraneoplastic RS3PE syndrome who fulfilled following criteria: (1) bilateral pitting edema of hands or feet or both, (2) sudden onset of polyarthritis, and (3) age >50 years, (4) seronegativity for rheumatoid factor (RF). A total of 33 cases fulfilled the above criteria. Eight patients (seven men and one woman) developed cancer within 2 years of RS3PE syndrome onset. There was no significant difference between the neoplastic and nonneoplastic groups in the proportions of patients with fever, symmetrical polyarthritis, pitting edema, and good response to corticosteroids. Serum matrix metalloproteinase 3 (MMP-3) level (median 437.3 ng/ml) in the paraneoplastic RS3PE patients was significantly higher than that in patients without neoplasia (median 114.7 ng/ml) (p

We aimed to investigate whether delayed treatment with tumor necrosis factor (TNF) inhibitors in incomplete responders to synthetic disease-modifying anti-rheumatic drugs (DMARDs) was effective among patients with very early rheumatoid arthritis (RA) with poor prognosis factors. We examined 22 patients with very early RA who were positive for anti-cyclic citrullinated peptide antibodies or IgM-rheumatoid factor. The mean disease duration at entry was 14.1 weeks. A treat-to-target strategy, aiming at simplified disease activity index (SDAI) remission, was initiated with synthetic DMARDs. SDAI remission was not achieved in 9 of the 22 patients with synthetic DMARDs alone, and TNF inhibitors were added in these patients. SDAI values in these 9 patients were further examined for the following 6 months. The TNF inhibitors (infliximab 8, etanercept 1) were added at a mean interval of 34.1 weeks after the initiation of synthetic DMARDs. SDAI remission was achieved in 4 of the 9 patients (44.4%) at 3 months and in 8 of the 9 patients (88.9%) at 6 months after the introduction of the TNF inhibitors. Radiographic damage had not progressed in these patients. Delayed treatment with TNF inhibitors is effective and tolerable for patients with very early RA with poor prognosis factors.

Spondyloarthritis may be increasingly present in older patients as life expectancy increases. We investigated clinical differences between early-onset and late-onset spondyloarthritis in Japan. We retrospectively reviewed 114 patients consecutively diagnosed with spondyloarthritis. The clinical course of each patient was observed for ?1 year. We defined early-onset and late-onset spondyloarthritis as, Medicine, 98(7), e14431; 2019

Protracted febrile myalgia syndrome (PFMS) is a rare manifestation of familial Mediterranean fever characterized by prolonged severe myalgia. We herein describe a case of PFMS with fasciitis on magnetic resonance imaging. The response to corticosteroid therapy was prompt, as is typical for PFMS. An MEFV gene analysis revealed the patient to be homozygous for E148Q and compound heterozygous for P369S-R408Q. This is the first case report of a Japanese patient with PFMS. MRI findings may help to diagnose such cases., Internal Medicine, 53(24), pp.2817-2819; 2014

We report the first 3 cases of inflammatory myopathy with abundant macrophages (IMAM) to be found in an Asian country. Diagnosis of IMAM was based on the infiltration of CD68+ macrophages into biopsied specimens, particularly the fascia. Proximal skeletal muscle symptoms and signs, elevation of creatine kinase, and myogenic changes in electromyography were found in all of the cases, and magnetic resonance imaging clearly revealed thickening of the fascia. Since dermatomyositis (DM)-specific skin alterations were not found, none of the patients in this study fulfilled Bohan and Peter's criteria for DM; however, anti-PL-7 antibody was detected in case number 1. In addition, CD20+ B-cell infiltration into the fascia was also detected in all of the cases, indicating further transition to DM. Severe illness, namely macrophage activation syndrome and acute respiratory distress syndrome, occurred in case 1 but was resolved with intensive combination therapy. The other 2 cases also required glucocorticoids to achieve remission., Rheumatology International, 33(4), pp.1059-1064; 2013

Objective Mizoribine (MZR) is an immunosuppressant that inhibits nucleic acid metabolism and is a relatively safe disease-modifying anti-rheumatic drug (DMARD). We evaluated the efficacy and safety of one single dose per day for patients with rheumatoid arthritis (RA). Patients and Methods In this study 32 patients with RA received MZR therapy. We evaluated the average dose of MZR and prednisolone, response to treatment and peak plasma level of MZR. Results The average dose of MZR was 146.1±31.2 (range: 50-200) mg/day. The average dose of prednisolone was 4.63±3.59 (range: 0-14) mg/day. The average plasma level of MZR, measured after 3 hours, was 2.20±0.49 μg/mL in the responder group and 1.59±0.82 μg/mL in the non-responder group (p=0.020). The treatment with MZR for 24 weeks was completed by 71.9% of patients and the proportion of patients who achieved a good and moderate response rate according to the European League Against Rheumatism (EULAR) criteria was 56.3% at 24 weeks. The plasma level of MZR which was greater than or equal to 2.12 μg/ mL was significantly correlated with the clinical response (p, Internal Medicine, 49(20), pp.2211-2218; 2010

Intensity noise on a probe beam is a serious obstacle to highly sensitive and high-speed pump-probe microscopy. In this report, a reference beam of the probe is prepared and delayed. The intensity modulation by the sample is measured as the phase modulation of the superposition of detected electrical signals of the probe and reference beams, and the intensity noise is canceled. We evaluate performance of the noise cancellation using the super-continuum light from a piece of photonic crystal fiber, and find that the noise is canceled by ∼26 dB. We then apply the method to a stimulated Raman microscope. This method contributes to highly sensitive and high-speed pump-probe imaging with various light sources.

In MDCK cells, hepatocyte growth factor/scatter factor (HGF/SF) induces epithelial cell dissociation, scattering, migration, growth and formation of branched tubular structures. By contrast, these cells neither scatter nor form tubular structures in response to the epidermal growth factor (EGF) family of growth factors. Heparin-binding EGF-like growth factor (HB-EGF) is a member of the EGF family of growth factors and is synthesized as a membrane-associated precursor molecule (proHB-EGF). ProHB-EGF is proteolytically cleaved to release a soluble ligand (sHB-EGF) that activates the EGF receptor. Although recent studies suggest possible physiological functions, the role of proHB-EGF remains largely undefined. Using MDCK cells stably expressing proHB-EGF, a noncleavable deletion mutant of proHB-EGF or soluble HB-EGF, we show that epithelial cell functions differ depending on the form of HB-EGF being expressed. Expression of noncleavable membrane-anchored HB-EGF promoted cell-matrix and cell-cell interactions and decreased cell migration, HGF/SF-induced cell scattering and formation of tubular structures. By contrast, expression of soluble HB-EGF induced increased cell migration, decreased cell-matrix and cell-cell interactions and promoted the development of long unbranched tubular structures in response to HGF/SF. These findings suggest that HB-EGF can not only modulate HGF/SF-induced cellular responses in MDCK cells but also that membrane-bound HB-EGF and soluble HB-EGF give rise to distinctly different effects on cell-cell and cell-extracellular matrix interactions.

Dermatomyositis (DM) is a heterogeneous disease with varying degrees and time courses of skin eruptions, myositis and internal organ involvement.1 Increasing evidence has demonstrated that myositis-specific autoantibodies (MSAs) are closely associated with distinct clinical subsets.2 Recently, Betteridge et al 3 ,4 reported a novel MSA against small ubiquitin-like modifier activating enzyme (SAE) in DM patients. In this study, we detected this autoantibody in a Japanese DM cohort and assessed its clinical correlations. We screened 456 consecutive Japanese patients with DM (11 children, 445 adults); 373 fulfilled the criteria of Bohan and Peter5 ,6 and the remaining 83 fulfilled Sontheimer's criteria for clinically amyopathic DM (CADM).7 Controls included 62 patients with polymyositis, 108 with systemic lupus erythematosus, 433 with systemic sclerosis and 124 with interstitial lung disease (ILD) alone. The institutional review board approved the study protocol. Immunoprecipitation assays were performed as described.8 Protein A-agarose beads preincubated with sera were incubated with 35S-methionine-labelled or unlabelled K562 cell extracts. Immunoprecipitants were fractionated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis, followed by autoradiography or …

A 57-year-old Japanese woman who had been diagnosed as having entero-Behçet's disease nine years earlier was admitted with a persistent high-grade fever. An Mediterranean fever (MEFV) gene analysis revealed the compound heterozygous P369S-R408Q variant. She was treated with colchicine, and her symptoms immediately improved. Prednisolone (PSL) was added to treat the punched-out ulcers in the terminal ileum, leading to remission. There has been no relapse since the PSL was discontinued. In Behçet's disease patients with MEFV variants, the use of colchicine should therefore be considered in such patients as well as immunosuppressive therapy.

Summary Inflammatory myopathy with abundant macrophages (IMAM) has recently been proposed as a new clinical condition. Although IMAM shares certain similarities with other inflammatory myopathies, the mechanisms responsible for this condition remain unknown. Patients with familial Mediterranean fever (FMF) and tumour necrosis factor receptor-associated periodic syndrome (TRAPS) also often develop myalgia. We therefore investigated the polymorphisms or mutations of MEFV and TNFRSF1A genes in patients with IMAM to identify their potential role in this condition. We analysed the clinical features of nine patients with IMAM and sequenced exons of the MEFV and TNFRSF1A genes. The patients with IMAM had clinical symptoms such as myalgia, muscle weakness, erythema, fever and arthralgia. Although none of the patients were diagnosed with FMF or TRAPS, seven demonstrated MEFV polymorphisms (G304R, R202R, E148Q, E148Q-L110P and P369S-R408Q), and one demonstrated a TNFRSF1A mutation (C43R). These results suggest that MEFV gene polymorphisms and TNFRSF1A mutation are susceptibility and modifier genes in IMAM.

Overgrowth of rheumatoid synoviocytes, which results in joint destruction, is due to impaired balance between cell proliferation and cell death (apoptosis). Ceramide is an important lipid messenger involved in mediating a variety of cell functions including apoptosis. We investigated the effects of ceramide on growth-promoting anti-apoptotic signals in rheumatoid synovial cells. Human synovial cells isolated from patients with rheumatoid arthritis (RA) were stimulated with platelet-derived growth factor (PDGF) in the presence or absence of C2-ceramide. The kinase activity of Akt, MEK, and ERK1/2 was analyzed in PDGF-stimulated synovial cells by Western blot analysis. Pretreatment with C2-ceramide completely inhibited PDGF-induced cell cycle progression of rheumatoid synovial cells. PDGF stimulation induced phosphorylation and activation of Akt, MEK, and ERK1/2 in rheumatoid synovial cells. C2-ceramide inhibited the activation of Akt, MEK and ERK1/2 in PDGF-stimulated synovial cells. Our data demonstrated that inhibition of anti-apoptotic kinases, such as Akt and ERK1/2, may play an important role in ceramide-mediated apoptosis of rheumatoid synovial cells.

We report on the development of a balanced detector suited for multicolor imaging. The source pulsed light is split into probe and reference pulsed light. The reference pulse is delayed through an optical path and the probe and reference pulses are detected by a single photodetector. The signs of the detected signals of the probe and reference pulses are flipped based on a signal synchronous to the light source. Then, the signals are averaged through a low-pass filter. The output signal is proportional to the intensity difference between the probe and the reference. This balanced detector has two features: (1) both the probe and reference pulsed lights are detected by a single photodetector and (2) a voltage bias on the sign flipping compensates for the optical-intensity unbalance between the probe and reference pulsed lights. The first feature enables the probe and reference pulses to travel along a common optical path from a sample through a spectrograph to the photodetector, which minimizes the intensity unbalance between the probe and reference pulses during imaging and spectroscopy. The second feature ensures the complete balanced-detection in whole wavelength range by compensating for the optical unbalance created by deviations in the splitting ratios of the probe and reference lights at different wavelengths. Although a higher signal to noise ratio (SNR) reached to near shot noise limited SNR is attained by attaching a resonator to the photodetector for pulse repetition, the electrical bias cannot compensate for the optical balance. This unbalance is, however, corrected by adjusting the phase of the synchronous signal. We applied the present balanced detection to a stimulated Raman microscope with supercontinuum probe light and demonstrated its noise cancelling performance through capturing polystyrene beads.

High-dose steroid pulse therapy is effective in transplant rejection and severe autoimmune diseases. Our goal was to identify the mechanism by which high-dose steroid exerts specific immunosuppressive actions. In this study, we investigated the in vivo effects of high-dose (1 g) methylprednisolone infusion on peripheral blood T lymphocyte apoptosis induction in 15 patients with severe autoimmune diseases. DNA fragmentation was detected in peripheral blood T cells isolated from these patients after 2 and 4 hr of steroid infusion. In contrast, T cells isolated from the same patients before or 8 or more hours after infusion did not show DNA fragmentation. DNA fragmentation was more significant in CD4+ than CD8+ T cells. The susceptibility of CD4+ T cells to apoptosis was associated with a lower expression of Bcl-2 in these cells compared with that on CD8+ T cells. To support the T-cell apoptosis induction by pulse therapy, peripheral blood T cells from normal subjects underwent DNA fragmentation after in vitro exposure to 2.5-10 microg/ml of methylprednisolone for 30 min. Our results indicate that induction of peripheral blood T-cell apoptosis is an important mechanism contributing to the immunosuppression observed after high-dose steroid therapy.

Superantigens activate a large number of T cells in a Vβ-restricted manner after binding to MHC class II molecules on the antigen presenting cells (APC). Superantigens also activate APC directly by interacting with their ligands, MHC class II molecules. In the present study, we examined the effects of superantigens on matrix metalloproteinases (MMPs) secretion from rheumatoid synovial fibroblasts. We demonstrated that stimulation of interferon (IFN)-γ-treated synovial fibroblasts with staphylococcal enterotoxin A (SEA) selectively induced the secretion of stromelysin, a neutral MMP, from synovial fibroblasts. Pretreatment of synovial fibroblasts with cycloheximide, an inhibitor of protein synthesis,prevented MMP-3 secretion from rheumatoid synovial cells suggesting that protein synthesis was required for SEA-induced MMP-3 secretion after SEA binding to MHC class II molecules. Our data suggest that in the synovium, bacterial superantigens are potent inducers of stromelysin which plays a critical role in articular destruction observed in inflammatory joint disease.

Granulocyte macrophage-colony stimulating factor (GM-CSF) regulates the growth and differentiation of hematopoietic cells and is also involved in angiogenesis. The induction of protein tyrosine phosphorylation is critical for cytokines and growth factor-mediated signal transduction. The protein tyrosine kinase (PTK), JAK2 is involved in signaling through a number of cytokine receptors, including GM-CSF receptors. In the present study, we investigated the effect of GM-CSF on the cell cycle and protein tyrosine phosphorylation in a human endothelial cell-derived cell line, EA.hy 926 cells. GM-CSF induced the cell cycle progression and tyrosine phosphorylation of cellular proteins including JAK2 kinase in EA.hy 926 cells. Herbimycin A, a PTK inhibitor, completely blocked the GM-CSF-induced cell cycle progression, protein tyrosine phosphorylation and JAK2 kinase activation in EA.hy 926 cells. Our results demonstrate that protein tyrosine phosphorylation and JAK2 kinase activation are closely related to the GM-CSF-mediated signal transduction and growth in vascular endothelial cells, and suggest the efficacy of herbimycin A in controlling angiogenesis.

Degradation of the extracellular matrix plays an important role in rheumatoid articular destruction. Rheumatoid synovial fibroblasts secrete a large amount of matrix-degrading metalloproteinases (MMPs), which initiate tissue damage by proteolytic degradation of collagens and proteoglycans. Cytokines, such as interleukin-1 alpha, -1 beta or tumour necrosis factor (TNF)-alpha, are potent inducers of MMPs in rheumatoid synovial fibroblasts, MMPs are synthesized and secreted as latent pro-enzymes and their activation is achieved by proteolytic cleavage or the propeptide domain at the N-terminus of the molecule. Thus, the interaction of the pro-enzymes with specific activators determines the enzymatic activity in the extracellular space. In the present study, we identified a novel mechanism for the activation of pro-MMP-2, which can be achieved through the interaction of the inflammatory cytokine, TNF-alpha, with synovial fibroblasts. Although MMP-2 is constitutively secreted by synovial fibroblasts as a pro-enzyme, stimulation of fibroblasts by TNF-alpha-induced secretion of MMP-2 in an active form. In support of this result, TNF-alpha stimulation-induced membrane-type matrix metalloproteinase (MT-MMP), a newly identified MMP-2-specific activator on synovial fibroblasts. Cycloheximide analysis demonstrated that protein synthesis may be required for TNF-alpha-mediated MT-MMP expression on synovial fibroblasts. Our results suggest that TNF-alpha induces MMP-2 activation in part by up-regulating MT-MMP expression, thus representing a new mechanism for cytokine-mediated articular destruction in rheumatoid arthritis (RA).

The presence of a putative autoantigen of autoimmune disorder in a target organ may cause accumulation of specific T cells in the inflammatory region. One of the mechanisms of such accumulation involves the migration of specific-circulating T cells through the endothelial cells into the target lesion. The presence of only a few specific T cells responsive to a putative autoantigen has hampered the investigation of specific migration of circulating T cells to the target organ. We used a superantigen to investigate specific T-cell adhesion to endothelial cells, because it stimulates a large proportion of T cells with particular V beta elements and adhesion of T cells to the endothelium is a vital step in the migration process. Adhesion of murine T cells to the human endothelial cell line, EA.hy926, was specifically increased in the presence of staphylococcal enterotoxin B (SEB). The increase was interferon-gamma (IFN-gamma)-dependent, and consisted mainly of CD4+ T cells. V beta 8.1,2+ T cells preferentially adhered to endothelial cells in the presence of SEB compared with V beta 6+ T cells. Pretreatment of endothelial cells with SEB increased the adherence of V beta 8.1,2+ T cells, while anti-human leucocyte antigen (HLA)-DR and -DQ antibodies inhibited the increased adherence of V beta 8.1,2+ T cells. Our results demonstrate that increased T-cell adhesion to endothelial cells is SEB specific, and that the specificity is dependent on major histocompatibility complex (MHC) class II molecules expressed on endothelial cells and on the recognition of the SEB-MHC class II complex by V beta 8.1,2+ T cells.

A 27-year-old woman presented with destructive scleritis of the left eye with subcutaneous haemorrhage and swelling of the lower eyelid. She had experienced recurrent nasal bleeding for the last six years, and chronic sinusitis resulting in the destruction of the nasal septum and left maxillary sinus. Nasal mucosal biopsies demonstrated granuloma formation with no evidence of vasculitis. The level of serum cytoplasmic anti-neutrophil cytoplasm antibody (c-ANCA) was significantly increased. Furthermore, multiple sites of complete occlusions were detected in the left subclavian and common carotid arteries by subtraction angiography and MRI. We describe a case of Wegener's granulomatosis overlapped with Takayasu arteritis, which, to our knowledge, has not been previously reported.

FK506 is an immunosuppressive drug that inhibits T cell receptor-mediated signal transduction. This drug can induce immunological tolerance in allograft recipients. In this study, we investigated the in vivo effects of FK506 on T cell receptor-mediated apoptosis induction. Injection of anti-CD3 antibody (Ab) in mice resulted in the elimination of CD4+ CD8+ thymocytes by DNA fragmentation. FK506 treatment significantly augmented thymic apoptosis induced by in vivo anti-CD3 Ab administration. Increased thymic apoptosis resulted in the disappearance of CD4+ CD8+ thymocytes after anti-CD3 Ab/FK506 treatment. DNA fragmentation triggered by FK506 was induced exclusively in antigen-stimulated T cells, since enhanced DNA fragmentation induced by in vivo staphylococcal enterotoxin B (SEB) injection was confirmed in SEB-reactive V beta 8+ thymocytes but not in SEB-nonreactive V beta 6+ thymocytes. In addition to thymocytes, mature peripheral T cells also die by activation-induced programmed cell death. A similar effect of FK506 on activation-induced programmed cell death was observed in SEB-activated peripheral spleen T cells. In contrast, cyclosporin A treatment did not enhance activation-induced programmed cell death of thymocytes and peripheral T cells. Apoptosis is required for the generation and maintenance of self-tolerance in the immune system. Our findings suggest that FK506-triggered apoptosis after elimination of antigen-activated T cells may represent a potential mechanism of the immunological tolerance achieved by FK506 treatment.

高γグロブリン血症と白血球数減少症を検出して以来, 14年後にSjogren症候群を, 20年後に全身性エリテマトーデスを合併した症例を経験した.症例は37歳家婦で, 17歳時(1973年)に学校検診で高γグロブリン血症を指摘され精査のために当科に第1回目入院する.各種検査を施行するも高γグロブリン血症と白血球減少症を認める以外に確定診断は得られなかった. 29歳(1985年)易感染症と全身倦怠感を自覚し当科を受診する.頚部および腋窩部にリンパ節腫脹を認め,抗核抗体,抗SS-A抗体,抗SS-B抗体が陽性であった. 33歳(1989年)眼・口腔内乾燥症状とRaynaud現象が出現した. 1992年8月抗dsDNA抗体が陽性となり1993年1月には発熱,関節痛,尿蛋白が出現し抗Sm抗体も陽性となり同年10月入院した.精査のうえ, Sjogren症候群と全身性エリテマトーデスの合併と診断した.プレドニゾロン投与,ステロイドパルス療法にて,臨床症状,所見はすみやかに改善した. 本症例は両疾患の発症,進展および両疾患の関連を追求するに示唆に富む症例と考え報告した.

We report a 72-year-old man with respiratory involvement of immunoglobulin G4 (IgG4)-related disease, who developed dry cough and shortness of breath on effort. The chest computed tomography scan image showed massive and diffuse ground-glass opacity, interlobular thickening, and bronchial wall thickening. The infiltration of IgG4-positive plasma cells in the transbronchial lung biopsy and high serum IgG4 concentrations were found. The patient was treated with 0.6 mg/kg oral prednisolone and showed rapid improvement. This is a case of IgG4-related disease in which the only complication was respiratory involvement.

Background Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is an acute edematous polyarthritis of the elderly subjects. Although an initial response to corticosteroids is very good, the further outcome of RS3PE syndrome remains to be elucidated. Objectives We have tried to investigate the further outcome in patients with RS3PE syndrome. Methods This is a retrospective multicenter study held in Nagasaki prefecture, Japan. We have consecutively registered the patients with RS3PE syndrome fulfilling the following criteria: (1) bilateral pitting edema of both hands or feet, or both, (2) sudden onset of polyarthritis, (3) age >50 years, (4) seronegative for rheumatoid factor (RF). The total of 29 cases, between October 2003 and September 2012, were diagnosed as RS3PE syndrome and registered in the present study. Patients gave their informed consent to be subjected to the protocol and the outcome was evaluated by the medical records for 1 year after initial introduction of corticosteroids. Results Although an excellent response to initial corticosteroids was noted in all the 29 patients, twenty-five out of 29 patients (86.2%) still received corticosteroids at 1 year and 13 out of 29 patients (44.8%) received prednisolone >5mg/day. Disease-modifying anti-rheumatic drugs including methotrexate were required in three patients (10.3%), furthermore, the elevation of CRP was still noted in 8 patients (27.6%) at 1 year. Accordingly, neoplasm was found in 12 patients (41.2%) and 3 died during 1 year. None of the RS3PE patients without neoplasm died during 1 year. Although there was no statistical difference, corticosteroids tended to be continued in the RS3PE patients with neoplasm (eleven out of 12: 91.7%) as compared with those without neoplasm (fourteen out of 17: 82.4%) during this follow up periods. Conclusions The present data suggest that the outcome of RS3PE syndrome may be variable and appears to be worse than expected. Coexistence of neoplasm might influence the outcome of these patients. References Arima K, Origuchi T, et al. RS3PE syndrome presenting as vascular endothelial growth factor associated disorder. Ann Rheum Dis. 2005 64(11):1653-5. Origuchi T, et al. High serum matrix metalloproteinase 3 is characteristic of patients with paraneoplastic remitting seronegative symmetrical synovitis with pitting edema syndrome. Modern Rheumatol. 2012 22(4):584-8. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4160

Background Recent report indicates that the presence of anti-SS-A antibodies are an independent factor associated with an insufficient response to tumour necrosis factor (TNF) inhibitors in patients with rheumatoid arthritis (RA) (Ref. 1). Since anti-SS-A antibodies are frequently found in patients with RA (20%), other classes of biologic disease modifying anti-rheumatic drugs (DMARDs) than TNF inhibitors may be indicative for active anti-SS-A antibodies-positive RA patients. Objectives To investigate whether abatacept (ABT) is effective for anti-SS-A antibodies-positive RA patients comparing with anti-SS-A antibodies-negative RA patients. Methods This is a prospective observational study and consists of 50 RA patients (42 females and 8 males) who had been administrated with ABT. Eighteen patients were anti-SS-A antibodies-positive whereas 32 were anti-SS-A antibodies-negative, respectively. Patients gave their informed consent to be subjected to the protocol. We have selected the anti-SS-A antibodies-negative RA patients whose baseline variables, including disease duration and clinical disease activity at baseline, were comparable with anti-SS-A antibodies-positive RA patients. The continuation rate and clinical disease activity including SDAI were evaluated during 6 months treatment of ABT. Statistical analysis included last observation carried forward (LOCF) method. Results At baseline, there was no statistical difference of SDAI in both groups: 20.47 in the anti-SS-A antibodies-positive RA group and 21.92 in the anti-SS-A antibodies-negative RA group, respectively ( p =0.9554, Student9s t test). At 6 months, although there was no statistically significant difference between the 2 groups, SDAI tended to be lowered in the anti-SS-A antibodies-positive RA group as compared with anti-SS-A antibodies-negative RA group (9.11 in the former vs 12.11 in the latter, p =0.2036, Welch9s t test). It is interesting to note that the discontinuation rate for ABT due to lack of efficacy or adverse events at 6 months was significantly lower in anti-SS-A antibodies-positive RA group as compared with anti-SS-A antibodies-negative group ( p =0.0475, Welch9s t test). Conclusions In comparison with TNF inhibitors, the present data suggest that ABT is a suitable biologic DMARDs in patients with anti-SS-A antibodies-positive RA. References Matsudaira R, Tamura N, Sekiya F, et al. Anti-Ro/SSA antibodies are an independent factor associated with an insufficient response to tumor necrosis factor inhibitors in patients with rheumatoid arthritis. J Rheumatol 2011; 38: 2346-54. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3956

Background Inflammatory myopathy with abundant macrophages (IMAM) is a new clinical condition characterized by diffuse infiltration of macrophages in fascia [1], but the mechanism remains unclear. Objectives The objective of this study was to investigate the MEFV and TNFRSF1A mutations in patients with IMAM. Methods Nine patients with IMAM were enrolled. Clinical characteristics, MRI, and pathologic findings were analyzed. Mutation analysis was performed by genomic sequencing of MEFV and TNFRSF1A. Results The patients with IMAM had clinical symptoms such as myalgia, muscle weakness, erythema, fever, and arthralgia. STIR images in MRI showed thickening of fascia in all patients. In biopsied specimens from 8 patients, a number of CD68+ macrophages were found apparently in the fascia in all samples. In gene analysis, 7 of 9 patients had MEFV polymorphisms ( G304R, R202R, E148Q, E148Q-L110P , and P369S-R408Q ) and one patient had TNFRSF1A mutation ( C43R ). Conclusions These results suggest that MEFV gene polymorphisms and TNRRSF1A mutations are susceptibility and modifier genes in IMAM. References Bassez G, Authier F-J, Lechapt-Zalcman E et al. Inflammatory myopathy with abundant macrophages (IMAM): a condition sharing similarities with cytophagic histiocytic panniculitis and distinct from macrophagic myofasciitis. J Neuropathol Exp Neurol 2003; 62: 464-74. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1474

Ischemia/reperfusion injury increases the expression of bioactive heparin-binding epidermal growth factor-like growth factor (HB-EGF) in the rat kidney, suggesting that oxidant stress or cell injury related to oxidant stress might affect HB-EGF expression in the injured renal parenchyma. We utilized a nontransformed rat renal epithelial cell line (NRK-52E cells) to investigate whether reactive oxygen species induced transcriptional activation of HB-EGF mRNA. Hypoxia/reoxygenation increased HB-EGF expression in NRK-52E cells, and at concentrations that induced sublethal cell injury, hydrogen peroxide (H2O2) increased HB-EGF mRNA expression 4.7-fold. The free radical scavengers, dimethylthiourea and N-acetylcysteine inhibited HB-EGF mRNA induction. In contrast, another free radical scavenger, pyrrolidine thiocarbamate (PDTC), augmented H2O2-mediated HB-EGF expression. Since PDTC has been reported to augment AP-1-mediated transcriptional activation, we utilized an electrophoretic mobility shift assay to confirm that H2O2 administration to NRK-52E cells did increase nuclear extract DNA-binding activity to a consensus AP-1 sequence. Using a CAT reporter assay coupled to the proximal 2,000 bp of the human HB-EGF 5′-untranslated region, we determined that H2O2 administration increased CAT activity 5.5-fold. Truncation or deletion mutations of a putative AP-1-binding site reduced the H2O2-stimulated activity by >60%, and there was increased DNA binding of nuclear extracts from H2O2-treated cells to a 24-bp oligonucleotide containing this putative AP-1 site. Anti-fos and jun antibodies inhibited this binding, and there was no binding to an oligonucleotide in which the putative AP-1 site was mutated.The site of the residual activation was found to exist in the most proximal 5′-untranslated region (–121 to +60), which contains two putative SP1 sites. Timing and localization of AP-1-binding activity from nuclear extracts from the post-ischemic tissue correlated with HB-EGF mRNA expression. Therefore, in renal epithelial cells, oxidant stress increases HB-EGF expression, which appears to be mediated in part by an increase in AP-1 binding. This activation may play an important role in the induction of HB-EGF mRNA in response to tissue injury and may regulate early stages of recovery following ischemic damage.

Several lipid second messengers are important mediators of extracellular signals. Among them ceramide, which is formed by cell membrane sphingomyelin, influences the apoptotic signal pathway through Fas antigen. We examined the apoptotic effect of cell-permeable C2-ceramide on rheumatoid synovial fibroblasts in vitro and in vivo. Exposure of cultured human rheumatoid synovial fibroblasts to C2-ceramide for 24 hours produced internucleosomal DNA fragmentation and morphologic changes characteristic of apoptosis. This C2-ceramide-mediated apoptosis was dose dependent as confirmed by analysis of cytosolic oligonucleosome-bound DNA of treated synovial fibroblasts. We also demonstrated that intra-articular administration of C2-ceramide into Fas-deficient MRL lpr/lpr mice produced a profound reduction of synovial hyperplasia within 24 hours. In situ nick end labeling analysis confirmed the induction of apoptosis in synovial lining cells. Our results indicate that C2-ceramide may function as a potent inducer of apoptosis in the synovium and suggest that pharmacologically-induced apoptosis may be useful as a new therapeutic modality for rheumatoid arthritis.

SUMMARY In the present study, we investigated the effects of an immunosuppressant, rapamycin, on bcl-2 expression and the susceptibility of human rheumatoid synovial fibroblasts to Fas-mediated apoptosis. Rapamycin treatment down-regulated bcl-2 expression on rheumatoid synovial cells in a dose-dependent manner. In contrast, Fas antigen expression was not influenced by rapamycin treatment. Rapamycin treatment also enhanced the susceptibility of rheumatoid synovial cells to anti-Fas monoclonal antibody-mediated apoptosis. Our results suggest that rapamycin augments the sensitivity of rheumatoid synovial fibroblasts to apoptosis by down-regulating bcl-2 expression. This pharmacological alteration of sensitivity to apoptosis in the rheumatoid synovium may represent a new therapeutic approach for rheumatoid arthritis.

SUMMARY RA is a chronic inflammatory disease characterized by mononuclear cell infiltration and the overgrowth of synovial fibroblast. This invasive growth of synovial tissues corresponds with the progressive destruction of articular carilage and bone. Several immunosuppresive agents, such as cyclophosphamide, cyclosporin A and mizoribine, have been clinically used to control disease progresssion, though relatively little is known of their effects on rheumatoid synovium. Rapamycin exhibits a strong immunosuppressive activity by acting on T cell signalling pathways. In the present study we examined the effects of rapamycin on the growth of synovial fibroblast isolated from RA patients. Platelet-derived growth factor (PDGF) is a potent growth factor in synovial fibroblasts isolated from RA patients. PDGF and serum stimulation resulted in a rapid phosphorylation of tyrosine and activation of mitogen-activated protein kinase (MAP kinase), 70-kD-S6 kinase (P70S6K) and 90-kD-S6 kinase (P90rsk). Rapamycin, a macrolide immunosuppressant, inhibited completely growth factor-induced synovial fibroblast proliferation and P70S6K activation. In contrast, tyrosine phosphorylation and activation of MAP kinases and P90rsk were not influenced by rapamycin treatment. Our data demonstrate that growth factor-mediated P70S6K activation is closely related to the growth of synovial fibroblast, and suggest the efficacy of rapamycin for controlling synovial hyperplasia in RA.

Transforming growth factor beta 1 (TGF-beta 1) is a potent growth inhibitor of human umbilical vein endothelial cells (HUVEC). We investigated whether apoptosis is involved in the TGF-beta 1 mediated HUVEC growth inhibition. Using immunofluorescence microscopy and staining by propidium iodide, we showed HUVEC treated with TGF-beta 1 contained characteristic apoptotic nuclei with condensation of chromatin. FACS analysis demonstrated that the number of cells with hypodiploid DNA contents were increased in HUVEC treated with TGF-beta 1. The DNA fragmentation assay exhibited typical ladder formation in TGF-beta 1-treated HUVEC. Using Western blot analysis, the expression of bcl-2 on HUVEC was down-regulated by TGF-beta 1-treatment. These findings suggest that TGF-beta 1 regulates the growth of HUVEC by inducing apoptosis accompanied with down-regulation of bcl-2 expression.

The histological features of rheumatoid arthritis (RA) consist of overgrowth of synovial cells. Several growth factors that cause synovial hyperplasia have been identified in RA synovium. The basic-fibroblast growth factor (b-FGF), representing one of these growth factors, may play an important role in the pathogenesis of RA. We examined the b-FGF mediated intracellular signal pathway involved in synovial cell growth. b-FGF-induced synovial cell growth was inhibited by protein tyrosine kinase (PTK) inhibitors, herbimycin A and genistein, but not by H7 that inhibits protein kinase C (PKC). Stimulation of synovial cells with b-FGF resulted in tyrosine phosphorylation of cellular proteins and MAP kinase activation. Our results also demonstrated that b-FGF-mediated activation of MAP kinase was inhibited by herbimycin A indicating that protein tyrosine kinase may he involved in the activation of MAP kinase in human synovial cells. However. inhibition of b-FGF-mediated MAP kinase activation by PKC downregulation did not occur.

Here we report a case of primary Sjögren's syndrome with hilar lymphadenopathy, interstitial pneumonitis and interstitial tubulo-nephritis. A 60-year old man was admitted to our hospital in May 1993 because of general fatigue and fever. He was noted to have hypergammaglobulinemia and had positive antibodies to nuclear antigens since 1990 in the absence of clinical manifestations. Since 9 months before admission, he presented with general fatigue, low grade fever and uveitis. On admission, chest X-ray and CT scan showed bilateral hilar lymphadenopathy and interstitial pneumonitis. The negative results for both serum angiotensin converting enzyme and histological findings of the cervical lymph node and the lung excluded the diagnosis of sarcoidosis. Serological examination exhibited marked elevation of polyclonal IgG level and anti-nuclear antibody, but neither anti-SS-A (Ro) nor anti-SS-B (La) antibody was detected. He did not have symptoms of xerophthalmia and xerostomia. Keratoconjunctivitis sicca was diagnosed by positive Schirmer's and rose bengal tests. His labial gland biopsy demonstrated severe mononuclear cell infiltration around the ducts. MRI findings of the parotid glands revealed heterogeneous and dotted high signal intensity similar to those in fat tissues in the T1- and T2-weighted images. These findings depicted that bilateral parotid gland was extensively destructed and was replaced by lipid tissue. Renal biopsy showed interstitial tubulo-nephritis. On the basis of the above findings, he was diagnosed to have primary Sjögren's syndrome and uveitis. Therefore, MR image of the parotid gland is considered to be a noninvasive and useful method for diagnosis of Sjögren's syndrome.