Low copy numbers of complement C4 and homozygous deficiency of C4A may predispose to severe disease and earlier disease onset in patients with systemic lupus erythematosus.

Objectives Low copy numbers and deletion of complement C4 genes are potent risk factors for systemic lupus erythematosus (SLE). However, it is not known whether this genetic association affects the clinical outcome. We investigated C4 copy number variation and its relationship to clinical and serological features in a Northern European lupus cohort. Methods We genotyped the C4 gene locus using polymerase chain reaction (PCR)-based TaqMan assays in 169 patients with SLE classified according to the 1997 revised American College of Rheumatology (ACR) criteria and in 520 matched controls. In the patient group the mean C4 serum protein concentrations nephelometrically measured during a 12-month period prior to genetic analysis were compared to C4 gene copy numbers. Severity of disease was classified according to the intensity of the immunosuppressive regimens applied and compared to C4 gene copy numbers, too. In addition, we performed a TaqMan based analysis of three lupus-associated single-nucleotide polymorphisms (SNPs) located inside the major histocompatibility complex (MHC) to investigate the independence of complement C4 in association with SLE. Results Homozygous deficiency of the C4A isotype was identified as the strongest risk factor for SLE (odds ratio (OR) = 5.329; p = 7.7 × 10-3) in the case-control comparison. Moreover, two copies of total C4 were associated with SLE (OR = 3.699; p = 6.8 × 10-3). C4 serum levels were strongly related to C4 gene copy numbers in patients, the mean concentration ranging from 0.110 g/l (two copies) to 0.256 g/l (five to six copies; p = 4.9 × 10-6). Two copies of total C4 and homozygous deletion of C4A were associated with a disease course requiring cyclophosphamide therapy (OR = 4.044; p = 0.040 and OR = 5.798; p = 0.034, respectively). Homozygous deletion of C4A was associated with earlier onset of SLE (median 24 vs. 34 years; p = 0.019) but not significant after correction for multiple testing. SNP analysis revealed a significant association of HLA-DRB1*0301 with SLE (OR = 2.231; p = 1.33 × 10-5). Conclusions Our findings confirm the important role of complement C4 genes in the development of SLE. Beyond the impact on the susceptibility for lupus, C4 copy numbers may be related to earlier onset and a more severe course of the disease. The association of homozygous deletion of C4A and SLE is accompanied by the presence of HLA-DRB1*0301 without a proven pathophysiological mechanism.

Small dense LDL cholesterol in human subjects with different chronic inflammatory diseases.

BACKGROUND AND AIMS: Chronic inflammatory diseases (CID) are associated with a profound increase in cardiovascular (CV) risk resulting in reduced life expectancy. However, LDL-cholesterol is reported to be low in CID patients which is referred to as the "LDL paradoxon". The aim of the present study was to investigate whether LDL-particles in CID exhibit an increased content of the highly atherogenic small-dense LDL subfraction (sdLDL). METHODS AND RESULTS: In this prospective, single center, observational study we enrolled 141 patients with CID (RA n = 59, inflammatory bowel disease (IBD) n = 35, ankylosing spondylitis (SpA) n = 25, Psoriasis n = 22) in 2011 through 2013 to evaluate sdLDL levels before as well as 6 and 26 weeks after initiation of different anti-cytokine therapies (anti-TNFα, anti-IL-6R antibodies). sdLDL levels were compared to 141 healthy individuals in a case control design. Compared to healthy controls, all CID patients displayed a significantly higher sdLDL content within the LDL cholesterol fraction: RA 35.0 ± 9.2% (p < 0.001), SpA 42.5 ± 10.5% (p < 0.001), IBD 37.5 ± 7.1% (p < 0.001), Psoriasis 33.6 ± 4.6% (p < 0.01). Furthermore, the sdLDL/LDL ratio was significantly higher in male compared to female RA subjects (p < 0.05). Neither anti-TNFα nor anti-IL6R medication altered sdLDL levels despite a significant improvement of disease activity. CONCLUSION: In several different chronic inflammatory disease entities, LDL-cholesterol is shifted toward a pro-atherogenic phenotype due to an increased sdLDL content which might in part explain the LDL paradoxon. Since premature CV disease is a major burden of affected patients, specifically targeting lipid metabolism should be considered routinely in clinical patient care. CLINICAL TRIALS: Registration at German Clinical Trial Register (DRKS): DRKS00005285.

Successful application of belimumab in two patients with systemic lupus erythematosus experiencing a flare during tocilizumab treatment.

This case report describes two female lupus patients who both received biological treatment with tocilizumab and with belimumab. The disease course was remarkably similar in both cases. Tocilizumab resulted in a transient improvement in pleurisy and arthritis but was then followed by a clinical flare accompanied by an increase in autoantibodies and a drop in complement levels. Alike, both patients experienced a rapid and sustained improvement after institution of belimumab. The clinical benefit obtained is currently stable under ongoing belimumab therapy.

[Pulmonary emergencies in connective tissues disorders and vasculitides]. / Pneumologische Notfälle bei Kollagenosen und Vaskulitiden.

Pulmonary emergencies in rheumatic diseases are rare, potentially life-threatening conditions that occur either as a manifestation of the disease itself or as an adverse event of immunosuppressive treatment. Diffuse alveolar hemorrhage, tracheal stenosis, acute pneumonitis and drug-induced lung injury belong to this category. The management of these emergencies requires intensive cooperation between rheumatology and pulmonology. The latter contributes its experience in the care of related conditions, specific endoscopic techniques and local interventions as well as the indispensable and life-supporting forms of assisted ventilation. The present article summarizes the current knowledge on diagnostic and therapeutic procedures including the newly available B-cell directed treatments.

Predictors of patient post-discharge opioid use after cesarean delivery: a prospective study.

BACKGROUND: The opioid crisis is a public health emergency in the United States of America. It is important to understand factors associated with outpatient opioid use. Our primary aim was to assess post-cesarean outpatient opioid use. The secondary aim was to identify characteristics associated with use. METHODS: We conducted a prospective cohort analysis of women who underwent cesarean delivery at an urban academic center. Phone surveys were done on post-discharge days three, seven, and 14. The primary outcome was post-discharge opioid use. RESULTS: Of 205 eligible patients contacted, 190 (91%) agreed to participate and 173 (84%) participated in all three surveys. Median amount of opioid prescribed was 75 mg morphine equivalents (MME) (interquartile range 60-113) and participants used a median of 15 MME (0-53) by discharge day 14. Most patients (139/190) filled their opioid prescription but 42% (80/190) did not consume the opioids prescribed. Outpatient opioid use was associated with increased in-hospital opioid consumption (P=0.0003), gravidity (P=0.003), parity (P=0.004) and number of previous cesarean deliveries (P=0.02). Higher amounts of in-hospital opioid use (P=0.0004), higher gravidity (P=0.02), higher outpatient pain scores (>3/10, P=0.01), and poor pain control (P=0.04) were associated with consuming all prescribed opioids. Patients used opioids for a median of two days post-discharge. Use of non-opioid pain medication was not associated with opioid use. CONCLUSION: Opioids were prescribed in excess of consumption and many patients did not use any opioids. Next steps include developing a prescribing algorithm to incorporate factors we found predictive of opioid use.

High dose intravenous immunoglobulin in autoimmune rheumatic disorders.

Since the effectiveness of high dose intravenous immunoglobulin (IVIg) was first demonstrated in autoimmune thrombocytopenia, IVIg has been investigated in the treatment of various autoimmune rheumatic disorders. Controlled randomised studies have established the efficacy of IVIg in Kawasaki's syndrome, for which combined IVIg and aspirin (acetylsalicylic acid) now constitutes the standard treatment. Another controlled study has demonstrated the benefit of IVIg in dermatomyositis. IVIg treatment in juvenile rheumatoid arthritis has produced contradictory results. Uncontrolled studies and case reports on the application of IVIg in systemic lupus erythematosus, ANCA-associated vasculitides and adult rheumatoid arthritis generally describe short term positive effects. Various mechanisms are thought to underlie the effect of IVIg on autoimmune rheumatic diseases, such as: blockade of Fc receptors;immunomodulation via anti-idiotypic interactions;inhibition of complement-mediated tissue damage;modulation of cytokine expression by leucocytes and endothelial cells; andinhibition of superantigen-mediated T cell activation. IVIg is considered to be a low-risk form of treatment. Reported adverse effects include headache, aseptic meningitis and transient impairment of renal function. Haemolysis and anaphylactic reactions are rare. The effect profile of IVIg makes it a relevant, although still experimental, form of treatment in autoimmune rheumatic disorders, but its high cost renders it unsuitable as a first-line treatment. Because IVIg does not weaken patients' resistance to infection, it might serve as a therapeutic option in bridging clinical situations where immunosuppressive or cytotoxic approaches are contraindicated in patients with autoimmune disorders, such as intercurrent infection or in the period immediately before and after surgery.

A randomized trial of plasmapheresis and subsequent pulse cyclophosphamide in severe lupus: design of the LPSG trial.

A group of clinics cooperating as the Lupus Plasmapheresis Study Group (LPSG) is starting an international multicenter study of the treatment of severe systemic lupus erythematosus. The primary goal of this randomized and prospective trial is to establish whether treatment with plasmapheresis and subsequent pulse cyclophosphamide improves the outcome compared to treatment with pulse cyclophosphamide alone. The underlying rationale assumes that plasmapheresis: a) eliminates pathogenic autoantibodies and immune complexes and b) induces a compensatory activation of pathogenic lymphocyte clones through a feed-back between circulating antibodies and their respective antibody-producing clones. Synchronization of plasmapheresis with subsequent pulse cyclophosphamide should enhance the deletion of pathogenic clones during the period of greatest vulnerability. This overview reviews the first results of treatment approaches based on this concept and summarizes the design of the LPSG trial.

[Eosinophilia - inflammation, proliferation, reaction. Part 1: diagnostics]. / Die Eosinophilie - Inflammation, Proliferation, Reaktion.

Eosinophilia presents a challenge to differential diagnostics due to the multitude of possible causes. An initial difficulty is often to distinguish between threatening disease symptoms and relatively harmless secondary reactions. A highly dynamic clinical progression with severe impairment of the vital functions, like breathing, for example, can make swift action necessary. An example of this is known as acute eosinophile pneumonia, which can often only be controlled with the rapid use of high steroid doses. However, a peripheral blood eosinophilia must not lead to an automatic use of steroids before the most important core tests, as this can compromise further diagnostic measures. Furthermore, less dramatic courses require careful handling of an eosinophilia. Various pneumological, infectological, rheumatological or haematological / oncological disease patterns with a prolonged course can develop seriously if they are not recognised in time and treated in a targeted manner. There is no guideline for eosinophile clinical pictures in general. Already the recommendations for a structured diagnosis are scarce and are often concentrated on internist emphases.

Reduced expression of C1q-mRNA in monocytes from patients with systemic lupus erythematosus.

Inherited C1q deficiency is associated strongly with the development of systemic lupus erythematosus (SLE). The aim of our study was to evaluate the ability of monocytes from SLE patients without inherited C1q deficiency to up-regulate C1q-mRNA upon stimulation. Furthermore, we wanted to elucidate the physiological stimulus for up-regulation of C1q-mRNA. Peripheral blood mononuclear cell (PBMC)-derived monocytes from 10 SLE patients, 10 patients with rheumatoid arthritis (RA) and 10 healthy controls (HC) were stimulated with dexamethasone (DXM), interferon-gamma or both. Additionally, purified monocytes from HC were stimulated with interleukin (IL)-10. C1q-mRNA expression was measured by quantitative reverse transcription-polymerase chain reaction (RT-PCR). C1q protein was detected using the standard alkaline phosphatase/anti-alkaline phosphatase (APAAP) technique. SLE monocytes were significantly less able to up-regulate C1q-mRNA when compared to RA or HC. IL-10 was identified as an important stimulus for C1q synthesis. In SLE patients there is a significant functional impairment of monocytes to synthesize C1q upon stimulation. As C1q is linked to the process of recognition and removal of apoptotic cells, this relative C1q deficiency is likely to contribute to the reduced phagocytosis of apoptotic material observed in SLE and thereby might be a central pathogenetic factor.

IL-1RA in refractory systemic lupus erythematosus.

There is evidence from animal and human studies that IL-1 might play an important role in the development and maintainence of inflammation in systemic lupus erythemathosus (SLE). We hypothesized that, in SLE, there might be a relative deficiency in the physiologic antagonist of IL-1, IL-1 receptor antagonist (IL-1RA). We therefore treated three patients with active SLE in whom conventional therapy has failed with the human IL-1RA, Anakinra. In two of the three patients there was a transient effect on muscle pain and/or polyarthritis. In one patient with lupus myositis there was no effect at all. The therapy was well tolerated and the only significant side effect was a transient drop in complement levels (C3 and C4) without clinical or laboratory signs of increased SLE activity in all three patients.

Effect of antigen-specific immunoadsorption on antibody kinetics in a rat model.

The investigation of antibody kinetics following antigen-specific immunoadsorption in alkaline phosphatase immunized rats revealed significantly lower antibody levels than in untreated controls over a follow-up period of 6 weeks. A rebounding antibody synthesis as a result of specific depletion was not observed. Non-adsorption of specific antiidiotypic antibodies may explain these findings.

Treatment-free remission in severe systemic lupus erythematosus following synchronization of plasmapheresis with subsequent pulse cyclophosphamide.

OBJECTIVE: To investigate the effect of an intensified treatment protocol synchronizing plasmapheresis with subsequent pulse cyclophosphamide for severe systemic lupus erythematosus (SLE). METHODS: A protocol of plasmapheresis (3 x 60 ml/kg) and subsequent high-dose pulse cyclophosphamide (36 mg/kg) followed by 6 months of peroral immunosuppression was used to treat 14 patients with severe SLE. RESULTS: Rapid improvement was achieved in all patients. Immunosuppressants, including corticosteroids, were withdrawn at month 6 in 12 patients. Eight patients continued without treatment for a mean observation period of 5.6 years (46-91 months). CONCLUSION: The results demonstrate that treatment-free clinical remission can be achieved in some patients with severe SLE.

High dose intravenous immunoglobulins in systemic lupus erythematosus: clinical and serological results of a pilot study.

OBJECTIVE: To investigate the effect of high dose intravenous immunoglobulins (IVIG) in systemic lupus erythematosus (SLE). METHODS: Twelve patients with mildly to moderately active disease were given 30 g of sulfonated IVIG preparation on each of Days 1-4 and 21-24. RESULTS: Within 6 weeks the mean disease activity score, the Systemic Lupus Activity Measure (SLAM), declined from 7.33 (range 3-15) to 5.25 (range 0-10) (p < 0.01). In 9/12 patients the SLAM dropped by at least 2 points. In 3/12 patients the improvement lasted 5 to 12 months. Within 1 week after initiation of therapy most patients showed a decline in ds-DNA antibodies, whereas titers of antinuclear antibodies and complement proteins were not affected. The treatment was well tolerated, with the exception of transient hypotension in one patient. CONCLUSION: In this uncontrolled study, IVIG had temporary beneficial effects in mildly to moderately active SLE.

[G-CSF in patients with lupus-associated neutropenia and infections]. / G-CSF bei Patienten mit Lupus-assoziierter Neutropenie und Infektionen.

Nine patients with SLE-associated neutropenia and infections received 48 Mio U G-CSF per day s.c. for 2-17 days as an adjunct to antibiotic treatment. Granulopoiesis was normal or hyperplastic in all cases. The mean granulocyte count increased within 2 days from 1.4 per nl to 11.4 per nl. Side-effects were exacerbating CNS symptoms in two patients and a case of leukocytoclastic vasculitis. G-CSF induced constantly a rapid and distinct increase of neutrophil granulocytes in lupus-associated neutropenia patients with normo- or hyperplastic granulopoiesis.

Recombinant human granulocyte colony stimulating factor in patients with systemic lupus erythematosus associated neutropenia and refractory infections.

OBJECTIVE: To investigate whether human recombinant granulocyte colony stimulating factor (GCSF) is capable of inducing increased neutrophil granulocyte (polymorphonuclear leukocytes, PMN) counts in patients with systemic lupus erythematosus (SLE) associated neutropenia and refractory infections. METHODS: Nine patients with SLE associated neutropenia and concomitant refractory infections received a total of 12 cycles of 48 Mio U GCSF per day subcutaneously for an average of 6 days (range 1-17 days) as an adjunct to antibiotic treatment. In one case of impaired wound healing, longterm GCSF was applied over 148 days. RESULTS: In each case, the average PMN count increased distinctly within 2 days from 1.3 per nl (range 0.7-2.4) to 8.4/nl (3.2-19.4). Major adverse events were exacerbation of central nervous system symptoms in 2 patients and leukocytoclastic vasculitis in one. CONCLUSION: GCSF induces a rapid increase in PMN counts in patients with lupus associated neutropenia and normal or hyperplastic granulopoiesis. In 3 of 9 patients we observed a flare of lupus associated symptoms.

Response of peripheral blood mononuclear cells from lupus patients to stimulation by CpG oligodeoxynucleotides.

OBJECTIVES: Increased levels of hypomethylated CpG-containing DNA in sera from patients with systemic lupus erythematosus (SLE) may contribute to the initiation and/or perpetuation of the disease. This study characterizes the in vitro response of peripheral blood mononuclear cells (PBMC) from SLE patients to CpG DNA. METHODS: Secretion of cytokines and IgM, cell proliferation and up-regulation of co-stimulatory molecules were evaluated in PBMC from SLE patients (n=24) and normal controls (n=24) after stimulation with synthetic oligodeoxynucleotides (ODN) containing CpG motifs. RESULTS: Up-regulation of co-stimulatory molecules and the secretion of interferon-alpha and interleukin-6 (IL-6) in response to CpG ODN was significantly reduced in monocytes and dendritic cells from SLE patients. Secretion of interferon-gamma by natural killer (NK) cells was also reduced. In contrast, the IgM and IL-10 response of B cells to CpG ODN was normal. CONCLUSION: Monocytes, dendritic cells and NK cells from SLE patients respond abnormally to CpG ODN stimulation, which may contribute to the cytokine imbalance observed in SLE.

Correlation between 18-fluorodeoxyglucose accumulation in large vessels and serological markers of inflammation in polymyalgia rheumatica: a quantitative PET study.

OBJECTIVE: To quantify 18-fluorodeoxyglucose (FDG) accumulation in large vessels in patients with polymyalgia rheumatica by positron emission tomography (PET), and to compare these data with serological markers of inflammation. METHODS: 13 untreated patients with active polymyalgia rheumatica underwent FDG positron emission tomography; eight were analysed in a second PET when in clinical remission. Six patients with other highly inflammatory conditions served as controls. For quantitative analysis, FDG uptake over nine defined vascular regions, divided by an individual background value, was expressed as a region of interest (ROI) index. These data were compared with the clinical status of the patient and with erythrocyte sedimentation rate (ESR), C reactive protein, haemoglobin, and platelet and leucocyte counts. RESULTS: By visual evaluation, 12 of the 13 patients showed an increased tracer uptake of the aorta or its major branches. By quantitative analysis, FDG uptake was significantly increased in polymyalgia rheumatica. In patients with active disease, the mean ROI index for all vascular regions exceeded that of controls by 70% (mean (SD): 1.58 (0.37) v 0.93 (0.12); p<0.001). In the eight patients who underwent follow up PET, the index declined substantially. In active polymyalgia rheumatica, FDG uptake was significantly correlated with C reactive protein (r = 0.8), ESR (r = 0.79), and platelet counts (r = 0.68). CONCLUSIONS: The observed FDG accumulation in the aorta and its branches and a strong correlation between tracer uptake and markers of inflammation is suggestive of large vessel arteritis. Quantitative ROI analysis appears to be a sensitive tool for detecting such inflammation.

Monoclonal cryo-antifibrinogenemia.

We report on a 54-year-old female patient with arthritis and a severe cold-induced leukocytoclastic vasculitis of the skin caused by a rare form of cryofibrinogenemia ("type II" cryofibrinogen). Affinity chromatography of cryoprecipitates from the patient's plasma revealed reversible cryoprecipitability of complexes composed of fibrinogen and a monoclonal antifibrinogen antibody (IgG3 kappa). Conventional serum and plasma electrophoresis did not detect the paraprotein. Control of symptoms was achieved by long-term plasmapheresis.