Clinical, serologic and instrumental data of ten patients affected by sclerodermatous chronic graft versus host disease: similarities and differences in respect to systemic sclerosis.

Chronic graft versus host disease (cGVHD), the most common late complication of allogeneic haematopoietic stem cell transplantation (HSCT), may present with sclerodermatous lesions resembling in some cases the cutaneous involvement of systemic sclerosis (SSc). Certain pathogenetic findings connect the two diseases. In this report we describe ten subjects affected by cGVHD who underwent the examinations routinely carried out to stage SSc patients. Demographic, clinical, serologic and instrumental data were recorded. These patients showed differences in appearance, extent and progression of the sclerodermatous lesions with greater involvement of the trunk and proximal part of the limbs than the extremities. In seven subjects ANA test was positive; scleroderma-associated autoantibodies were not detected in any of the cases. Moreover, typical organ involvement of SSc was not found. Only one patient developed Raynauds phenomenon after HSCT and only one patient demonstrated a nailfold videocapillaroscopic scleroderma pattern. Except for cutaneous involvement of cGVHD, that may resemble SSc, the clinical features of the two diseases are quite different, suggesting that the fibrotic process characterizing cGVHD and SSc has different etiologies and different initial pathobiologic events.

Study on the possible role of the -174G>C IL-6 promoter polymorphism in predicting response to rituximab in rheumatoid arthritis.

OBJECTIVE: Identification of genetic biomarkers of response to biologics in rheumatoid arthritis (RA) is a relevant issue. The -174G>C interleukin-6 (IL-6) promoter polymorphism was investigated in RA patients treated with rituximab (RTX), being IL-6 a key cytokine for B cell survival and proliferation, thus possibly implicated in rituximab efficacy. METHODS: The study was conducted in a real-life retrospective cohort of 142 unselected RA patients (120F/22M) treated with RTX and referred to 7 rheumatologic centres in the north of Italy. One hundred and thirteen (79.6%) patients were rheumatoid factor (RF)-positive and 112 (78.9%) were anti-CCP antibodies positive. The response to therapy was evaluated at the end of the sixth month after the first RTX infusion, by using both the EULAR criteria (DAS28) and the ACR criteria. The IL-6 -174G>C promoter polymorphism was analyzed by RFLP following previously reported methods. RESULTS: Lack of response to RTX at month +6 by EULAR criteria was more prevalent in RA patients with the IL-6 -174 CC genotypes (9/21, 42.8%), than in the GC/GG patients (23/121, 19.0%) (OR 3.196, 95% CI=1.204-8.485; p=0.0234). Similar results were found when evaluating the response by ACR criteria. No differences were found in RA duration, baseline DAS28, baseline HAQ, RF status, anti-CCP status according to the different IL-6 -174 genotypes. CONCLUSION: IL-6 promoter genotyping may be useful to better plan treatment with RTX in RA. Larger replication studies are in course to confirm these preliminary results.

[Sustained response to infliximab treatment in two cases of early rheumatoid arthritis that has been maintained after drug withdrawal]. / Due casi di artrite reumatoide trattati in fase precoce con infliximab con mantenimento dell'effetto dopo la sospensione del farmaco.

The authors report two cases of active seropositive rheumatoid arthritis who were treated in an early phase of the disease with infliximab plus methotrexate obtaining a clinical remission. The benefit was maintained after the discontinuation of the anti-TNF alpha inhibitor for adverse events, indicating that the early administration of the drug may be followed by a sustained remission.

[Chikungunya arthritis: report of 6 cases]. / Artropatia da Chikungunya: descrizione di 6 casi.

Chikungunya is an arboviral disease transmitted by Aedes mosquitoes. The disease typically consists of an acute illness characterised by fever, rash, and incapacitating arthralgia, that can persist for months. Chikungunya virus, a member of the genus Alphavirus, has recently caused a large outbreak on islands in the Indian Ocean and on the Indian subcontinent. The ongoing outbreak has involved more than 1.5 million patients, including travellers who have visited these areas. We describe our casistic of six travellers with Chikungunya arthropathy. All patients experienced fever and rash of short term during a travel in areas of epidemicity. All patients had peripheral poliarthralgias, which duration was >2 months in 4 cases (66%) and >6 months in 1 case (16%).

Specific and non-specific folate binding protein in normal and malignant human tissues.

Binding of tritiated folic acid by supernatants prepared from extracts of normal and leukaemic leucocytes, normal mucosa, and malignant tumours from different parts of the gastrointestinal tract has been measured using Sephadex-gel filtration and albumin-coated charcoal techniques. Non-specific binding (measured by Sephadex G-75 gel filtration) was almost invariably greater than specific binding measured by albumin-coated charcoal separation of bound and unbound folate. In nine normal leucocyte extracts, binding measured by Sephadex G-75 filtration ranged from 1.3 to 18.2 (mean 8.2) pg/mg protein and by albumin-coated charcoal from 1.0 to 14.8 (mean 6.7) pg/mg protein. Raised specific binding was found in the extracts from leucocytes of eight of 14 patients with chronic granulocytic leukaemia, in four substantially so (389, 121, 108, 59.7 pg/mg protein), but was only marginally increased in one of eight cases of acute myeloid leukaemia and in two of five cases of chronic lymphocytic leukaemia. Binding was normal in the extracts of all three cases of acute lymphoblastic leukaemia tested. Among the tissues of the gastrointestinal tract binding was greatest by the duodenal mucosa and liver. Extracts of carcinoma of the stomach and colon bound greater amounts of (3)H-folic acid than the corresponding normal mucosal extracts but the differences were not large. Sephadex G-200 gel chromatography showed more than one binding peak in the extracts of liver and duodenum but only one peak in the other tissues of the gastrointestinal tract, and only one peak, of molecular weight either about 50 000 or over 200 000, in the leucocyte extracts.

Enthesopathies and diabetes mellitus.

OBJECTIVE: There is evidence of a close relationship between diabetes mellitus and disorders of the insertions of tendons, ligaments and articular capsules into bone (enthesopathies). It has been suggested that these disorders may represent genuine complications of diabetes. We therefore conducted a study to determine whether insertion disorders at the calcaneum (calcaneal spurs) represent a complication of non-insulin-dependent diabetes. METHODS: The incidence of calcaneal spurs was studied in a group of 100 patients with non-insulin-dependent diabetes in comparison to 100 sex- and age-matched controls. Patients with disorders involving hyperostosis were excluded. RESULTS: Calcaneal insertion disorders were found to be more common among the diabetics than among the controls. These disorders, however, were also associated with other factors such as the body mass index and age. Discriminant analysis, which would have in theory highlighted any relationship between diabetes and insertion disorders at the calcaneum, did not show definitively that these disorders were a complication of diabetes. CONCLUSION: These results suggest that enthesopathies are not a complication of diabetes mellitus, and we would suggest that this conclusion may be extended to the relationship between diabetes and insertion disorders at other joints.

Middle ear function in rheumatoid arthritis: a multiple frequency tympanometric study.

OBJECTIVE: To evaluate the modifications in the mechanical properties of the middle ear in rheumatoid arthritis by assessing its resonance frequency. METHODS: Thirty patients with rheumatoid arthritis (RA) aged 20 to 68 years (mean age 45.8 +/- 12.4 yrs) were investigated by multiple frequency tympanometry and their data were compared with those obtained in a control group of 48 subjects aged from 19 to 65 years. RESULTS: Normal values, calculated at the 95th percentile from the control group, ranged from 800 to 1250 Hz. Eleven RA patients (36.6%) displayed abnormal resonance values. These findings were monolateral in 9 patients and bilateral in 2 (in all a total of 13 ears). Nine out of 13 ears with abnormal multiple frequency tympanometry data were characterized by an increase in resonance and 4 by a decrease. CONCLUSION: These findings were attributed to abnormal acoustic impedence of the middle ear and indicate a possible involvement of the ossicular diarthroses in RA. Our study suggests that RA may involve the incudo-malleolar and incudo-stapedial joints, altering the ossicular mechanisms in response to static air pressure modifications.

Elimination diet in the treatment of selected patients with hypersensitivity vasculitis.

We have evaluated the effects of an elimination diet in 5 patients with hypersensitivity vasculitis and a personal or family history of allergy. The presence of autoimmune disorders, infections and neoplastic diseases was excluded on the basis of physical examination, clinical history and laboratory data. Three patients had elevated serum immune complexes and evidence of complement consumption before the oligoantigenic diet. In one patient food allergy was diagnosed on the basis of a positive and concordant challenge test, skin prick test and RAST. The study consisted of a 3 week elimination diet, followed by open and double blind challenge tests with specific foods and additives. Four patients achieved a complete remission and one patient experienced great improvement on the elimination diet. In three cases the vasculitis relapsed following the introduction of food additives; in one case with the addition of potatoes and green vegetables (i.e., beans and green peas) and in the last case with the addition of eggs to the diet. The offending foods and additives were subsequently eliminated from the usual diet and no relapses were observed in 2 years of follow-up. These results show that in selected patients with a history of allergy, hypersensitivity vasculitis can be triggered and sustained by food antigens or additives.

Neutrophil functions, spondylarthropathies and HLA-B27: a study of 43 patients.

OBJECTIVES: Several hypotheses have been proposed regarding the role of HLA-B27 antigen in the pathogenesis of the spondylarthropathies. METHODS: We studied some neutrophil functions in vivo in patients affected by ankylosing spondylitis or by reactive arthritis, with or without HLA-B27, and in healthy control subjects. In vivo neutrophil migration was investigated by Senn's skin window technique. An adhesion assay was also conducted and superoxide production was measured in circulating and migrating neutrophils after different stimuli. RESULTS: Neutrophil migration in vivo was higher in the HLA-B27 positive patients than in the controls, while no difference was found between the HLA-B27 negative patients and controls. Our data showed an increased response to formyl-methionyl-leucyl-phenylalanine by circulating neutrophils in the patients with ankylosing spondylitis, both HLA-B27 positive and negative, in comparison with all the other subjects. CONCLUSIONS: Our results revive the question of the role of HLA-B27 in the regulation of neutrophil migration; the reported in vivo priming of circulating neutrophils seems to be related to ankylosing spondylitis rather than to HLA-B27.

Copper and zinc status in rheumatoid arthritis: studies of plasma, erythrocytes, and urine, and their relationship to disease activity markers and pharmacological treatment.

We studied the status of copper and zinc in rheumatoid arthritis (RA). The aims of the work were to ascertain whether or not RA is associated with copper and/or zinc deficiency, to establish the relationship between these trace metals and the main biohumoral and clinical indices of the disease, and to examine the effect on copper and zinc of the drugs normally used by RA patients. Metal levels were measured by atomic absorption spectroscopy in the plasma, whole blood cells and 24 hr urine of 120 RA patients; 70 patients suffering from primary osteoarthritis were used as the control group. In the plasma of RA patients copper and ceruloplasmin levels were found to be significantly increased whereas zinc levels were significantly decreased. No major variations were observed in the blood cell and 24 hr urine copper and zinc levels. Plasma copper was significantly correlated with some of the biohumoral markers of RA, but did not correlate with any of the clinical indices of the disease. Plasma zinc was significantly correlated with numerous of the biohumoral as well as clinical markers of RA. With the exception of an increased urinary excretion of copper in D-penicillamine treated RA patients, drug therapy did not influence the copper status in RA. Conversely, plasma zinc was found to be lower in RA patients taking NSAIDs and/or steroids. These results suggest the following conclusions: i) RA patients do not seem to be deficient in either copper or zinc; ii) plasma copper appears to be a poor index of RA severity; iii) plasma zinc could have some practical value in defining the overall severity of the disease.

Effects of cyclosporin on joint damage in rheumatoid arthritis. The Italian Rheumatologists Study Group on Rheumatoid Arthritis.

According to the most recent literature, few antirheumatic drugs can claim disease-controlling properties over the anatomical joint damage in rheumatoid arthritis (RA). A small number of studies have favored one or another of the available agents, in particular parenteral gold salts, sulphasalazine and methotrexate, but the evidence regarding their efficacy is not convincing when analysed using methodological criteria known to be important in evaluating radiologic evidence of joint damage. The radiologic results in long-standing RA patients have shown that CsA may be of benefit in reducing disease progression. Data from the second year of a clinical trial designed to compare the disease-controlling, anti-rheumatic properties of CsA with those of conventional disease-modifying anti-rheumatic drugs (DMARDs) in early RA support the hypothesis that CsA may be useful in delaying the appearance of new joint erosion.

Studies of skin-window exudate human neutrophils: complex patterns of adherence to serum-coated surfaces in dependence on FMLP doses.

Human neutrophils were isolated both from peripheral blood (PB) and from aseptic inflammatory exudates obtained by the Senn's skin-window (SW) technique. The respiratory burst (O2- release) and the adherence to serum-coated wells of culture microplates was investigated using a simultaneous assay. Unstimulated PB resting neutrophils did not produce a significant amount of O2- and were incapable of adhering to serum-coated plastic surfaces, while unstimulated SW neutrophils showed augmented adhesion to serum-coated culture wells. SW neutrophils were primed to enhanced FMLP-dependent O2- release in response to n-formyl-methionyl-leucylphenylalanine (FMLP). Adhesion of SW neutrophils was significantly decreased by addition of low doses (10(-10)-10(-8) M) of FMLP (from 17.1% to 8.4%, P < 0.01, N = 12), while fully activating doses (> 5 x 10(-8) M) of FMLP induced a marked increase of the cell adhesion, more pronounced in SW (39.2%) than in PB cells (27.2%). Low (5 x 10(-9) M) and high (5 x 10(-7) M) FMLP doses induced morphological changes (polarization) and actin polymerization in the neutrophils from both sources. Biphasic dose-response curves of SW neutrophil adherence were observed using FMLP, but not using concanavalin A or phorbol myristate acetate as stimulatory agents. Therefore, the adherence of SW cells appears to be regulated in a complex fashion, nonlinearly dependent on the chemotactic peptide doses and specifically regulated according to the receptors involved.

Factor-specific changes in oxidative burst response of human neutrophils in skin-window exudates.

Human neutrophils were isolated from blood and aseptic inflammatory exudates. The respiratory burst response was measured as superoxide (O2-) production by a microplate assay system and polarographically as oxygen consumption. Exudate cells exhibited a respiratory burst in response to n-formyl-methionyl-leucyl-phenyl-alanine (FMLP) that was two- to threefold higher than the burst exhibited by peripheral blood cells. The O2- production induced by substance P was also found to be fivefold higher in exudate cells, while the metabolic response to other stimulants such as concanavalin A (con A), phorbol-myristate acetate (PMA), NaF, and immunocomplexes was not primed. Serum-treated zymosan (STZ)-stimulated activity was primed by only 11%. In contrast, superoxide production in response to tumor necrosis factor-alpha (TNF) was decreased in exudate versus blood cells by about 50%. Therefore, the skin-window cells, compared to blood cells, appear to be at the same time primed, unmodified, and desensitized, according to the different stimulants employed.

Studies of skin-window exudate human neutrophils: increased resistance to pentoxifylline of the respiratory burst in primed cells.

Human neutrophils were isolated both from peripheral blood (PB) and from aseptic inflammatory exudates obtained by the Senn's skin window technique (SW). The respiratory burst (O2- production) induced by in response to n-formyl-methionyl-lencyl-phenylalanine (fMLP) and by serum-treated zymosan (STZ) was investigated using a microplate assay. SW neutrophils were primed to enhanced fMLP-dependent O2- production in response to fMLP but not to STZ. Pentoxifylline, a cAMP-elevating drug, dose-dependently inhibited the respiratory burst in any experimental condition, but the dose-effect curves were markedly different according the stimulant used and the source of the cells. With fMLP as stimulant, a significant inhibition of the O2- production by PB neutrophils was obtained using doses of 10 micrograms/ml, while SW neutrophils were inhibited only by doses equal or higher than 100 micrograms/ml. With STZ as stimulant, the inhibition of the respiratory burst of PB neutrophils and of SW neutrophils was obtained only with doses higher than 400 micrograms/ml and 1 mg/ml respectively. Pentoxifylline dose-dependently (10 micrograms/ml to 1 mg/ml) increased the intracellular adenosine 3'-5'-cyclic monophosphate (cAMP) to the same extent in SW and in PB neutrophils. These data indicate that the priming of neutrophil oxidative metabolism by in vivo inflammation is associated with an increase in the resistance to the regulating effect of cAMP on the fMLP-dependent activation pathway of NADPH oxidase. The fact that therapeutic doses of pentoxifylline do not inhibit the respiratory burst of primed neutrophils may have relevance in the interpretation of the clinical effects of this drug.

Effects of dietary fish oil and soy phosphatidylcholine on neutrophil fatty acid composition, superoxide release, and adhesion.

Fifty-seven healthy volunteers matched for sex and age were subdivided in 3 groups and their usual Western diets were supplemented according to three different protocols: group 1, fish oil supplement (20 ml/day); group 2, soybean phosphatidylcholine (PC) (25 g/day) and group 3, no supplementation (control group). After 2 weeks several important modifications of neutrophil fatty acid composition were observed: fish oil induced a significant decrease of linoleic (LA) and arachidonic acid (AA) and a significant increase of eicosapentaenoic (EPA) and docosahexaenoic acid (DHA), while soy PC induced significant increases of LA, total polyunsaturated fatty acid (PUFA) and PUFA/SFA ratio. Neutrophil superoxide generation and adhesion were not modified by fish oil diet, on the contrary a slight but significant increase of O2.- production in response to fMLP was measured after soy PC diet. Our study confirms the possibility of changing neutrophil fatty acid composition in vivo by dietary means, but also suggests that the manipulation of cell functions, like superoxide anion generation and adhesion, is not easily and directly achieved by controlling membrane lipid environment.

Neutrophil migration, oxidative metabolism, and adhesion in elderly and young subjects.

OBJECTIVE: To evaluate neutrophil functions in the elderly. METHODS: We investigated the PMN migration in vivo and PMN superoxide production and adhesion in response to a variety of compounds; PMN have been isolated both from blood and from a skin experimental exudate (obtained by Senn's skin window technique) of 25 normal elderly and of 25 normal young control subjects. RESULTS: No difference was found in PMN migration in vivo (62.9 +/- 21.3 x 10(6) and 65.5 +/- 9.1 x 10(6) PMN/cm2/24 hours in elderly and young subjects respectively), neither were different the adhesion under basal condition and after some stimuli and the superoxide production in basal condition and in response to STZ and PMA in two groups. In elderly subjects superoxide production, in response to fMLP, markedly resulted lower than in young controls both by circulating PMNs (3.6 +/- 2.7 and 9.3 +/- 3.3 nMOLES O2-/10(6) PMN respectively, p < 0.0001) and by exudate PMNs (13.6 +/- 4.3 and 19.4 +/- 6 nMOLES O2-/10(6) PMNs respectively, p < 0.005). CONCLUSION: Many PMN functions in the elderly do not differ from young people, suggesting that the overall defense function of these cells is not affected by aging. The only parameter that we have found to be different between the two groups is the poor superoxide production after fMLP stimulus of PMNs. The stimulus- and function-specificity of this defect in PMNs from elderly subjects indicates the existence of a dysregulation of the signal transduction pathway distal to fMLP receptor and proximal to NADPH oxidase activation.

Changes of fatty acid composition and oxidative metabolism of human neutrophils migrating into an inflammatory exudate.

The peripheral blood neutrophils and the neutrophils accumulated into a skin-window experimental exudate were compared for their ability to release superoxide anion (O2-) and for their fatty acid composition, determined by capillary gaschromatography. The basal O2- release and the phorbol myristate acetate (PMA)-induced O2- release were not significantly different in the two neutrophil populations, while in response to formyl-methionyl-leucyl-phenylalanine (fMLP) the exudate cells showed an activity that was two fold higher than that of blood cells. The most significant changes of fatty acid composition of exudate versus blood cells were the following: i) increase of C16:0 (palmitic acid) from 21.3 +/- 1.2% to 23.5 +/- 1.3% (+ 10.2%) of total fatty acids (p < 0.001),ii) increase of C18:2 (linoleic acid) from 9.3 +/- 1.7% to 11.0 +/- 2.1% (+ 18.3%) (p = 0.005), iii) decrease of C20:4 (arachidonic acid) from 12.8 +/- 1.6% to 10.6 +/- 1.2% (-17.3%) (p < 0.001), whereas C18:1 (oleic acid) did not change. The total content of saturated or unsaturated fatty acids did not change. In exudate cells, a strong negative correlation was found between palmitic acid content and O2- release in response to both fMLP and PMA (r = -0.52, p < 0.02 and r = -0.49, p < 0.05, respectively) whereas arachidonic acid correlated positively, but weakly, with O2- (r = 0.40, p = 0.07 and r = 0.47, p = 0.05, with fMLP and PMA as stimulants respectively). A positive correlation was also found between the arachidonic acid content of blood cells and the number of cells that migrated into the inflammatory exudate. These results indicate that the process of extravasation from blood into the exudate causes specific and consistent modifications of the fatty acid composition of neutrophils and suggest that these modifications have a role in the activation and the regulation of the O2- forming system.

Neutrophil functions and IL-8 in psoriatic arthritis and in cutaneous psoriasis.

The aim of this study is to determine some functions of neutrophil in patients affected by psoriatic arthritis and to compare them to those of patients affected by cutaneous psoriasis and to normal controls. We used a model of experimental cutaneous inflammation allowing to separate a cluster of purified and viable PMN cells. Then we analyzed, within the three groups, the IL-8 concentration in serum and in the supernatant obtained from the inflammatory site to gather data on the possible pathogenic role played by this cytokine in psoriatic arthritis. We studied neutrophil functions in patients with cutaneous psoriasis and psoriatic arthritis, in acute phase, in comparison with healthy control subjects. We investigated in vivo neutrophil migration by Senn's skin window technique and measured adhesion assay and superoxide production in circulating and migrating neutrophils after different stimuli. We also measured IL-8 concentration in serum and in the supernatant obtained from the inflammatory site, artificially created through the skin window scrape. Neutrophil migration in vivo was significantly higher in both groups of patients than in controls. In the presence of fMLP, blood cells showed a burst of superoxide release, which was significantly more pronounced in patients when compared to healthy controls. Neutrophils from skin window scrape showed a much higher response to fMLP as compared to blood cells of all subject groups, but no differences were observed between patients and controls. No correlation was found between the three groups in adhesion ability under basal condition or in response to different stimuli by circulating and migrating neutrophils. Our results also show a great increase of IL-8 in the exudate from patients compared to controls. Our study shows that there is no difference in neutrophil functions between patients with psoriatic arthritis and cutaneous psoriasis; moreover we suggest that the source of high IL-8 levels are neutrophils rather than the keratinocytes.

Panniculitis induced by collagen and plexiglas microsphere injections used for aesthetic treatment.

The authors report an unusual case characterised by the prompt appearance of panniculitis after injections of collagen and plexiglas microsphere for aesthetic aim and review the literature about aesthetic treatments and rheumatic disorders.