Immunomodulatory effect of vitamin D supplementation on Behçet's disease patients: effect on nitric oxide and Th17/Treg cytokines production.

INTRODUCTION: In the last decade, an immuno-modulatory effect of vitamin D supplementation have emerged as a potential therapeutic approach for some inflammatory and autoimmune diseases. As previously reported, vitamin D deficiency was strongly linked to several diseases as Behçet's disease (BD). BD is a chronic systemic inflammatory disorder with autoimmunity, genetic and environmental factors involvement. The aim of our current study is to set up a new therapeutic strategy in BD, combining conventional therapy and vitamin D supplementation. MATERIALS AND METHODS: Blood samples were collected from active and inactive BD patients and healthy controls (HC) to evaluate 25(OH) vitamin D levels using an electrochemiluminescence method. All deficient and insufficient vitamin D BD patients' were supplemented with vitamin D3 (CHOLECALCIFEROL, 200 000 UI/1 ml). In this context, NO, IL-17A and IL-10 levels were evaluated in patients and HC in vivo and ex vivo using Griess and ELISA methods respectively. RESULTS: Before supplementation, we noted with interest that BD patients had vitamin D deficiency, associated with elevated in vivo and ex vivo NO and IL-17A levels compared to HC. Conversely, low IL-10 levels were observed in the same BD patients in comparison to HC. Interestingly, restored vitamin D status in supplemented BD patients was related to the decreased NO levels. In the same way, the IL-10/IL-17A ratio was improved. CONCLUSIONS: Collectively, our data suggest that vitamin D supplementation in combination with conventional treatments has a beneficial effect and could constitute a good therapeutic candidate for alleviating inflammatory responses during Behçet disease.

Vitamin D status in Algerian Behçet's disease patients: an immunomodulatory effect on NO pathway.

Behçet's disease (BD) is an inflammatory multisystemic disorder associated with orogenital ulcers, uveitis and skin lesions with unpredictable episodes of exacerbations and remissions. Even though several immunological and environmental factors contribute to BD progression, its ethiopathogenesis remains uncertain and elusive. Considered as one of the potent environmental factors that can increase prevalence of some autoimmune and inflammatory disorders, vitamin D deficiency has been linked to several diseases as BD. The aim of this study is to assess vitamin D status in Algerian BD patients and its relationship with disease activity. Immunomodulatory effect of this vitamin on nitric oxide (NO), inflammatory mediator, was also undertaken. Serum 25(OH) vitamin D levels were measured in healthy controls (HC), active and inactive BD patients with an electrochemiluminescence method. After treatment of HCs' and patients' peripheral blood mononuclear cells with different concentrations of vitamin D3, NO production was evaluated with Griess method, while inducible nitric oxide synthase (iNOS) and NF-κB expression with immunofluorescence test. A high decrease of vitamin D levels was noted in active BD patients compared to those of inactive stage and HC. However, a higher NO production was observed during active stage of BD compared to inactive one. In inactive BD, vitamin D levels correlates negatively with NO. Interestingly, vitamin D3 inhibits ex vivo NO production, iNOS and NF-κB expression in BD patients. In conclusion, vitamin D deficiency was associated with active BD. This vitamin down-modulates NO production in BD patients, suggesting that it may be considered as promising therapy modulating inflammation during BD.

Ex vivo immunomodulatory effect of all-trans-retinoic acid during Behçet's disease: a study in Algerian patients.

Uveitis, recurrent oral and genital ulcerations associated with skin lesions are the major symptoms of a chronic multisystemic inflammatory disorder known as Behçet's disease (BD). High prevalence of this dreaded disease has been observed in the Mediterranean basin, including Algeria and along the Silk Road. Although the etiologic agent of this disease remains uncertain, many hypotheses have been advanced in its pathogenesis. Our team has previously reported high levels of nitric oxide (NO) in sera of BD patients, suggesting its deleterious effect during chronic inflammation. In our current study, the aim is to investigate the ex vivo immunomodulatory effect of all-trans-retinoic acid (ATRA) on NO pathway in Algerian BD patients. First, peripheral blood mononuclear cells isolated from active and inactive BD patients and healthy controls were cultured with different concentrations of ATRA. NO production was estimated with the Griess method. To elucidate the underlying mechanisms of ATRA effect on NO production, we analyze inducible nitric oxide synthase expression and nuclear factor-κB (NF-κB) activity by immunofluorescence test. Our results revealed a higher production of NO in active BD compared with the inactive stage and healthy controls. We observed that ATRA inhibits NO production in BD both in active and inactive stages and inhibits NF-κB translocation. In conclusion, we report a relationship between NO production and the disease activity. ATRA down-regulates NO production in BD patients. This immunomodulatory effect seems to be mediated through NF-κB pathway. All these findings suggest that ATRA could be considered as a promising therapy for BD.

Disease activity score for still's disease.

OBJECTIVE: To develop the Still's Disease Activity Score (SDAS). METHODS: We used data from the prospective adult-onset Still's disease cohort study and evaluated the disease activity. An expert group selected the most frequent, reproducible, and objective variables significantly modified in statistical analysis when comparing patients in the active group and in the remission group. These criteria were weighted to design the Still's Disease Activity Score (SDAS). The Delphi method was used to appreciate the level of disease activity. Total SDAS was calculated for each patient and compared to final consensus experts. RESULTS: At the diagnosis, all patients had an active disease (n = 80), while 48 patients were in remission at 6 months. The SDAS criteria were weighted as follows: fever ≥ 38.5 °C (1 point), rash (1 point), joint involvement (arthralgia: 1 point, swollen joints count "SJC": 1-3 SJC: 2 points, ≥ 4 SJC: 3 points), physician global assessment VAS ≥ 5/10 or a raise in physician VAS ≥ 2/10 (3 points), patient VAS ≥ 5 or a raise in patient VAS ≥ 2/10 (1 point), and CRP (> 10 mg/l: 1 point, ≥ 100 mg/l: 2 points). At 6 months, the consensus was achieved for 76 (95%) patients with 40 in remission (0-1 point), 8 in low disease activity (2-3 points), 16 in moderate disease activity (4-7 points), and 12 in severe disease activity (≥ 8 points). CONCLUSION: The Still's Disease Activity Score is a valid and sensitive assessment of the disease activity and the therapeutic response in Still's disease, despite its heterogeneous manifestations and patterns with systemic and articular forms. Key Points • The Still's Disease Activity Score (SDAS) is a good simple tool to assess the activity of the disease in a stable state for a week. • The SDAS is developed specifically for Still's disease without the need for an application or a calculator to calculate SDAS in routine clinical practice. • SDAS is a composite score classifying the disease activity in remission, low disease activity, moderate disease activity, and severe disease activity despite its heterogeneous patterns (systemic and articular forms). • The SDAS is a valid, reliable, and sensitive score and can be useful to guide the therapeutic strategy in clinical practice and in research.

Increased Salivary Cytokines and Nitric Oxide Levels in Behçet's Disease: Interleukin-32, a Novel Player in Disease Prognosis.

BACKGROUND: Oral aphthosis is one of the major manifestations of Behçet's disease (BD), a chronic, multisystemic vasculitis. BD etio-pathogenicity related to oral health lack. OBJECTIVE: This study investigated the possible relationships between poor oral hygiene, oral activity, disease severity and saliva's Interleukin (IL)-32, IL-6, IL-10 and nitric oxide (NO) levels in Behçet's patients to determine their role in disease prognosis and their potential therapeutic interest. METHODS: Fifty-six patients with BD (22 orally active; 34 orally inactive) and 31 healthy subjects have been included in our study. Salivary levels of IL-32, IL-6, and IL-10 were measured using ELISA, while NO levels were assessed by modified Griess's method. Oral health status and disease severity scores were recorded for each participant. Kruskal-Wallis test and Spearman's test were performed for statistical analyses. RESULTS: We observed that the tested molecules were increased in BD patients compared to healthy controls (p˂0.05). Moreover, only IL-32 levels were associated with oral activity in patients (p˂0.05). Interestingly, the disease severity score was noted to be correlated positively and significantly with both IL-32 saliva levels (p˂0.01) and plaque index (p˂0.05) in BD patients. Furthermore, IL-32 levels were correlated with plaque index (p˂0.0001). CONCLUSION: Our results suggest that IL-32, IL- 6, IL-10 and NO were increased in saliva during BD. Our study indicated that IL-32 was associated with the genesis of oral ulcers in response to dental plaque. Ultimately, salivary IL-32 may serve as a prognostic biomarker and a possible therapeutic target for managing Behçet's disease severity.

Proposal of a new diagnostic algorithm for adult-onset Still's disease.

OBJECTIVE: This study was performed to develop a new diagnostic algorithm for adult-onset Still's disease (AOSD). METHODS: We conducted a multicenter prospective nationwide case-control study in tertiary Internal Medicine, Rheumatology, and Infectious Diseases departments, to include successively patients with suspected AOSD based on the presence of two or more major criteria of Yamaguchi and/or Fautrel classifications. Patients were classified as AOSD or controls according to a predefined procedure. A receiving operating characteristic curve was used to determine the best cutoff value of the points-based score for disease classification. A diagnostic algorithm was developed to help the physician in the diagnostic approach. RESULTS: A total of 160 patients were included, 80 patients with AOSD and 60 controls with different diagnoses. Twenty patients with incomplete data were excluded. In the multivariate analysis, 6 items remained independently associated with AOSD diagnosis: typical rash (OR: 24.01, 3 points), fever ≥ 39 °C (OR: 17.34, 3 points), pharyngitis (OR: 10.23, 2 points), arthritis (OR: 9.01, 2 points), NLR ≥ 4 (OR: 11.10, 2 points), and glycosylated ferritin ≤ 20% (OR: 1.59, 1 point). AOSD should be considered if the patient satisfies 7 points with a sensitivity of 92.5%, specificity of 93.3%, and accuracy of 92.8% (area under the curve (AUC): 0.97 [95% CI: 0.94-0.99]). The present points-based score was more accurate and sensitive than the Yamaguchi classification (78.8%, 92.5%, p = 0.01) and Fautrel classification (76.3%, 92.5%, p = 0.004). A typical rash associated with a points-based score ≥ 7 points leads to a very likely disease. CONCLUSION: The proposed new algorithm could be a good diagnostic tool for adult-onset Still's disease in clinical practice and research. Key Points • A diagnostic algorithm was performed to help the physician in the diagnostic approach of AOSD. • The points-based score included in this algorithm had a high sensitivity and accuracy. • This diagnostic algorithm can be useful in the clinical research.

Validation of the neutrophil-to-lymphocyte ratio as a new simple biomarker of adult onset Still's disease: A STROBE-Compliant prospective observational study.

This study was performed to investigate the role of neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of adult onset Still disease (AOSD) and its performance to improve the sensitivity of the classifications criteria (Yamaguchi and Fautrel Classifications). We conducted a multicenter prospective nationwide case-control study in Internal medicine, Rheumatology and Infectious disease departments, to include successively patients with suspected AOSD (2 or more major criteria of Yamaguchi or Fautrel classifications). All clinical and biological features were collected in a consensual and standardized clinical assessment at baseline and during follow-up. A receiving operating characteristic (ROC) curve was used to reassess the cutoff value of NLR. After determination of the cutoff value for NLR by ROC curve, 2 composite sets (Yamaguchi classification + NLR as a major criterion and Fautrel classification + NLR as a major criterion) were performed and evaluated. One hundred sixty patients were included, 80 patients with AOSD and 60 controls with different diagnoses. Twenty patients with incomplete data were excluded. The cutoff value for NLR equals 4 (area under the curve, AUC: 0.82). The NLR was ≥ 4 in 93.7% (75/80) of AOSD patients with a sensitivity of 93.8% and specificity of 61.7%. The association of NLR as a major criterion with the classification of Yamaguchi or Fautrel improved their sensitivity, respectively for Fautrel (76.3% to 92.5%, P = .004) and Yamaguchi (78.8% to 90%, P = .05). This study validates the NLR as a good simple biomarker of AOSD with a cutoff value of 4 and high sensitivity (93.8%). The addition of NLR (NLR ≥ 4) as a major criterion to the classifications (Yamaguchi and Fautrel) improved significantly their sensitivity and accuracy.

Cytokines Modulate the "Immune-Metabolism" Interactions during Behçet Disease: Effect on Arginine Metabolism.

Aim and Methods. In this study, we evaluated NOS and arginase activities and their regulation during Behçet disease, a systemic chronic inflammatory disorder with uncertain etiology. The peripheral blood mononuclear cells of 36 patients and 15 control samples (PBMC) were cultured in either RPMI 1640, MEM, or DMEM complemented with 10% of FBS and antibiotics. Cultures were performed with or without the control or patients plasma. Subsequent treatment contained anticytokines (IL-6, TGF-ß), a mitogenic effector (PHA), or NOS modulators (L-NMMA, BH4). Culture supernatants were harvested after 24 h of incubation. NO and urea measurements were, respectively, performed by modified Griess and Berthelot methods. Results. Higher urea levels were found in patients' plasma compared to the control's (P < 0.05). NOS modulators induced inverted production profiles for NO and urea (P < 0.05). Their results differed depending on the clinical findings (P < 0.05). It was also found that cytokine neutralization induced different response profiles in patients as opposed to control cultures (P < 0.05). Conclusion. Our results suggest that arginases can compete with NOS2 for L-arginine during Behçet disease. Both enzymes are regulated by environmental cytokines and substrate availability. Furthermore, it seems that NOS/arginase balance is dependent on clinical expression.

Ex vivo effects of flavonoïds extracted from Artemisia herba alba on cytokines and nitric oxide production in Algerian patients with Adamantiades-Behçet's disease.

BACKGROUND: Adamantiades-Behçet's disease (ABD) is a chronic multisystemic inflammation with unknown pathophysiology. This disorder is associated with a dysregulation of the cytokine network that hyperactivates neutrophils and macrophages. In this study, we investigate the modulatory effects of flavonoïd compounds extracted from Algerian medicinal plant Artemisia herba alba on Th1 and Th2 cytokines and nitric oxide production. METHODS: The modulatory effects of flavonoïds extracted from Artemisia herba alba on cytokines and nitric oxide production by peripheral blood mononuclear cells isolated from Algerian ABD patients and healthy controls were respectively measured by means of ELISA assays and Griess modified method. RESULTS: Our results show that flavonoïds significantly reduce the production of interleukin-12, the key effector of T helper 1 (Th1) cells and nitric oxide in a dose-dependent manner in Adamantiades-Behçet's disease. In contrast, the production of IL-4, the key marker of Th2 cells was increased. CONCLUSION: This study suggests that in vitro supplementation with flavonoïds extracted from Artemisia herba alba could have potential immuno-modulatory effects characterised by a down-regulation and up-regulation of Th1 and Th2 cytokines, respectively. Moreover, flavonoïds may prevent nitric oxide induced damages.