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OBJECTIVES: To assess the prevalence and severity of ultrasonographic abnormalities of the hand and wrist of asymptomatic patients with systemic lupus erythematosus (SLE) and compare these findings with those from patients with SLE with musculoskeletal signs or symptoms and healthy controls. METHODS: We conducted a prospective cross-sectional study that evaluated bilaterally, with grey-scale and power Doppler (PD) ultrasound (US), the dorsal hand (2nd to 5th metacarpophalangeal and 2nd to 5th proximal interphalangeal joints) and wrist (radiocarpal, ulnocarpal and intercarpal joints) of 30 asymptomatic patients with SLE, 6 symptomatic patients with SLE and 10 controls. Synovial hypertrophy (SH) and intra-articular PD signal were scored using semiquantitative grading scales (0-3). Individual scores were graded as normal (SH≤1 and PD=0) or abnormal (SH≥2 or PD≥1). Global indexes for SH and PD were also calculated. US findings were correlated with clinical and laboratory data and disease activity indexes. RESULTS: US detected SH (score ≥1) in 77% asymptomatic patients with SLE, mostly graded as minimal (score 1: 63%). 23% of the asymptomatic patients with SLE showed abnormal US PD findings (SH≥2 or PD≥1). SH was present in all symptomatic patients with SLE, mostly graded as moderate (grade 2: 67%), and with associated PD signal (83%). SH (score 1) was identified in 50% of controls, however, none presented abnormal US PD findings. SH index in the asymptomatic SLE group was higher than in the control group (2.0 (0-5) vs 0.5 (0-2), median (range), p=0.01) and lower than in the symptomatic SLE group (7.0 (4-23), median (range), p

ObjectivesDevelop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS).MethodsSystematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus.ResultsFamily planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease.ConclusionsRecommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.

In the wake of the Portuguese vaccination program 50th anniversary it seems appropriate to review vaccination in patients with systemic lupus erythematosus. Controversial issues as regards the association between autoimmune diseases, infections, and vaccines are discussed as well as vaccine safety and efficacy issues as regards chronic immunosuppressant (IS) drug therapy. After a brief overview of national policies, specific recommendations are made as regards vaccination for adult patients with SLE with a particular focus on current IS therapy and unmet needs.

Purpose Intravenous IgG (ivIg) is a therapeutic alternative for lupus erythematosus, the mechanism of which remains to be fully understood. Here we investigated whether ivIg affects two established sub-phenotypes of SLE, namely relative oligoclonality of circulating T-cells and reduced activity of CD4+Foxp3+ regulatory T-cells (Tregs) reflected by lower CD25 surface density. Methods We conducted a longitudinal study of 15 lupus patients (14 with SLE and one with discoid LE) treated with ivIg in cycles of 2–6 consecutive monthly infusions. Among these 15 patients, 10 responded to ivIg therapy with clear clinical improvement. We characterized Tregs and determined TCR spectratypes of four Vβ families with reported oligoclonality. Cell counts, cytometry and TCR spectratypes were obtained from peripheral blood at various time points before, during and after ivIg treatment. T-cell oligoclonality was assessed as Vβ-familywise repertoire perturbation, calculated for each patient in respect to an individual reference profile averaged over all available time points. Results For 11 out of 15 patients, average Vβ1/Vβ2/Vβ11/ Vβ14 repertoires were less perturbed under than outside ivIg therapy. The four exceptions with relatively increased average perturbation during ivIg therapy included three patients who failed to respond clinically to an ivIg therapy cycle. Patients' Treg CD25 surface density (cytometric MFI) was clearly reducedwhencomparedtohealthycontrols,but not obviously influenced by ivIg. However, patients' average Treg CD25 MFI was found negatively correlated with both Vβ11 and Vβ14 perturbations measured under ivIg therapy. Conclusions This indicates a role of active Tregs in the therapeutic effect of ivIg.

Thymocytes differentiate into CD4+ Foxp3+ regulatory T cells (TR) upon interaction between their TCR and peptide–MHC II complexes locally expressed in the thymus. Conversion of naive CD4+ T cells into TR can additionally take place in the periphery under noninflammatory conditions of Ag encounter. In this study, making use of TCR transgenic models naturally devoid of Foxp3+ cells, we report de novo generation of TR upon a single footpad injection of Ag mixed with a classic proinflammatory adjuvant. Abrupt TR differentiation upon immunization occurred intrathymically and was essential for robust tolerance induction in a mouse model of spontaneous encephalomyelitis. This phenomenon could be attributed to a specific feature of thymocytes, which, in contrast to mature peripheral CD4+ T cells, were insensitive to the inhibitory effects of IL-6 on the induction of Foxp3 expression. Our findings uncover a pathway for TR generation with major implications for immunity and tolerance induction.

Expression of the IL-2 receptor α chain (CD25) by peripheral CD4 T cells follows cellular activation. However, CD25 expression by CD4 cells is widely used as a marker to identify regulatory T cells (TR), although cells with regulatory properties are also found in the CD4+CD25–subset. By usingin vivofunctional assays and Foxp3 expression as a faithful marker of TRdifferentiation, we have evaluated the requirements for CD25 expression by peripheral TR. We first show thatin vivodepletion of CD25+cells prevents the development of spontaneous encephalomyelitis in recombination-activating gene (RAG)-deficient anti-myelin basic protein T cell antigen receptor (TCR) transgenic mice, and allows disease induction in otherwise healthy RAG-competent transgenic mice. Similar treatment in normal thymectomized animals is followed by the fast recovery of a normal number of CD25+TR. Consistently, Foxp3-expressing TRencompassed in the CD25–cell population convert to CD25+after homeostatic expansion and are selectable by IL-2in vitro. Surface expression of CD25 on TRis controlled by the activity of conventional CD4 cells and is fully labile because it can be lost and regained without affecting the functional potential of the cells. These findings reveal that Foxp3-expressing CD25–cells constitute a peripheral reservoir of differentiated TR, recruited to the CD25+pool upon homeostatic expansion and/or activation. This analysis, together with the notion that physiological commitment of TRtakes place exclusively in the thymus should help for the interpretation of experiments assessing peripheral TRdifferentiation from naive CD4 T cells, defined as CD25–.

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Patients with systemic lupus erythematosus (SLE) can be affected by a multitude of neurologic and psychiatric symptoms with a wide range of prevalence and severity. Irrespectively from attribution to SLE or other causes, neuropsychiatric (NP) symptoms strongly impact short-term and long-term outcomes, thus NP evaluation during routine clinical practice in SLE should be undertaken regularly. The assessment of NP involvement in SLE patients is challenging and the available diagnostic tools fail to guarantee optimal diagnostic accuracy, sensitivity to changes as well as feasibility in routine clinical care. Standardised questionnaires (both physician-administered and self-reported) can offer valuable help to the treating physician to capture all possible NP syndromes; few SLE-specific NP questionnaire have been developed but validation in large cohort or cross-cultural adaptations are still pending. On the other hand, general instruments have been largely applied to SLE patients. Both kinds of questionnaires can address all possible NP manifestations either globally or, more frequently, focus on specific NP symptoms. These latter have been mainly used in SLE to detect and classify mild and subtle symptoms, more likely to be overlooked during routine clinical assessment such as headache, cognitive impairment and psychiatric manifestations. In conclusion, this literature review highlights a clear case for validation studies in this area and the wider implementation of questionnaires to assess NP involvement is still warranted. The broader use of such instruments could have important consequences; first of all, by standardising symptom assessment, a better definition of the prevalence of NP manifestation across different centres could be achieved. Secondly, prospective studies could allow for the evaluation of clinical significance of mild symptoms and their impact on the patient's function and quality of life.

© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd., Aim: To explain the missing heritability after the genome-wide association studies era, sequencing studies allow the identification of low-frequency variants with a stronger effect on disease risk. Common variants in the interleukin 10 gene (IL10) have been consistently associated with Behçet's disease (BD) and the goal of this study is to investigate the role of low-frequency IL10 variants in BD susceptibility. Methods: To identify IL10 low-frequency variants, a discovery group of 50 Portuguese BD patients were Sanger-sequenced in a 7.7 kb genomic region encompassing the complete IL10 gene, 0.9 kb upstream and 2 kb downstream, and two conserved regions in the putative promoter. To assess if the novel variants are BD- and/or Portuguese-specific, they were assayed in an additional group of BD patients (26 Portuguese and 964 Iranian) and controls (104 Portuguese and 823 Iranian). Results: Rare IL10 coding variants were not detected in BD patients, but we identified 28 known single nucleotide polymorphisms with minor allele frequencies ranging from 0.010 to 0.390, and five novel non-coding variants in five heterozygous cases. ss836185595, located in the IL10 3' untranslated region, was also detected in one Iranian control individual and therefore is not specific to BD. The remaining novel IL10 variants (ss836185596 and ss836185602 in intron 3, ss836185598 and ss836185604 in the putative promoter region) were not found in the replication dataset. Conclusion: This study highlights the importance of screening the whole gene and regulatory regions when searching for novel variants associated with complex diseases, and the need to develop bioinformatics tools to predict the functional impact of non-coding variants and statistical tests which incorporate these predictions., This work was supported by the Portuguese Fundação para a Ciência e a Tecnologia (grant PTDC/SAU-GMG/098937/2008, fellowships SFRH/BD/43895/2008 to JMX, SFRH/BPD/35737/2007 to PA, SFRH/BPD/70008/2010 to IS, a Ciência and an Investigator-FCT contract to SAO) and the Research Committee of the Tehran University of Medical Sciences (grant 132/714).

© Springer-Verlag Berlin Heidelberg 2013, Behçet's disease (BD) is a complex disease with genetic and environmental risk factors implicated in its etiology; however, its pathophysiology is poorly understood. To decipher BD's genetic underpinnings, we combined gene expression profiling with pathway analysis and association studies. We compared the gene expression profiles in peripheral blood mononuclear cells (PBMCs) of 15 patients and 14 matched controls using Affymetrix microarrays and found that the neuregulin signaling pathway was over-represented among the differentially expressed genes. The Epiregulin (EREG), Amphiregulin (AREG), and Neuregulin-1 (NRG1) genes of this pathway stand out as they are also among the top differentially expressed genes. Twelve haplotype tagging SNPs at the EREG-AREG locus and 15 SNPs in NRG1 found associated in at least one published BD genome-wide association study were tested for association with BD in a dataset of 976 Iranian patients and 839 controls. We found a novel association with BD for the rs6845297 SNP located downstream of EREG, and replicated three associations at NRG1 (rs4489285, rs383632, and rs1462891). Multifactor dimensionality reduction analysis indicated the existence of epistatic interactions between EREG and NRG1 variants. EREG-AREG and NRG1, which are members of the epidermal growth factor (EGF) family, seem to modulate BD susceptibility through main effects and gene-gene interactions. These association findings support a role for the EGF/ErbB signaling pathway in BD pathogenesis that warrants further investigation and highlight the importance of combining genetic and genomic approaches to dissect the genetic architecture of complex diseases., This research was supported by the Research Committee of the Tehran University of Medical Sciences (grant 132/714), the Portuguese Fundação para a Ciência e a Tecnologia (grant PTDC/SAU-GMG/098937/2008, doctoral fellowship SFRH/BD/43895/2008 to JMX, and a Ciência contract to SAO), and the Portuguese Instituto do Emprego e Formação Profissional (fellowship to JMX, TK, BVF).

Sir, We read with interest the report ‘Progressive multifocal leukoencephalopathy in patients with systemic lupus erythematosus: a systematic literature review’ and wish to emphasize that lymphopenia, which may be the most important risk factor for progressive multifocal leukoencephalopathy (PML), failed to be mentioned. In their thorough literature review, Henegar et al. 1 found that most systemic lupus erythematosus (SLE) patients (32 out of 35) were on immunosuppressant therapy (IST) at the time of PML diagnosis. Even though the IST type was discriminated, individual duration and effect of IST on the immune system could not be analysed. A recent case report from our units was associated with a fatal outcome. 2 The patient had severe CD4 þ T cell lymphopenia. Our review of the literature revealed that information about lymphocyte counts was scarce, but when available lymphopenia was invariably present in SLE patients with PML. PML was initially described in patients subjected to chemotherapy 3 and is a feared complication of idiopathic CD4 þ T cell lymphopenia. 4 Altogether, such compelling evidence leads us to believe that in order to prevent PML in SLE, lymphocyte counts should be frequently monitored and IST adjusted in order to avoid severe lymphopenia. Current recommendations support maintaining a total count above 1000 � 10 6 /L, 5 but in current practice we believe the management of lymphopenia in SLE remains an unmet need.

Background Current recommendations for Rheumatoid Arthritis (RA) treatment focus on a treat to target approach [1, 2]. Long term individual drug persistence has been associated to factors such as type of biological agent and higher disease activity [3, 4]. Here we present data from a tertiary referral centre. Objectives To determine factors associated to drug persistence, switch or withdrawal of first-line biological therapy. Methods Retrospectively collected data (01/2002 to 12/2015) from our Unit included patients classified as RA according to ACR 1987 [5] and 2010 [6] criteria. The analysis included 288 patients, 29% (n=85) of which were lost to follow-up and 15% (n=44) of which were deceased. The present study was restricted to current biological therapy. We extracted baseline characteristics (age, gender, presence of RF and anti-CCP, duration of RA, year of initiation of therapy), first biologic and causes of switch or withdrawal, adverse events and treatment efficacy (according to DAS28). Data were collected through to December 2015. Outcomes were compared using the Man-Whitney test comparing those that maintained the same biologic to those that switched. We limited the analysis to patients treated with Etanercept (ETN), Adalimumab (ADA), Rituximab (RTX) and Tocilizumab (TCZ). Results A total of 85 patients (53%) were started on biological therapy (bDMARD), instituted after methotrexate (MTX) failure or intolerance (mean peak MTX dose 17 mg/week). Mean age [±SD]=59 [±10.2] years,79% female (n=65), mean disease duration 11.3 [±7.2] years (ranging from 1 to 37 years), 6 (7%) non-white, the majority positive for rheumatoid factor and/or anti-CCP (n=61, 72%). These patients were originally treated with ETN (n=56), Infliximab – INFLIX (n=3), ADA (n=12), RTX (n=6), TCZ (n=7) and Golimumab (n=1) (Graph I). After mean 4 [±2.9 [±SD] years of follow-up, ranging from 1 to 14 years (Graph II), 70 of 85 patients are currently still on bDMARD, mostly on ETN (n=34), TCZ (n=13), RTX (n=11) and ADA (n=9). Abatacept has been started on one patient. The median time of receiving ETN, ADA, RTX and TCZ was 5.0, 3.5, 2.0 and 4.0 years and retention rates were 71%, 67%, 83% and 86%, respectively. Overall, more than 95% of treatment switch was due to drug inefficacy. Severe infections occurred with ETN (one Pneumocystis pneumonia) and ADA (one genitourinary tuberculosis). Lack of efficacy due to TCZ was only seen in a single patient. There was no statistically significant differences between retention and non-retention groups. Conclusions Biological drugs for RA treatment in our Unit were determined by drug development and National Authority of Medicines and Health Products authorization. ETN was the most frequently used and for the longest duration with a 71% retention rate. Overall we found that the other agents were also well tolerated and effective in patients between 50 and 70 years of age. This information may be useful for clinicians with an ageing population. References Singh Arthritis Care Res (Hoboken), 2015; Smolen Ann Rheum Dis, 2014; Favalli Arthritis Care Res (Hoboken), 2015; Frazier-Mironer Joint Bone Spine, 2014; Arnett Arthritis Rheum, 1988; Aletaha Arthritis Rheum, 2010. Acknowledgement Patients, Medical, Nursing and Administrative Staff of Unidade de Doencas Auto-imunes, Hospital Curry Cabral Disclosure of Interest M. Fernandes: None declared, I. Figueiredo: None declared, N. Riso: None declared, A. Panarra: None declared, M. F. Moraes-Fontes Grant/research support from: Roche, AbbVie, Pfizer, Biomarin, Actelion, Consultant for: Pfizer

In order to establish if neuropsychiatric systemic lupus erythematosus (NPSLE) can be identified by any characteristic other than those used to diagnose the neuropsychiatric (NP) disease itself, we retrospectively reviewed 98 systemic lupus erythematosus (SLE) patients followed over a mean period of 10 years. NPSLE was identified in 22 patients. Stroke and generalized seizures were the most frequent NP manifestations. The NPSLE and non-NPSLE groups were similar with regard to demographic characteristics, ACR criteria, serum autoantibodies, and frequency of hypertension and hypercholesterolemia. Of note, compared to the non-NPSLE group, NPSLE was associated with a higher frequency of smoking (78 versus 26%), organ damage (73 versus 34%), and cumulative mortality rate (14 versus 7%). The series of patients was further analysed according to the presence of antiphospholipid syndrome (APS). Significantly, the interval between the onset of NP disease and SLE diagnosis was shorter in the APS− (0.3±1 years) than in the APS+ (5±7 years) groups. Recurrence and/or persistence of NP events were only documented in the APS− group. Overall cumulative mortality was highest in NPSLE and in APS+ patients with inadequate anticoagulation control, identifying an aspect that requires improved vigilance and the development of novel therapeutic modalities.

In human systemic lupus erythematosus (SLE), diverse autoantibodies accumulate over years before disease manifestation. Unaffected relatives of SLE patients frequently share a sustained production of autoantibodies with indiscriminable specificity, usually without ever acquiring the disease. We studied relations of IgG autoantibody profiles and peripheral blood activated regulatory T-cells (aTregs), represented by CD4(+)CD25(bright) T-cells that were regularly 70-90% Foxp3(+). We found consistent positive correlations of broad-range as well as specific SLE-associated IgG with aTreg frequencies within unaffected relatives, but not patients or unrelated controls. Our interpretation: unaffected relatives with shared genetic factors compensated pathogenic effects by aTregs engaged in parallel with the individual autoantibody production. To study this further, we applied a novel analytic approach named coreferentiality that tests the indirect relatedness of parameters in respect to multivariate phenotype data. Results show that independently of their direct correlation, aTreg frequencies and specific SLE-associated IgG were likely functionally related in unaffected relatives: they significantly parallelled each other in their relations to broad-range immunoblot autoantibody profiles. In unaffected relatives, we also found coreferential effects of genetic variation in the loci encoding IL-2 and CD25. A model of CD25 functional genetic effects constructed by coreferentiality maximization suggests that IL-2-CD25 interaction, likely stimulating aTregs in unaffected relatives, had an opposed effect in SLE patients, presumably triggering primarily T-effector cells in this group. Coreferentiality modeling as we do it here could also be useful in other contexts, particularly to explore combined functional genetic effects. Fundação para a Ciência e a Tecnologia grant: (POCTI/SAU-MMO/59913/2004), and FCT postdoctoral fellowships.

Intravenous IgG (ivIg) is a therapeutic alternative for lupus erythematosus. Relative oligoclonality of circulating T-cells in SLE has been reported. Also CD4+Foxp3+ regulatory T-cells (Tregs) have a characteristically reduced activity in SLE, reflected by CD25 surface density. Aiming to study the role of Tregs for ivIg therapy, we characterized Tregs and determined TCR spectratypes of four Vb families with reported oligoclonality, in 15 lupus patients (14 with SLE and one with discoid LE) treated with ivIg in cycles of 2-6 consecutive monthly infusions. Among these 15 patients, 11 responded with clinical improvement. Cell counts, cytometry and TCR spectratypes were obtained from peripheral blood at various time points before, during and after ivIg treatment. T-cell oligoclonality was assessed as Vb-familywise repertoire perturbation, calculated for each patient in respect to an individual reference profile averaged over all available time points. For 11/15 patients, average Vb1/Vb2/Vb11/Vb14 repertoires were less perturbed under ivIg treatment than outside ivIg therapy. The four exceptions with relatively increased average perturbation during ivIg therapy included three patients who failed to respond clinically to an ivIg therapy cycle. Patients' Treg CD25 surface density (cytometric MFI) was, other than Treg/CD4+ frequency, clearly reduced when compared to healthy controls, but not obviously influenced by ivIg. However, patients' average Treg CD25 MFI was found negatively correlated with both Vb11 and Vb14 perturbations measured under ivIg therapy, which indicates a role of active Tregs in the therapeutic effect of ivIg.

BackgroundCD4+CD25+regulatory T cells play an essential role in maintaining immune homeostasis and preventing autoimmunity. Therefore, defects in Treg development, maintenance or function have been associated with several human autoimmune diseases including Systemic Lupus Erythematosus (SLE), a systemic autoimmune disease characterized by loss of tolerance to nuclear components and significantly more frequent in females.ResultsTo investigate the involvement of Treg in SLE pathogenesis, we determined the frequency of CD4+CD25+CD45RO+T cells, which encompass the majority of Treg activity, in the PBMC of 148 SLE patients (76 patients were part of 54 families), 166 relatives and 117 controls. SLE patients and their relatives were recruited in several Portuguese hospitals and through the Portuguese Lupus Association. Control individuals were blood donors recruited from several regional blood donor centers. Treg frequency was significantly lower in SLE patients than healthy controls (z = -6.161,P< 0.00001) and intermediate in the relatives' group. Remarkably, this T cell subset was also lower in females, most strikingly in the control population (z = 4.121,P< 0.001). We further ascertained that the decreased frequency of Treg in SLE patients resulted from the specific reduction ofbona fideFOXP3+CD4+CD25+Treg. Treg frequency was negatively correlated with SLE activity index (SLEDAI) and titers of serum anti-dsDNA antibodies. Both Treg frequency and disease activity were modulated by IVIg treatment in a documented SLE case. The segregation of Treg frequency within the SLE families was indicative of a genetic trait. Candidate gene analysis revealed that specific variants ofCTLA4andTGFβwere associated with the decreased frequency of Treg in PBMC, whileFOXP3gene variants were associated with affection status, but not with Treg frequency.ConclusionSLE patients have impaired Treg production or maintenance, a trait strongly associated with SLE disease activity and autoantibody titers, and possibly resulting from the inability to convert FOXP3+CD25-into FOXP3+CD25+T cells. Treg frequency is highly heritable within SLE families, with specific variants of theCTLA4andTGFβgenes contributing to this trait, whileFOXP3contributes to SLE through mechanisms not involving a modulation of Treg frequency. These findings establish that the genetic components in SLE pathogenesis include genes related to Treg generation or maintenance.

Corticosteroids are commonly used in the therapy of autoimmune disease (AID), although they are rarely, if ever, curative. This failure may result from their deleterious effects on regulatory T cells (Treg). In this work, we directly tested the effects of hydrocortisone (HC) administration on Treg number and function in established mouse models of multiple sclerosis and colitis. Treatment with pertussis toxin (Ptx) or Cyclophosphamide (Cyp), two compounds known to affect Treg function served as controls. We first show that contrarily to Ptx, HC administration to mice transgenic for a TCR specific to myelin basic protein induces a mild lymphopenia, without selective depletion of Treg, nor induction of experimental autoimmune encephalomyelitis (EAE). We next report that HC administration to normal mice has no effect on Treg suppressive function tested in vitro. Moreover, we document that Treg isolated from HC-treated animals maintain their capacity to prevent T cell-induced colitis. In contrast, the combined administration of HC and Cyp, as is frequently used in the therapy of severe AID, dramatically enhanced the deleterious effect of Cyp on Treg number and function. Our analysis indicates that while a short course of corticosteroids alone is not deleterious to immune regulation, combined therapies, notably with Cyp, should be avoided.

Background Regulatory T cell (Treg) defects are associated with autoimmune diseases [1]. Immunoglobulin E (IgE) is elevated in primary immunodeficiencies associated to Regulatory T cell (Treg) defects [2] and is known to be positively correlated to disease activity in Systemic Lupus Erythematosus (SLE) [3,4]. More specifically, Treg frequency (increased) and CD25 expression (decreased) are dissociated in patients with active SLE [5,6]. Objectives To establish the relationship between circulating Treg frequency/number and phenotype and total IgE/IgE auto-antibodies and test the hypothesis that total IgE could be a marker of a generalized Treg deficit. Methods We first tested a large cross-sectional collection of plasma samples from unselected patients with a diagnosis of SLE according to ACR criteria (n=123) and from healthy controls (n=153). We then started a prospective longitudinal study of SLE patients (n=33, 30 females, mean age 41±10 years). A median of 4 samples were obtained per patient. Clinical characteristics, SLEDAI 2 K as index of disease activity, SELENA-SLEDAI score for definition of flare and sample collection were undertaken. During follow-up 13/33 patients experienced a flare. Samples were analysed by an ELISA “in house” method optimized for total IgE, antigen-specific IgE (anti-DNA, Sm, RNP), IgG anti-DNA and IgG anti-Sm. FACS analysis determined Treg frequency (CD4 + CD45RO + Foxp3 high ) and CD25 MFI expression. The Mann-Whiney Test and Spearman correlation were used with values of p Results While there was no significant difference in total IgE, IgE anti-DNA was higher in patients (p=0.02) and positively correlated with SLEDAI (p=0.009). In the longitudinal prospective collection there was a positive correlation between IgG anti-DNA (p=0.002) or IgE anti-DNA (p=0.0003) and disease activity. IgE anti-DNA was increased in some patients with high SLEDAI and no IgG anti-DNA. The frequency of active Treg was positively correlated with SLEDAI (p=0.006) and with IgG anti-DNA (p=0.0004) while their CD25 expression was negatively correlated with SLEDAI (p=0.008) and IgG anti-DNA (p=0.002). There was no association between total IgE or IgE anti-DNA and Treg frequency or CD25 expression in either the cross-sectional study or the longitudinal patient collection. Conclusions These results indicate that unlike IgG anti-DNA, IgE anti-DNA is not associated with Treg frequency or CD25 expression, raising questions regarding its affinity and pathogenicity. Still, as previously described, IgE anti-DNA behaved as a biomarker of SLE disease activity. In this study we demonstrate that it may be a useful biomarker in the absence of IgG anti-DNA. References Bennett Nat Genet 2001 27(1):20-1. Ozcan J Allergy Clin Immunol 2008. 122(6):1054-62. Charles Nat Med 2010 16(6):701-7. Dema Plos One 2014 9(2)e90424. Bonelli Ann Rheum Dis 2008 67(5):664-71. Suen Immunology 2009 127(2):196-205. Acknowledgements Jocelyne Demengeot (JD) for grant submission and ongoing support, JD, W Haas and J Lafaille for helpful discussions and R van Vollenhoven for scientific input. Staff at UIC and ICBAS (Porto), HSM, CHLO, Santarem, HFF, HCC and Patients and Patient Association for sample collections. Funding FCT EXPL/DTP-PIC/0644/2012 Disclosure of Interest None declared

Natural T regulatory cells (NatTReg) limit immunopathology and protective immune responses induced upon microbial infection. In addition, infection increases the number and activity of NatTReg. These findings need to be conciliated with the process of ‘self–nonself’ discrimination based on the function of NatTReg committed intrathymically and positively selected (and activated) on thymic epithelial cells. A review of the available evidence comforts the assumptions that, in physiological conditions, NatTReg engaged in the immune responses to microbial infections are drawn from the autoreactive repertoire even if some may appear to be microbe specific. This contention also provides a suitable explanation for the ‘hygiene hypothesis’: infections re-enforce the physiological mechanisms of natural dominant tolerance, through the expansion of naturally occurring regulatory T cells. Accumulating evidence demonstrates that pro-inflammatory ligands of Toll-like receptors expressed by NatTReg, both of microbial (e.g., lipopolysaccharide, flagellin, peptidoglycans) and endogenous (e.g., stress proteins and degradation products of the extracellular matrix) origin, may play a critical role in their activation and expansion. As NatTReg vigorously respond to IL-2/IL-15 locally produced by ongoing effector responses, this whole set of mechanisms provides for a robust feedback process that limits tissue damage and accounts for an ‘organism-centered’ quality control of immune responses. Detailed knowledge on these molecular and cellular bases should open novel opportunities for intervention in a variety of critical conditions, such as autoimmunity, allergy, chronic infections, and cancer, for which we currently lack effective therapies.

This article presents the results of a prospective multivariable study of elderly patients aged over 70 years, hospitalized in an Internal Medicine Department of a Central Lisbon Hospital. The study aimed to identify, at the beginning of hospital admission (HA), predictive factors of hospital mortality (HM) and mortality at 6 months, of duration of HA, of admission to a nursing home at the time of discharge and during a period of 6 months thereafter and of hospital readmission during the 6 months following discharge. The study included 158 patients with a mean hospital stay of 15 days and a hospital mortality of 12%. The main pathologies responsible for hospital admission were cerebrovascular accident (22%), heart failure (20%) and pneumonia (16%). Mortality at 6 months was 29% and hospital readmission in the 6 months thereafter was 24%. When the patient was cared for by the spouse there was a statistically significant correlation with a shorter duration of admission (p = 0.006). Mean hospital stay was not significantly associated with any other variable. A subjective medical evaluation (SME) at the start of HA (p = 0.001), a low Barthel score prior to and at the time of HA, low serum albumin (p = 0.001) and a high leucocyte count (p = 0.005) were correlated with a higher HM. Nursing home admission was only positively correlated with cerebrovascular pathology. Mortality at 6 months was significantly correlated with the SME (p = 0.001), a low Barthel score prior to admission (p0.008) and at the time of HA (p0.001), nursing home residency (p0.005) and a low mental test score (p0.01). Hospital readmission at 6 months was influenced by the SME (p0.04) and by the reduction in the Barthel score caused by the illness and HA (p = 0.004). These correlations enabled the development of mathematical models that predict HM and mortality at 6 months and admission to a nursing home at the time of discharge and during a period of 6 months thereafter. They could be important in identifying elderly patients' needs early in the hospital admission and in the improvement of the strategy necessary for a successful and dignified hospital discharge.

Background FOXP3+ regulatory T-cells (Tregs) in Systemic Lupus Erythematosus (SLE) are in a functionally deficient state with a characteristic reduction or absence of surface CD25 (the IL-2 receptor alpha chain). Genetic variation in the CD25-encoding IL2RA locus is associated with other autoimmune disorders. Methods We have studied Treg and Treg subset CD25 by flow cytometry and typed 24 SNPs in the IL2RA locus in 47 SLE patients, 108 SLE-unaffected first-degree relatives of SLE patients, and 61 unrelated control subjects. Results In both SLE patients and unaffected relatives, surface CD25 was found strongly reduced not only in activated, but already in circulating CD4+ FOXP3+ CD45RO-CD31 + recent thymic emigrant (RTE) Tregs. In contrast, unaffected relatives clearly differed from SLE patients in properties of activated CD4+ FOXP3highCD45RO + Tregs, which showed a CD25 upregulation versus non-activated CD45RO- Tregs in these relatives similar to control subjects, while not in SLE patients. The distinction of these two components contributing to the previously described SLE-characteristic Treg CD25 reduction was corroborated by our finding that the two components were influenced by polymorphisms in different regions of the IL2RA locus. Furthermore, we found that only RTE Treg CD25, as well as the genetic variants influencing it, were significantly related to numbers and relative frequencies of circulating activated Tregs, whereas CD25 upregulation upon Treg activation was not. Conclusions Our results point to (a) an intrathymic effect present in an extended population carrying SLE susceptibility factors that is responsible for reduced surface CD25 in early Tregs and a subsequently decreased activation capacity. This effect might be compensated in unaffected relatives by (b) CD25 upregulation upon Treg activation, which seemed functionally independent and was selectively deficient in SLE patients. This second component appears of particular interest for therapeutic targeting.

This is a case report of a 29-year-old white female patient with Kikuchi's disease, presenting fever, polyarthritis, lymph gland enlargement, anemia, leucopenia with a relative lymphocytosis, altered liver function tests and circulating immune complexes. A literature review is made with emphasis on the etiology, clinical course and pathogenesis of this illness.

according to gender, age, seropositive RA, DAS28, mean disease duration, use of BMR, type and onset of primary malignancy. Results: Of the n= 155 pts with RA, n = 57 were receiving a biological agent. Of these n= 38 pts were female, with an average age of 55.37 years, a mean disease duration of 9.35 years andmean duration of BMR use of 3.6 years. The mean DAS28 was 5.9 and after BMR use 3.1. The n= 6 pts with neoplasia had an average age of 67.33 years (only n= 1 pt b65 years), a mean disease duration of 11.83 years; a mean duration of BMR use of 5.2 years (etanercept n= 3 pts, rituximab n= 2 pts and adalimumab n= 1 pt). The mean DAS28 was 5.3 and after BMR use 3.0. Neoplasia onset was previous to the use of a BMR in n= 2 pts (12 and 15 years), of which ovary n= 1 pt, breast and cervix n= 1 pt, there were no recurrences; in n= 4 pts the neoplasia occurred after the use of BMR (3, 4, 5 and 7 years), of which skin n= 2, breast n = 1 and prostate n= 1. None of the pts died, but n= 1 suspended BMR. Of the n= 108 pts under traditional DMARDs, n= 13 had the diagnosis of malignant diseasewith themean age of 61.54 years and n= 6 of themhad it before the diagnosis of RA. The remaining n= 7had the diagnosis of neoplasia a mean of 11.43 years after the diagnosis of RA. The types of primary neoplasia were gynecological n = 4, gastrointestinal tract n= 3, breast n = 2, leukemia n= 1, lung n= 1, kidney n= 1 and prostate n= 1. Conclusions: In our sample, the pts with malignancy were older, with a longer mean duration of a BMR use and similar DAS28 to all of the pts with RA. However, pts with RA without BMR have a lower age of onset and the distribution between the types of primary neoplasia is slightly different, which might be explained by the therapy's antiinflammatory effects in some malignancies vs. immunosuppression in others.

Takayasu's arteritis (TA) is a disease of unknown aetiology, characterized histologically by an inflammatory cell infiltrate that affects all layers of the arterial wall. Its association with tuberculosis (TB) was described 50 years ago, based on the presence of Langhan's giant cells and granulomas similar to those found in tuberculous lesions. The presence of TB in patients with TA well as been reported in several studies as well as a positive tuberculous response, but these associations could be fortuitous in countries where TB is endemic. Recent studies have shown that patients with TA have a heightened humoral response to mycobacterial antigens including the 65 kDa fraction, a heat shock protein (HSP) that has also been found to be expressed in the arterial wall of patients with TA. The purpose of this study was to determine lymphoproliferative response and interferon-gamma (IFN-gamma) production by peripheral blood mononuclear cells (PBMC) stimulated by live Mycobacterium tuberculosis (Mtb) H37Rv and a panel of mycobacterial antigens, in the hope of contributing to a better understanding of the cellular immune responses to Tuberculosis in Takayasu's arteritis.Standard lymphoproliferation tests and IFN-gamma determination (ELISA) were performed in a 47-year old black man who fulfilled criteria for TA and 10 healthy controls, BCG vaccinated, Mantoux positive. The following were used: Mtb H37Rv, Purified Protein Derivative (PPD), purified 30 kDa, recombinant M. bovis BCG 10 kDa, 38 kDa, 65 kDa, 70 kDa, Short Term-Culture Filtrate Proteins (ST-CFP), Mid Term-Culture Filtrate Proteins (MT-CFP) obtained from H37Rv and phytohemaglutinin (PHA) as mitogen for positive control.PBMC from the patient with TA when compared to the mean values of the 10 healthy donors showed decreased proliferation in response to all antigens, with the exception of 65 kDa. The TA patient showed a similar pattern of IFN-gamma production to that obtained with control donors, with the exception of higher IFN-gamma production in response to ST-CFP and MT-CFP.We have shown reactivity of peripheral lymphocytes to HSP 65 kDa and a trend towards higher production of IFN-gamma in response to ST-CFP and MT-CFP in a patient with TA. These facts, together with the already established heightened humoral response, strengthens the association between TB and TA. However, HSP 65 kDa is not specific to TB and we conclude that similar studies using lymphocytes obtained from the arterial wall of TA patients may help to clarify the role of mycobacterial infection in Takayasu's arteritis.

Objective To identify biochemical and dietary factors which may play a role in the low incidence of stone formation in the black South African population. Subjects and methods The study included 31 semi-urbanized black and 29 urbanized white subjects. The protocol and modern laboratory techniques used to assess recurrent stone formers were followed. Urinary sodium, potassium, creatinine, calcium, phosphate and urate levels were measured, and urinary citrate, oxalate and cystine assessed. Results Black subjects ate a diet significantly higher in sodium (P

Hepatopulmonary Syndrome is an uncommon clinical situation of unknown cause. It remains the focus of intense investigation and ongoing debate. The authors present a case of a 77 year old man with chronic liver disease known for 5 years, who developed central cyanoses, digital clubbing and hypoxemia. On searching for the cause of these clinical features, the diagnosis of Hepatopulmonary Syndrome was admitted and confirmed by contrast enhanced echocardiography using agitated saline, and also by technetium 99m-labelled macroaggregated albumin scanning.

A 2-year retrospective study of aetiology, age distribution, seasonal variation and antimicrobial sensitivity patterns of bacteria isolated from patients with meningitis in five Johannesburg hospitals for White, Black, Coloured and Asian patients was performed. Neisseria meningitidis was isolated most frequently, followed by Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli and Streptococcus group B. In the Black population 73% of the meningococcal infections occurred in patients over 3 years of age, and the majority of these infections were caused by serogroup A organisms. Virtually all (93%) of the H. influenzae infections occurred in children of less than 3 years of age. Of the isolates tested, 16% of the meningococci, 4,5% of the H. influenzae and 47% of the pneumococci were resistant to sulphadiazine, ampicillin and penicillin respectively.

To our knowledge, this is the first case report of a broncho-splenic fistula of hydatid origin. We discuss the clinical, radiological and therapeutic aspects of this rare complication of hydatid disease.