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Sustained response off-treatment (SROT) after thrombopoietin receptor agonist (TPO-RA) discontinuation has been reported in ITP. This prospective multicenter interventional study enrolled adults with persistent or chronic primary ITP and complete response on TPO-RAs. The primary endpoint was the proportion of patients achieving SROT (platelet count > 30x109/L and no bleeding) at W24 with no other ITP-specific medications. Secondary endpoints included the proportion of sustained complete response off-treatment (SCROT, platelet count > 100x109/L and no bleeding) and SROT at W52, bleeding events, and pattern of response to a new course of TPO-RAs. We included 48 patients with median (IQR) age 58.5 years (41-73.5); 30/48 (63%) had chronic ITP at TPO-RA initiation. In the intention-to-treat analysis, 27/48 (56.2%, 95% CI, 41.2-70.5) achieved SROT; 15/48 (31.3%; 95% CI, 18.9-44.5) achieved SCROT at W24, and 25/48 (52.1%; 95% CI, 37.2-66.7) achieved respectively SROT and 14/48 (29.2%; 95% CI, 17.2-42.3) SCROT at W52. No severe bleeding episode occurred in patients who relapsed. Among patients re-challenged with TPO-RA, 11/12 achieved CR. We found no significant clinical predictors of SROT at W24. Single-cell RNA-seq revealed enrichment of a "TNFα signaling via NF-κB" signature in CD8+ T cells of patients with no sustained response after TPO-RA discontinuation, which was further confirmed by a significant overexpression of CD69 on CD8+ T cells at baseline in these patients as compared with those achieving SCROT/SROT. Our results strongly support a strategy based of progressive tapering and discontinuation of TPO-RAs for patients with chronic ITP who achieved a stable CR on treatment. Clinical trial number: NCT03119974

OBJECTIVE: This study was undertaken to characterize kidney and urine antibody-secreting cells (ASCs) from patients with active lupus nephritis, before and after induction therapy. METHODS: We included patients with biopsy-proven active lupus nephritis and performed anti-CD138 staining of kidney biopsy samples to visualize ASCs. We performed single-cell gene expression profiling on sorted ASCs from fresh biopsy samples using multiplex reverse transcriptase-polymerase chain reaction. We used a gene set that allowed for the study of ASC maturation from plasmablasts to long-lived plasma cells. We quantified urine ASCs from untreated patients with lupus nephritis at diagnosis and after 6 months of prospective follow-up during induction therapy. RESULTS: The number of kidney CD138+ ASCs in 46 untreated patients with lupus nephritis was correlated with a low estimated glomerular filtration rate and with tubulointerstitial damage. Most kidney ASCs from 3 untreated patients had a plasmablast molecular signature; in contrast, in 4 patients with refractory lupus nephritis, the kidney ASCs were mainly long-lived plasma cells, representing an ASC transcriptional profile similar to that in the bone marrow of 2 healthy donors. Some urine ASCs with a plasmablast signature were detected in patients with untreated active lupus nephritis. The presence of urine ASCs at 6 months was associated with treatment failure. CONCLUSION: Our results suggest potential for ASC-directed therapy in refractory lupus nephritis.

The major therapeutic goal for immune thrombocytopenia (ITP) is to restore normal platelet counts using drugs to promote platelet production or by interfering with mechanisms responsible for platelet destruction. 80% of patients possess anti-integrin αIIbβ3 (GPIIbIIIa) IgG autoantibodies causing platelet opsonization and phagocytosis. The spleen is considered the primary site of autoantibody production by autoreactive B cells and platelet destruction. The immediate failure in ~50% of patients to recover a normal platelet count after anti-CD20 Rituximab-mediated B cell depletion and splenectomy suggest that autoreactive, rituximab-resistant, IgG-secreting B cells (IgG-SC) reside in other anatomical compartments. We analyzed >3,300 single IgG-SC from spleen, bone marrow and/or blood of 27 patients with ITP revealing high inter-individual variability in affinity for GPIIbIIIa with variations over 3 logs. IgG-SC dissemination and range of affinities were however similar per patient. Longitudinal analysis of autoreactive IgG-SC upon treatment with anti-CD38 mAb daratumumab demonstrated variable outcomes, from complete remission to failure with persistence of high-affinity anti-GPIIbIIIa IgG-SC in the bone marrow. This study demonstrates the existence and dissemination of high-affinity autoreactive plasma cells in multiple anatomical compartments of patients with ITP that may cause the failure of current therapies.

Previous data have suggested that B-cell-depletion therapy may induce the settlement of autoreactive long-lived plasma cells (LLPCs) in the spleen of patients with autoimmune cytopenia. To investigate this process, we used the AID-CreERT2-EYFP mouse model to follow plasma cells (PCs) engaged in an immune response. Multiplex polymerase chain reaction at the single-cell level revealed that only a small fraction of splenic PCs had a long-lived signature, whereas PCs present after anti-CD20 antibody treatment appeared more mature, similar to bone marrow PCs. This observation suggested that, in addition to a process of selection, a maturation induced on B-cell depletion drove PCs toward a long-lived program. We showed that B-cell activating factor (BAFF) and CD4+ T cells play a major role in the PC survival niche, because combining anti-CD20 with anti-BAFF or anti-CD4 antibody greatly reduce the number of splenic PCs. Similar results were obtained in the lupus-prone NZB/W model. These different contributions of soluble and cellular components of the PC niche in the spleen demonstrate that the LLPC expression profile is not cell intrinsic but largely depends on signals provided by the splenic microenvironment, implying that interfering with these components at the time of B-cell depletion might improve the response rate in autoimmune cytopenia.

Background: Thrombopoietin receptor agonists(TPO-RAs) have been thought to play only a supporting role in ITP management. Several retrospective studies and a recent prospective study have reported unexpected cases of durable remission after TPO-RAs discontinuation in adult ITP in up to 30%. However, newly diagnosed ITP cases for which spontaneous remission may occur have been included in most of these studies. Thus, the main purpose of this study was to determine the proportion of patients with either persistent or chronic phase and no recent exposure to any potentially curative therapy (i.e., splenectomy or rituximab) achieving long-term remission off-treatment at 24 and 52 months after at least 3 months of TPO-RAs exposure with a complete response (CR). Patients/methods: We conducted a nationwide prospective multicenter interventional study (NCT03119974). Inclusion criteria were: 1) Patients aged > 18 years, with persistent or chronic primary ITP, 2) A stable CR defined by a platelet count > 100 x 10 9/L for more than 2 months on TPO-RA therapy, 3) Treatment with TPO-RA for at least 3 months. Main exclusion criteria were: 1) Anticoagulation or anti-platelet treatment, 2) Previous failure of TPO-RA discontinuation, 3) Concomitant treatment with corticosteroids ± intravenous immunoglobulin 4) Rituximab or splenectomy within the 2 months preceding or after TPO-RA initiation. After inclusion, the decrease and wean of either eltrombopag or romiplostim was initiated according to a standardized protocol (respectively tapering of 25 mg every 2 weeks or tapering of 1 ug/kg every week). In any case TPO-RAs had to be stopped at week 10. In case of relapse after TPO-RA discontinuation, the decision to start a new therapy was left at every investigator discretion. The primary endpoint was the proportion of patients achieving an overall response (CR + R) at week 24 (6 months) after TPO-RAs discontinuation. Secondary outcomes were overall response rate over the study period (W52), bleeding events, and to identify predictive factors, for overall prolonged response (W24 and W52). Results: Forty-nine patients (30 females, 61%), with persistent (n=2) or chronic (n=47, 96%) chronic ITP, with a median age of 58.5 years IQR (41 to 73) fulfilling the eligibility criteria were included over 2 year-period in 22 centers from the French reference network for adult' ITP. Forty patients received eltrombopag and 9 romiplostim at the time of inclusion. One patient was excluded since she was diagnosed pregnant one day after inclusion. In intention to treat 27/48 (56.2%; 95% CI, 29.5 to 58.8) patients achieved the primary-endpoint and maintained an overall response at week 24 after TPO-RAS discontinuation with a complete response for 15/27 (55%). During the full follow-up period of 52 weeks after TPO-RAs discontinuation, overall response was observed in 25/48 (52.1%; 95% CI, 37.2 to 66.2) patients (Figure 1). Bleeding events occurred in 13/21 (61.9%) and 15/23 (65.2%) patients relapsing respectively at 24 and 52 months with a median platelet count of 31´10 9/L(26 to 39) and 31 ´10 9/L(23 to 39). No severe bleeding episode (French bleeding score > 8) occurred. Median time of relapse after tapering initiation was 8 weeks. Among 21 patients with a relapse ( Conclusion: These results showed an unexpectedly high rate of sustained off-treatment remission after TPO-RAs discontinuation in chronic ITP among patients who initially achieve a stable CR. When they occur, relapses are mainly observed within the first weeks after discontinuation, very rarely afterwards and with no severe bleeding. While no predictive factor of lasting remission has been yet identified, our study strongly supports a progressive tapering of the dose of TPO-RAs in patients achieving a stable CR on treatment. Figure 1: Relapse at 52 weeks after TPO-RAs discontinuation Figure 1 Figure 1. Disclosures Mahevas: GSK: Research Funding; Amgen: Honoraria. Viallard: Novartis: Consultancy; Grifols: Consultancy; LFB: Consultancy; Amgen: Consultancy. Moulis: Amgen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Argenx: Membership on an entity's Board of Directors or advisory committees; Grifols: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sobi: Membership on an entity's Board of Directors or advisory committees. Terriou: Sanofi: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Michel: Novartis: Consultancy; Amgen: Consultancy; UCB: Honoraria; Argenx: Honoraria; Rigel: Honoraria; Alexion: Honoraria. Godeau: Sobi: Consultancy; Novartis: Consultancy; Amgen: Consultancy; Grifols: Consultancy.

Aurélie Brunet,1 Yohan N’Guyen,1,* Annick Lefebvre,2,* Anne Poncet,3 Ailsa Robbins,1 Odile Bajolet,2 Yves Saade,3 Vito Giovanni Ruggieri,3,* Sylvain Rubin3,* 1Internal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Reims, France; 2Operational Hygiene Team, Robert Debré University Hospital, Reims, France; 3Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France*These authors contributed equally to this workCorrespondence: Yohan N’GuyenInternal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Avenue du général Koenig, Reims 51092, FranceTel (+33) 3 26 78 94 22Fax (+33) 3 26 78 40 90Email yohan.nguyen@wanadoo.frPurpose: Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG.Patients and Methods: Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value< 0.10 in univariate analysis were entered into a stepwise logistic regression model.Results: Among the 182 patients (145 male (79.6%), median age 68.0 [45.0– 87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7– 50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0– 38.0] versus 5.0[3.0– 21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0– 134.0] versus 9.0 [7.0– 51.0] days in hospital, p< 0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64– 80.75], OR 4.64 [1.61– 13.34] and OR 1.27 [1.02– 1.58], respectively).Conclusion: The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.Keywords: obesity, preoperative anaemia, coronary artery bypass graft surgery, internal mammary arteries

Background: Pathogenic antibody secreting cells (ASC) have been identified in the kidney of SLE-prone mice, but are poorly characterized in human lupus nephritis (LN). We hypothesized that long-lived plasma cells may contribute to the failure of immunosuppressive therapy in refractory patients. Objectives: To characterize and compare the single cell molecular signature of ASC in kidney and urine from patients with active LN, either untreated or after immunosuppressive therapy failure. Methods: We included patients with biopsy proven active LN from 4 centers and meeting the ACR revised classification criteria for SLE diagnosis. Renal biopsies were scored according to 2003 International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification, and stained with anti-CD138 to visualize ASC. ASC were single cell sorted as CD3-/CD14-/CD16-/CD27high/CD38high cells. Single-cell gene expression profiling was performed by multiplex RT-PCR using Fluidigm Dynamic Arrays. We used a set of genes derived from a previous transcriptomic analysis of human splenic and bone marrow ASC to distinguish the process of ASC maturation from plasmablast (PB) to long-lived PC. We also studied ASC transcriptional program from urine of untreated LN patients at diagnosis and after 3 and 6 months of a prospective follow up during induction therapy (Plasmo-Lup study). Results: Immunohistochemistry stainings on kidney biopsies from both untreated (N=15) and refractory patients (N=6) showed infiltrates of CD138+ ASC mainly located in the interstitium, particularly in untreated patients. Single cell molecular signature of kidney ASC from 3 untreated patients with class IV LN revealed that these cells were mostly PB expressing multiple genes linked with cell division, and PC without long-lived genes expression. This contrasted with ASC signature from 3 patients with active LN and mycophenolate mofetil (MMF) failure that expressed long-lived PC genes and no proliferative genes. Primary component analysis of 170 single-cells showed clustering of ASC from MMF treated patients with long-lived bone marrow PC from healthy donors that were distinct from PB/PC from untreated patients (Figure 1). A PB signature was observed in urine ASC at diagnosis, similar to their kidney counterpart. The concentration of ASC in urine in 22 untreated patients correlated with ISN/RPS classification, with higher concentration in class IV patients (p Conclusion: These results suggest that PB infiltrate kidney of untreated LN patients, and that kidney long-lived PC may contribute to the failure of immunosuppressive therapy. Acknowledgement: This work was supported by Foreum Disclosure of Interests: None declared

Les cytopenies autoimmunes refractaires a plusieurs lignes therapeutiques sont associees a une morbi-mortalite importante et des alternatives therapeutiques sont necessaires. Le daratumumab, anticorps monoclonal anti-CD38 utilise dans le traitement du myelome, pourrait permettre de cibler les plasmocytes auto-reactifs impliques dans la survenue et la persistance des cytopenies auto-immunes. Cette etude observationnelle, retrospective, multicentrique conduite par le CERECAI, a inclus des patients traites par daratumumab a titre compassionnel entre 2020 et 2021 pour une cytopenie autoimmune (purpura thrombopenique immunologique/PTI ou anemie hemolytique auto-immune/AHAI) refractaire. Les donnees cliniques, biologiques, et evolutives des patients ont ete recueillies retrospectivement de facon standardisee. La reponse (R) et la reponse complete (RC) etaient definies selon les criteres internationaux en vigueur : pour le PTI, R : > 30 G/L avec au moins un doublement du taux initial, et RC : > 100 G/L ;pour l'AHAI, RC, hemoglobine > 12 g/dl a distance d'une transfusion et avec des parametres d'hemolyse normaux, et R > 10 g/dl avec une augmentation d'au moins 2 points d'hemoglobine par rapport au chiffre avant traitement a distance de toute transfusion. Nous avons inclus 8 patients, (5 femmes), d'âge median a la premiere perfusion de 45 ans [34-70]. Le daratumumab etait prescrit pour un PTI refractaire (n = 5), une AHAI refractaire (n = 2) et un syndrome de Glanzmann acquis (n = 1) dont la duree mediane d'evolution a compter du diagnostic etait de 84,5 mois [18-174]. Sur les 8 patients, 5 avaient un syndrome d'Evans, et 1 avait un PTI secondaire a un syndrome des anti-phospholipides arteriel et veineux. Cinq patients etaient splenectomises (1 AHAI, 3 PTI, 1 Glanzmann acquis), tous etaient en echec du rituximab avec un delai median depuis la derniere injection de 11 mois [3-98]. Le nombre median de lignes therapeutiques recu etait de 5,5 [2-7]. Le daratumumab etait prescrit a la dose de 16 mg/kg en perfusion hebdomadaire pour une mediane de 6 administrations [4-11] avec une premedication par dexamethasone. La tolerance clinique immediate etait bonne malgre 3 reactions allergiques mineures lors de la premiere perfusion sans recidive lors des administrations ulterieures. Apres un suivi median de 6 mois [3-9], 2 episodes infectieux severes ont ete observes (une pneumopathie non documentee et une pneumopathie COVID19). En excluant les patients ayant recu des immunoglobulines intraveineuses avant le dosage, une hypogammaglobulinemie (gammaglobulines < 6 g/L) etait observee chez 5/6 patients. La concentration mediane de gammaglobulines etaient de 7,1 g/L [4,8-16,2] avant traitement, contre 4,2 g/L [3,5-7,6] a 3 mois, et 6,1 g/L [6-15,5] a 9 mois. Parmi les 5 patients avec un PTI refractaire (plaquettes mediane 11 G/L [0-21]), une RC a ete observee chez 2 patients, apres respectivement 3 et 4 perfusions de daratumumab. Un autre patient initialement non-repondeur apres 4 injections et corticodependant a pu maintenir une RC sans autre traitement apres une augmentation transitoire de la corticotherapie suivie d'un sevrage, suggerant une reponse retardee. Concernant les patients avec AHAI, une patiente avait une RC durant 9 mois apres 4 perfusions, tandis que l'autre etait en echec du traitement avec toutefois un espacement des transfusions apres 3 mois de traitement. Le daratumumab n'avait pas d'efficacite clinique chez la patiente avec un syndrome de Glanzmann acquis, mais en revanche on notait une disparition des anticorps anti-β2GP1 et de l'anticoagulant circulant chez le patient avec un SAPL. Ces premieres donnees observationnelles suggerent que le daratumumab pourrait etre efficace chez certains patients avec une cytopenie autoimmune refractaire et en situation d'impasse therapeutique avec les traitements habituels. La tolerance clinique semble acceptable dans ces situations therapeutiques complexes, vec cependant un risque d'hypogammaglobulinemie profonde, qui doit etre pris en compte dans l'evaluation du rapport benefices/risques. Des essais prospectifs sont necessaires pour confirmer ces donnees preliminaires. (French) [ABSTRACT FROM AUTHOR] Copyright of Revue de Medecine Interne is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

International audience; Rationale: Pyoderma gangrenosum (PG), like other neutrophilic dermatosis, may be associated with a variety of systemic disorders including inflammatory bowel diseases, rheumatoid arthritis, and hematologic disorders. Conversely, the association between PG and systemic lupus erythematosus (SLE) has rarely been reported.Patient concerns: We report here 2 cases of this association.Diagnoses: The first case involves a 32-year-old woman who developed, 1 year after SLE diagnosis, 3 painful nodular lesions of PG on her face, and cervical area. The second case was observed in a 37-year-old woman referred for ulcerative nodular papules of PG on her legs, whereas she had been diagnosed with SLE 10 years before. SLE was inactive in the first case, whereas PG occurred during a lupus flare up in the second one.Interventions: We found 23 previous cases of SLE and PG in the literature with most cases (12/20) occurring during a lupus flare.Outcomes: Although rare, this association may be supported by common innate immunity dysregulation and abnormal neutrophil activation.Lessons: PG and other neutrophilic diseases reported in patients with SLE may be added to the large clinical spectrum of cutaneous lesions observed in SLE.

Geophagy, or the ingestion of earth or clay, is widespread among women of Sub-Saharan African, Caribbean or French Guiana origin. Little is known about this practice among HIV patients native of these countries and who are followed-up in France. The aims of this study were to determine (i) the prevalence and factors associated with geophagy among HIV patients native of these countries, (ii) patients' knowledge about the harmful effects of geophagy, and (iii) the association of geophagy with iron deficiency, or a history of anemia or constipation. Among the 119 included patients, current geophagy and previous geophagy were present in 11/119 (9%) and 47/119 (40%) patients, respectively. Female gender was the only factor associated with consumption (OR 5.37; 95% CI 2.07-15.92 p = 0.001). Awareness about the risk of iron-deficient anemia was low (24%). Preventive education should be integrated into the care of HIV adults from countries in which geophagy is a culture and widely accepted practice.

Previous data have suggested that B-cell-depletion therapy may induce the settlement of autoreactive long-lived plasma cells (LLPCs) in the spleen of patients with autoimmune cytopenia. To investigate this process, we used the AID-CreERT2-EYFP mouse model to follow plasma cells (PCs) engaged in an immune response. Multiplex polymerase chain reaction at the single-cell level revealed that only a small fraction of splenic PCs had a long-lived signature, whereas PCs present after anti-CD20 antibody treatment appeared more mature, similar to bone marrow PCs. This observation suggested that, in addition to a process of selection, a maturation induced on B-cell depletion drove PCs toward a long-lived program. We showed that B-cell activating factor (BAFF) and CD4

Introduction Le role pathogenique des cellules secretrices d’anticorps (CSA) renales au cours de la nephrite lupique (NL) a ete etudie dans des modeles murins, mais reste mal caracterise chez l’homme. Nous avons fait l’hypothese que des plasmocytes a longue duree de vie pouvaient contribuer a l’echec du traitement immunosuppresseur chez les patients refractaires. Notre objectif etait de caracteriser et comparer la signature moleculaire a l’echelle unicellulaire des CSA dans le rein et les urines de patients avec une NL active lors du diagnostic avant traitement, ou apres echec du traitement immunosuppresseur. Materiels et methodes Nous avons inclus des patients issus de 4 centres, avec un diagnostic de lupus selon les criteres de l’ACR revises, et presentant une NL active prouvee histologiquement. Les biopsies renales ont ete evaluees selon la classification de 2003 de l’International Society of Nephrology/Renal Pathology Society (ISN/RPS) et marquees avec un anticorps anti-CD138 pour visualiser les CSA. Nous avons aussi trie par cytometrie les CSA CD3-/CD14-/CD16-/CD27high/CD38high, et etudie leur profil d’expression en cellule unique apres RT-PCR multiplex en utilisant la technologie Fluidigm. Nous avons utilise un set de genes provenant d’une analyse transcriptomique anterieure realisee sur des CSA spleniques et de la moelle osseuse, pour distinguer differents profils de maturation du stade de plasmablaste a celui de plasmocyte a longue duree de vie. Nous avons egalement etudie le programme transcriptionnel des CSA provenant de l’urine de patients avec NL non traites au diagnostic, et apres 3 et 6 mois de suivi prospectif apres traitement immunosuppresseur. Resultats Les marquages immunohistochimiques sur les biopsies de patients non traites (N = 15) et refractaires au traitement immunosuppresseur (N = 6), ont revele des infiltrats de CSA CD138+ principalement localises dans l’interstitium, particulierement chez les patients non traites. Les signatures moleculaires a l’echelle unicellulaire des CSA de 3 patients avec NL de classe IV non traites ont montre que ces cellules etaient principalement des plasmablastes exprimant des genes en lien avec la division cellulaire, et des plasmocytes sans expression de genes de longue vie. Ces signatures contrastaient avec celles de CSA issues de 3 patients avec une NL en echec du mycophenolate mofetil (MMF), montrant l’expression de genes de longue vie sans expression de genes lies a la proliferation. L’analyse en composante principale des signatures de 170 cellules uniques montrait un regroupement des CSA de patients en echec du MMF avec des plasmocytes a longue vie de la moelle de donneurs sains, tandis que les plasmablastes/plasmocytes des patients non traites formaient un groupe distinct. La signature des CSA triees a partir des urines de patients au diagnostic etait celle de plasmablastes. La concentration de CSA dans les urines de 22 patients non-traites correlait avec la classification ISN/RPS, des concentrations superieures etant retrouvees chez les patients avec une classe IV (p Conclusion Nos resultats montrent que les reins de patients avec une NL non traitee sont infiltres par des plasmablastes, et que des plasmocytes a longue vie peuvent persister chez les patients refractaires, suggerant un mecanisme de resistance au traitement immunosuppresseur.

A 62-year-old woman was referred to our hospital in September, 2013, with fever, arthralgia, and dyspnoea lasting for 6 days. Her medical history was uneventful apart from hypertension and active tobacco use. Her glomerular fi ltration rate at admission was 82 mL/min per 1·73 m2 (normal range ≥90 mL/min per 1·73 m2). Blood cultures on admission grew Strepto coccus agalactiae and acute aortic infective endocarditis was rapidly diagnosed with transoesophageal echocardiography. She was immediately started on highdose intravenous amoxicillin (200 mg/kg per day) with intravenous gentamicin (240 mg once-daily). After 4 days, we noticed cloudy urine, with a thin granular appearance (fi gure). Her urine pH was 5·5. Direct examination of the urine showed amoxicillin crystalluria with large, typically aggregated needle-shaped crystals (fi gure) that were birefringent under polarised light microscopy. Her clinical condition worsened with oliguria, acute renal failure, and pulmonary oedema within 24 h. An aortic ring abscess was evident on a second echocardiography. After emergency valve replacement surgery and renal replacement therapy, she recovered well and was discharged home in October, 2013, without further renal replacement therapy, and with improving renal function. Her last glomerular fi ltration rate was 45 mL/min per 1·73 m2 in March, 2014. At last follow-up, in September, 2014, the patient was asymptomatic. Amoxicillin is known to cause urine crystallisation, although its incidence is unknown. Amoxicillin crystalluria usually occurs with high-dose amoxicillin therapy, in urines that have a low pH and are highdensity (mainly due to insuffi cient fl uid intakes). Amoxicillin crystalluria can be microscopic or macroscopic. The typical microscopic appearance described here is usually suffi cient for diagnosis in a compatible context but the amoxicillin composition of these crystals can be confi rmed by infrared spectroscopy if needed. Amoxicillin crystalluria can be asymptomatic or can be responsible for haematuria or acute renal failure attributable to intratubular precipitation or urinary tract obstruction. In our patient, acute renal failure was multifactorial, but we speculate that amoxicillin crystalluria could have played a part. Physicians should be aware of such a complication of amoxicillin because high intravenous doses are frequently prescribed worldwide and because urine alkalinisation and increased fl uid intake might prevent crystalluria.

Introduction L’anticorps (Ac) monoclonal anti-CD20 (rituximab) est largement utilise dans le traitement des maladies auto-immunes, avec pourtant des resultats heterogenes selon les indications, voire meme decevants au cours du lupus. De precedentes etudes au cours du purpura thrombopenique immunologique (PTI) et de l’anemie hemolytique auto-immune (AHAI) ont suggere que l’Ac anti-CD20 induisait de facon paradoxale la differenciation des plasmocytes (PC) de la rate en plasmocytes de longue duree de vie (PLDV), proches des plasmocytes de longue vie naturels de la moelle osseuse. Certains de ces PLDV sont auto-reactifs, pouvant expliquer l’echec au rituximab et le succes de la splenectomie. Nous avons souhaite explorer les mecanismes qui sous-tendent ce processus de differenciation plasmocytaire paradoxale dans un modele murin. Pour ce faire, nous avons utilise le modele de souris transgenique AID-Cre-ERT2 × Rosa26-loxP-EYFP qui permet de marquer irreversiblement par la proteine EYFP les cellules B lors de leur passage dans un centre germinatif au cours d’une reponse immune apres injection de tamoxifene, puis de les suivre in vivo. Les plasmocytes EYFP ont ete generes suite a 2 immunisations avec des globules rouges de mouton. Grâce a ce modele, nous avons pu identifier les PC avec les seuls marqueurs EYFP + B220−, sans necessite des autres marqueurs tels que le CD138 dont l’expression est heterogene au niveau de la rate. Resultats Dans un premier temps, nous avons realise une analyse transcriptomique des PC EYFP+ de la rate dits « matures » car analyses plusieurs mois apres immunisation. Nous les avons compares aux PC EYFP+ nouvellement generes de la rate, analyses 6 jours apres une 3 e immunisation. Parmi les 224 genes surexprimes (fold > 4, p Nous avons ensuite analyse le programme des PC EYFP+ par RT-PCR multiplex sur cellules uniques. A partir des donnees de notre transcriptome, et completees avec les donnees de la litterature, nous avons selectionne des genes permettant d’etablir les signatures plasmablastiques (Chek1, Bcl2l11, CXCR3, Mki67, Bub1, Aurka, Ccnd2 et Rrm2b) et plasmocytaires (Tnfaip3, Bcl2, Runx2, Nfkb2, Tox2, Mt2, Tesc, PerP, Tnfrsf17, Tmem176b, Fos et Klf6). Nous avons compare le programme des PC EYFP+ de la rate de souris traitees par anti-CD20 a celui des plasmablastes EYFP+ (analyses 3 jours apres une 3 e immunisation), des PC EYFP+ de rates controles generes de la meme facon et analyses au meme temps que les PC EYFP+ des souris traitees par anti-CD20 et des PC EYFP+ de la moelle osseuse. Les souris traitees par anti-CD20 (3 injections) avaient un taux residuel de cellules B dans la rate de l’ordre de 2 % au nadir de la depletion B, soit a j50 de la premiere injection d’anti-CD20. Par cette analyse, nous avons pu etablir des differences claires entre le programme des PC anti-CD20 et celui des PC de la rate des souris controles. Les PC controles de la rate presentent un profil intermediaire, n’exprimant quasiment plus de genes de proliferation mais un petit nombre de genes de plasmocytes de longue vie par cellule individuelle ; les PC de la rate des souris traitees par anti-CD20 composent par contre une population homogene exprimant de nombreux genes de PC, se rapprochant du programme des PLDV de la moelle osseuse. Non seulement le nombre de PC EYFP+ ne diminue pas de facon significative dans la rate avec le traitement anti-CD20, mais surtout le programme differe clairement entre les 2 populations. Ces resultats signifient que le traitement anti-CD20 induit un processus de maturation plasmocytaire dans la rate et non une selection de PLDV preexistants. Conclusion En conclusion, nos donnees suggerent que la differenciation paradoxale plasmocytaire avec le traitement anti-CD20 est un mecanisme general, que ce soit chez l’homme ou chez la souris. Comprendre les mecanismes qui sous-tendent ce processus est donc un enjeu capital pour interferer sur la differenciation plasmocytaire et tenter d’obtenir de meilleures reponses cliniques avec le traitement anti-CD20 au cours des maladies auto-immunes chez l’homme.

The use of monoclonal anti-CD20 antibody (Rituximab) has greatly improved the treatment of B-cell mediated autoimmune diseases, albeit with variable outcomes. Our previous data in humans suggested that Rituximab induced paradoxically the settlement of splenic long-lived plasma cells (LLPC) in the context of 2 autoimmune cytopenia, immune thrombocytopenia and warm autoimmune hemolytic anemia (1) (2). The presence of splenic autoreactive LLPC explained the failure of Rituximab treatment. To investigate whether this mechanism could have a general relevance and decipher the cellular and molecular mechanism of this process, we used both non auto-immune and auto-immune mouse models. We have taken advantage of the knock-in transgenic mouse model AID-CreERT2-EYFP, which allows the irreversible expression of EYFP in B cells engaged in a germinal center-dependent immune response after tamoxifen regimen, to follow plasma cells (PC) at different times of immunization by sheep red blood cells, and upon anti-CD20 regimen (clone 18B12, Biogen Idec), in the spleen and bone marrow (3). By using a set of diagnostic genes that allowed us to distinguish short-lived and long-lived plasma cells, we compared the transcriptional program by multiplex PCR of EYFP+ B220- PC from controls and anti-CD20 treated mice, immunized and analyzed at the same time, corresponding to the nadir of B-cell depletion. While splenic PC of untreated mice displayed an intermediate profile between short-lived and long-lived plasma cells, splenic PC from anti-CD20 treated mice composed a homogeneous population that displayed a more mature program, similar to the one of natural long-lived bone marrow PC. The absolute number of splenic EYFP+ B220- did not change upon anti-CD20 treatment indicating that B-cell depletion promoted PC differentiation rather than a long-lived PC selection. We identified BAFF (B-cell activating factor) as a major player of this process. Indeed, as described in human spleens, we observed that BAFF level was increased in the supernatants of splenocytes after B-cell depletion. Above all, combination of anti-CD20 and anti-BAFF (clone 10F4, GSK) antibodies dramatically reduced the number of splenic EYFP+B220- LLPC (decrease >5 fold compared with anti-CD20 and control groups, P < 0.001). Targeting BAFF had no major impact on protective long-lived bone marrow PC as IgG1 level in the sera remained unchanged after combination therapy. We identified neutrophils as the main source of BAFF production in the spleen. Finally, CD4+ T-cells also appeared to play a key role in context of B-cell depletion for supporting plasma cell survival in the spleen as they appeared to closely interact with EYFP+ plasma cells by confocal microscopy. Moreover, their depletion (clones YTS 191.1 or GK 1.5, Bioxcell) in vivo induced a significant decrease in the number of splenic LLPCs (decrease > 2 fold compared with anti-CD20 group, P < 0.05). To assess whether B-cell depletion could also modify the splenic plasma cell program in an auto-immune context characterized by an ongoing immune response, we used NZB/NZW mice that spontaneously develop a disease closely resembling human systemic lupus. In line with our previous findings, anti-CD20 treatment also promoted the differentiation of LLPC in the spleen of the NZB/NZW model, while a treatment combining anti-CD20 with anti-BAFF induced a marked reduction in total PC numbers(decrease > 3 fold compared with anti-CD20 group, P < 0.05). In conclusion, the process of PC maturation upon anti-CD20 treatment appeared to be a general mechanism, both in non auto-immune and auto-immune models. We identified BAFF and CD4+ T-cells as key factors in the splenic environment responsible for the emergence of such LLPC. Finally, our results suggest that interfering with the plasma cell survival niche with monoclonal anti-BAFF antibody at the time of B-cell depletion might greatly improve the response rate in B-cell mediated auto-immune cytopenia. (1) Mahevas M, et al, Journal of Clinical Investigation , 2013 (2) Mahevas M, et al, Journal of Autoimmunity, 2015 (3) Dogan I, et al, Nature Immunology, 2009 Disclosures No relevant conflicts of interest to declare.

International audience; Background: The rare descriptions, in the literature, of ocular infections due to Pasteurella multocida include: endophtalmitis, keratitis and corneal ulcers, Parinaud's oculoglandular syndrome, and conjunctivitis. Here, we report a rare case of rapidly evolving conjunctivitis due to Pasteurella multocida, occurring after direct inoculation with animal droplets in an immuno-compromised host. Case presentation: A 69-year-old, Caucasian male was referred to our department with purulent conjunctivitis, occurring five days after chemotherapy for an angioimmunoblastic-T-cell-lymphoma, and thirty-three hours after being struck in his right eye by his sneezing Dachshund dog. Physical examination revealed purulent conjunctivitis of the right eye associated with inflammatory edema of both lids. Direct bacteriological examination of conjunctival secretions showed gram-negative bacilli and regular, grey non-hemolytic colonies appearing the next day on blood agar. The oxidase test was positive for these colonies. An antibiotherapy associating intravenous amoxicillin and amoxicillin/clavulanate was administered. The outcome was favorable in the next three days allowing discharge of the patient with amoxicillin (2 g tid per os). Conclusion: This case report may be of interest for infectious diseases, ophthalmology or oncology specialists, especially nowadays with chemotherapy being administered in day care centres, where unusual home pathogens can be encountered in health related infections. In this case, previous animal contact and conjunctival samples showing Enterobacteriaceae like colonies with positive oxidase test were two important clues which could help clinicians to make the diagnosis of Pasteurella conjunctivitis in every day practice.