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 Table of Contents  
Year : 2016  |  Volume : 11  |  Issue : 5  |  Page : 2-19

IRACON 2016: Oral Presentations

Date of Web Publication27-Oct-2016

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How to cite this article:
. IRACON 2016: Oral Presentations. Indian J Rheumatol 2016;11, Suppl S1:2-19

How to cite this URL:
. IRACON 2016: Oral Presentations. Indian J Rheumatol [serial online] 2016 [cited 2019 Jan 20];11, Suppl S1:2-19. Available from:

  O1 Category: Paediatric Rheumatology Top

Gut microbiome in children with enthesitis-related arthritis in a developing country, and the effect of probiotic administration

Amita Aggarwal, Aditya N Sarangi, Priyanka Gaur, Anuj Shukla, Rakesh Aggarwal; Departments of Clinical Immunology, *Gastroenterology and #ICMR center for Bioinformatics. Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Introduction: In Asia, enthesitis-related arthritis (ERA) is the most-frequent category of juvenile idiopathic arthritis. ERA has a strong association with HLA-B27 and subclinical gut inflammation. In a HLA-B27 transgenic rat model, presence of Bacteroidesbacteria in the gut appears to cause spondyloarthropathy (SpA). Thus, we studied gut flora in children with ERA.

Methods: Stool specimens from 33 patients with ERA and 14 age-matched healthy controls were studied; none had any gastrointestinal symptom, or had received a drug known to affect gut motility or flora in the preceding 6 weeks. From each specimen, a cDNA library for V3 region of bacterial 16S rRNA was subjected to high-throughput, massively-parallel sequencing. Relationship of specimens was studied using principal co-ordinate analysis (PCoA), and abundances of various bacterial taxa and alpha diversity were compared between groups. In 8 patients, a repeat fecal specimen was studied after 12 weeks of probiotic therapy.

Results: The 55 specimens yielded a median (range) of 359,547 (102,093-1,502,380) high-quality reads each. In PCoA, gut flora from ERA showed a wider dispersion than those from controls. In patients, families Bacteroidaceae and Enterobacteriaceae were more abundant and Prevotellaceae were less abundant than in controls. Also, genera Bacteroides, EntercoccusandKlebsiella were overrepresented, and genus Prevotella was under-represented in ERA patients. Probiotic therapy led to a non-significant increase in Prevotellaceae.

Conclusion: Patients with ERA have a dysbiosis in the gut, with increased abundance of Bacteroides and reduction of Prevotella. Probiotic supplementation in a subset of patients did not significantly reverse these changes.

  O2 Category: Spondyloarthropathy Top

Simplified version of Ankylosing Spondylitis Disease Activity Score (ASDAS) for Indian AS Patients

Nagma Bansal, Jeet Patel, Neeraj Jain, Lalit Duggal, Bhandari Gurbir Singh; Department of Rheumatology and Clinical Immunology, Sir Ganga Ram Hospital, New Delhi, India

Background: ASDAS is a complex score to calculate. This study aimed to develop a simplified version which may be useful in AS patients in India.

Methods: 350 consenting AS patients (modified New York and/or Assessment in Ankylosing Spondylitis 2009 criteria) were recruited. Sociodemographic data and disease characteristics including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and ASDAS were collected. Simplified ASDAS (SASDAS) was calculated as the simple sum of patient global assessment, back pain, peripheral pain and swelling, morning stiffness and either ESR in millimeters per hour (for SASDAS-ESR) or CRP in mg/L (for SASDAS-CRP); this sum was divided by 10 to obtain the final score.

Results: Most (307/350, 87.7 %) were men. Median age at onset and diagnosis were 25.8 years and 30 years respectively. Average delay in diagnosis was 5.8 years. SASDAS-ESR and SASDAS-CRP showed good correlation with the ASDAS-ESR and ASDAS-CRP respectively (r2 =0.91 and 0.75 respectively). SASDAS-ESR showed good correlation with back pain (r=0.54), morning stiffness (r=0.51), patient global assessment (PGA) (r=0.61), BASFI (r= 0.63), ESR (r= 0.96) and CRP (r=0.72); SASDAS-CRP showed good correlation with spinal pain (r= 0.58), PGA (r= 0.67), EMS (r= 0.55), BASFI (r=0.70), ESR (r=0.71) and CRP (r= 0.91). Using established ASDAS cut-off values, the corresponding cut-off points between inactive disease, moderate disease activity, high disease activity, and very high disease activity with optimum sensitivity and specificity for SASDAS-ESR were 1.43, 2.83 and 4.93 and for SASDAS-CRP were 0.91, 1.85, and 3.28. While SASDAS-ESR agreed with ASDAS-ESR in the extremes of the condition only, SASDAS-CRP agreed with ASDAS-CRP throughout the range of disease activity.

Conclusion: SASDAS-ESR and SASDAS-CRP are simple, feasible and easy to use tools for evaluating disease severity in AS patients in cost constrained countries such as ours.

  O3 Category: Spondyloarthropathy Top

Elevated levels of serum Myeloid Related Protein 8/14 in ankylosing spondylitis: Associated with peripheral arthritis and active disease

Latika Gupta , Shruti Bhattacharya, Vikas Agarwal, Amita Aggarwal; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Background/Purpose: Monocytes of patients with Ankylosing Spondylitis (AS) show Toll-like receptor 4 (TLR4) over-expression. Myeloid-related proteins (MRP) 8/14 protein complexes are calcium-binding proteins, which act as endogenous ligands to TLR4. Thus we studied the levels of MRP8/14 in adult AS patients.

Methods: MRP8/14 levels were assessed in 99 adult AS patients satisfying ASAS 2010 criteria and 23 healthy controls by ELISA. Patient disease parameters like patient and physician global assessment, BASDAI, swollen and tender joint count, entheseal count by Maastricht Enthesitis index, Erythrocyte Sedimentation Rate (ESR) and C Reactive Protein (CRP) were also recorded. Levels were reassessed in 23 patients after 2-5 months of treatment with NSAIDs. All values are in median and IQR.

Results: The median serum MRP8/14 levels in patients [34.1 (17.94-264.58) μg/ml] were significantly higher than in healthy controls [5.97 (IQR 4.64-11.43) μg /ml (p<0.0001)]. Patients with peripheral arthritis (n=50) had higher levels than those with pure axial disease (n=49) [40.63 (IQR 28.41-73.15) μg /ml vs. 23.72 (11.04-61.55) μg /ml; p=0.012]. Levels of MRP8/14 correlated with ASDAS CRP (r=0.23, 95%CI=0.038-0.422, p=0.02) and CRP (r=0.28, 95%CI=0.081-0.45, p=0.01), and the correlation was better in early disease [≤5 years disease duration, (r=0.40, p=0.007) and (r=0.57, p=<0.0001) respectively]. MRP8/14 levels did not correlate with clinical disease activity measures such as BASDAI, Maastricht entheseal count, and patient and physician global assessment. Baseline levels were higher in treatment responders than in non-responders [51.17 vs. 32.22 μg /ml; p=0.02]. Change in MRP8/14 levels correlated with change in BASDAI and ASDAS CRP (r= 0.489, p=0.018 and r=0·498, p=0.016 respectively).

Conclusion: MRP8/14 levels may be used as a biomarker for activity, peripheral arthritis and response to therapy.

  O4 Category: Spondyloarthropathy Top

Gender Differences in Psoriatic Arthritis and relevance of Age of Onset of Psoriasis

Taral Parikh, Sapan Pandya, Rakesh Solanki; Vedanta Institute of Rheumatic diseases, Ahmadabad, Gujarat, India

Background/Purpose: Males with spondyloarthritis (SpA) have more spinal disease, in females peripheral joint involvement is dominant. Gender differences have not been studied well in psoriatic arthritis (PsA). The present study describes the clinical features and gender differences in a cohort of PsA, from a single centre in India.

Methods: 94 consecutive patients, between 2012 and 2015, fulfilling the Classification criteria for psoriatic arthritis (CASPAR), were analysed from the rheumatology outpatient department of. The population was stratified by age at the time of onset of psoriasis, a cutoff point of 40 years for distinguishing between Type 1 and Type 2 psoriasis.


Demographic profile:
n = (94): Mean age was 43.7 (±10.3), weight 70.3 (±13.9), duration of psoriasis onset 7.3(±7.1), duration of PsA 3.3(±4.09), psoriatic area severity index (PASI); 3 (±4.9), swollen joint counts 4.2 (±4), tender joint counts 6.3 (±5.1), patient global assessment for psoriasis (0-10 scale) 3.6(±2.6), patient global assessment of PsA 6.7 (±1.8). 6.3% had a family history of psoriasis.

Arthritis pattern: Axial 43 (45%), oligoarthritis 26 (27%) and polyarthritis 25 (26%), 1 (1.06%) DIP and 3(3.19%) isolated axial involvement. Enthesitis in 6(6.4%) and dactylitis in 27 (28.7%) patients.

Conclusion: The commonest pattern of PsA was axial followed by oligoarthritis. As reported previously males had more axial involvement and females had more peripheral involvement, even when stratified by age of onset, females had longer duration of psoriais.

  O5 Category: Spondyloarthropathy Top

Ultrasonographic and clinical assessment of peripheral enthesitis in Indian spondyloarthritis patients

Saumya Ranjan Tripathy, Anupam Wakhlu, Puneet Kumar, Urmila Dhakad, Archana Wakhlu1 ; Departments of Immunology,1 Radiodiagnosis, King George's Medical University, Lucknow, India

Background/Purpose : Enthesitis is hypothesized to be the primary manifestation of spondyloarthritis. Ultrasonography(USG) is an emerging tool to detect enthesitis. Data on prevalence of USG detected enthesitis in spondyloarthritis from India is lacking.

Methods : Patients satisfying the ASAS criteria for axial and/or peripheral spondyloarthritis were recruited. USG was done using multi-frequency linear-array transducer (8-13MHz) of Logiq E; GE Medical Systems Ultrasound machine. B-mode settings used: dynamic range(40-50dB); GS- frequency(11-13 MHz); GSgain(60 dB). PD mode settings used: pulsed repetition frequency(400-800 Hz); PD-gain (highest possible gain with minimum background noise). The following entheseal sites were screened: bilateral plantar fascia on calcaneus (PF), Achilles tendon at calcaneus, quadriceps tendon on patella(QT) and patellar tendons proximally on patella(PTprox) and distally on tibia(PTdistal). USG parameters included detection of erosion/ hypoechogenicity/ enthesophytes/ increased thickness/intratendinous calcification and presence of PD-signals as per OMERACT 2014 guidelines(Terslev et al). Power Doppler was graded on a scale of 0-3(Kiris etal, 2006). USG-score was calculated by adding 1 point for each finding and the grade of Power Doppler. Clinically peripheral enthesitis was evaluated using the MASES (Maastricht Ankylosing Spondylitis enthesitis score) and additionally at PF, QT, PTprox, PTdistal bilaterally. Prevalence of clinical and USG detected enthesitis was estimated and compared.

Results : 52 spondyloarthritis patients(37 AS, 11 PsA, 2 ReA and 2 IBD associated arthritis) were recruited. USG detected enthesitis at least at 1 site in 49 patients(94%) compared to clinically detected enthesitis in 36 patients(69%) with p-value<0.01. The most common abnormality was increased thickness followed by presence of PD signals. PD-signals were positive in 36 patients (including 27 sites without other USG features). One patient with clinical enthesitis did not have USG findings. USG-score did not correlate with BASDAI, BASFI or ASDAS-ESR.

Conclusion : Ultrasonography including Power Doppler has higher sensitivity than clinical examination for detection of enthesitis. Correlation with disease activity will need larger studies.

  O6 Category: Spondyloarthropathy Top

Evidence of inflammation amplifier in Reactive arthritis.

Sandeep Kumar1, Rajeev Singh2, Abhishek Kumar Singh3, Kamimura Daisuke3,Smriti Chaurasia1, Yasunobu Arima3, Toru Atsumi3, Ratnadeep Mukherjee4, B Ravindran4, Vikas Agarwal1, Masaaki Murakami3, Ramnath Misra1 ; Department of Clinical Immunology, SGPGIMS, Lucknow, India.2 Department of Biochemistry, KGMU, Lucknow, India.3 Molecular Neuroimmunology, Institute for Genetic Medicine,Hokkaido University, Japan,4 Institute of Life Sciences, Bhubneshwer, India

Background/Purpose: F759 mice with a single amino-acid substitution in signal transducer subunit of IL-6 receptor gp130 (Y759F) develops arthritisspontaneously due to IL-17A and IL-6 mediated synergistic activation of positive-feedback loop of NF-kB signaling (inflammation amplifier).We sought to see whether this mechanism is operational in Reactive arthritis.

Methods: Arthritis was induced with oral feeding of salmonella enterica followed by ankle microbleeding in the ankle joints of F759 mice. Sera IL-6 along with IL-6 mRNA and STAT3 phosphorylation in synovium were measured. Further,exosomes isolated from sera of  Salmonella More Details infected and control mice and were injected into the joints of mice, and measured the expression of proinflammatory cytokine, chemokines and growth factor. On the other hand, sera and synovial fluid of patients with ReA multiple cytokines, chemokines and growth factors were also measured. Finally, synovial fibroblasts (FLS) were cultured to purity and stimulated with IL-6, IL-17, IL-6 plus IL-17 and IL-6 were measured to see synergistic activation.

Results: IL-6 in sera of arthritic mice were significantly higher (p<0.05) than control mice along with increase STAT3phophorylation in the synovium. Exosomesfrom salmonella infected mice induced arthritis in ankle joint and significantly increased IL-6 expression (p<0.05). SF concentrations of IL-6, CCL-20, PLGF and FGF-basic were significantly higher in patients with ReA/uSpA as compared to OA patients. Further, levels of these factors were also high in SF compared to sera in ReA patients. Finally, in comparison to IL-6 and IL-17 alone these cytokines synergistically induced more IL-6 production from FLS isolated from ReA patients.

Conclusions: Data of mice and patients support that synovitis in ReA is perpetuated by inflammation amplifier or synergistic induction of IL-6 and IL-17.

  O7 Category: Systemic Lupus Erythematosus Top

To Compare the Efficacy of Low Dose versus High Dose Cyclophosphamide Regimen as Induction Therapy in the Treatment of Proliferative Lupus Nephritis

Sonal Mehra, Jignesh Usdadiya, Vikramraj Jain, Bharat Singh, Ankit Jain, Dantis Emmanuel, Chengappa KG ,Mithun CB, Durga Prasanna Misra, Vir Singh Negi; Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Background/Purpose : Lupus nephritis increases the risks of end stage renal disease, cardiovascular disease, and death. The objective of our study was to evaluate the efficacy and compare the adverse effects profile of low dose and high dose cyclophosphamide in Indian SLE patients.

Methods : We recruited seventy lupus nephritis subjects (Class III/IV) by block randomization into low dose (n=36) and high dose (n=34) groups. All received methylprednisolone (1 gm) followed by cyclophosphamide 500 mg two weekly for 12 weeks followed by azathioprine in the low dose and cyclophosphamide 750mg/m2 every 4 weeks for 24 weeks in the high dose regimen. The renal response was compared at the end of 12 and 24 weeks. Renal SLEDAI, complements and anti-dsDNA antibodies titres were measured at baseline, 12 weeks and 24 weeks.

Results : We observed that the complete/partial renal response was statistically significant at the completion of 12 weeks in the low dose arm as compared to the high dose arm [p value 0.04]. However, at the completion of 24 weeks both regimens demonstrated equal efficacy in inducing remission [p value 0.98].At 24 weeks, the prevalence of hypocomplimentemia and anti-dsDna antibody positivity declined more in the high dose cyclophosphamide arm as compared to the low dose arm. The treatment discontinuation owing to adverse events and nonrenal flare were responsible for higher withdrawals in the low dose group (n=4) as compared to (n=2) in the high dose group. Results did not differ between treatment groups for majority of the adverse events including infections except for alopecia and cyclophosphamide induced leucopenia were significantly higher in the high dose arm.

Conclusion : At 24 weeks, both low and high dose cyclophosphamide were able to produce a similar rate of complete response, however high dose regimen was more effective in reducing the prevalence of hypocomplimentemia and anti-dsDna titres. This might be beneficial for higher and sustained renal remission and reduced relapses and disease flares in the long term. The mortality rates and adverse events were also comparable. We propose that high dose cyclophosphamide may be better for inducing renal remission without significantly increasing the infection risk.

  O8 Category: Systemic Lupus Erythematosus Top

NMR-based serum metabolomics reveals distinctive metabolic signatures for monitoring patients with Lupus Nephritis

Ramnath Misra1, Anupam Guleria2, Ranjan Gupta1,

Sukesh Edavalath1, Smriti Chaurasia1, Durgesh Dubey2, Umesh Kumar2, Amita Aggarwal1, Dinesh Kumar2 ; Department of1 Clinical Immunology and2 Center for Bio-Medical Research, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, India

Background: We have recently reported that lupus nephritis (LN) patients have distinctive metabolomic signature as compared to non-nephritis patients. In this study, we explored whether the abnormal LN metabolic changesreset back towards their normal serum levels in response to treatment.

Methods: Twenty SLE patients satisfying ACR, 1982 classification criteria and having LN were enrolled. Disease activity at baseline was assessed using SLEDAI and renal SLEDAI and serum was collected. All were treated with cyclophosphamide/Mycophenolate as per ACR, 2012 guidelines and followed up at 6-9 months. Re-assessment for disease activity was done and follow-up serum samples were collected. Sera from 29 healthy subjects (HC) were also analyzed as controls. All sera were analysed using1D1 H-CPMG NMR and discriminatory metabolites were identified using PLS-DA based multivariate analysis. The discriminatory metabolites were validated using student's t-test analysis (i.e. p<0.05 was used as the criterion for statistical-significance).

Results: Patients with LN had high disease activity as shown by SLEDAI and rSLEDAI which decreased significantly with treatment (Table 1). PLS-DA analysis also revealed separate clustering of HC and LN patients. Serum of LN patients was characterized by lower levels of amino acids (leucine, valine, alanine and glutamate) and lactate compared with HC, whereas levels of lipoproteins (LDL and VLDL), and α/β glucose were significantly elevated in sera of LN patients. The PLS-DA score plot of 3 groups showed that with treatment in LN,these metabolic markers were modulated towards the healthy controls (Figure 1) and lie in between HC and naive LN patients with some overlap with the naive LN patients.

Conclusion: Significant and relevant metabolic differences are found in treated LN patients compared to naïve LN patients suggesting that NMR-based serum metabolic profiling has definite potential to be a surrogate clinical tactic for diagnosis and monitoring the efficacy of treatment in LN.

  O9 Category: Systemic Lupus Erythematosus Top

Influence of HLADRB1 Susceptibility Alleles on the Clinical Phenotypes of Systemic Lupus Erythematosus Patients

Shiva Krishna Katkam1, Liza Rajasekhar2, Konda Kumaraswami2, Ramesh Manthri2, Vijay Kumar Kutala1 ; Departments of1 Clinical Pharmacology and2 Therapeutics and Rheumatology, Nizam's Institute of Medical Sciences (NIMS), Hyderabad, India

Background/Purpose: SLE is a multisystem autoimmune disorder with myriad clinical presentations encompassing almost all organs and tissues. The disease severity and frequency of flares is unpredictable. There is need for biomarkers to predict the course of the disease. Earlier studies have shown an association between human leukocyte antigen (HLA) allele frequencies and susceptibility to SLE.

Methods: Patients satisfying the ACR 1997 update of 1982 SLE classification criteria were included in the study. Individual lupus manifestations and category A organ manifestations as defined by the BILAG scoring system were tested for association with HLADRB1and DQB1 alleles. The maximum Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was recorded. The PCR-SSP method using Histo Type DR DQB (SSP Kit), BAG Health Care GmbH, Germany was used for HLA-DRB1and DQB1 genotyping in 100 SLE patients and 86 healthy controls.

Results: The age of the patients and controls at sampling was 28.04 ± 10.60 and 30.00 ±11.2 yrs respectively. The disease duration of cohort was 5.49 ± 4.15 yrs. A significant positive association with SLE was observed for HLA-DRB1*07 allele (OR: 2.65, 95% CI: 1.38-5.0, p =0.002).A significant protective association was found with DRB1*14allele (OR:0.45, 95% CI: 0.22-0.91,p =0.033) and DRB1*4-DQB1*05 haplotype (frequency 3% in patients vs. 16.27% in controls, OR: 0.15, 95% CI:0.04-0.57, p = 0.001). DRB1*10-DQB1*05 (OR: 0.23, 95% CI: 0.08-0.64, p=0.004), DRB1*14-DQB1*05 (OR: 0.35, 95% CI: 0.16-0.75, p = 0.008) haplotypes also showed protection from SLE disease. SLE patients with HLADRB1*07 allele showed significant association with different clinical and autoantibody phenotypes like discoid lupus (OR:4.5, 95% CI:1.62-11.66, p =0.003), BILAG category A cutaneous lupus (OR:4.6, 95% CI:1.66-13.09, p=0.003), BILAG category A neuropsychiatric lupus (OR:7.4, 95% CI:2.66-20.69, p=0.0001), BILAG category A cardio-respiratory manifestations (OR: 3.4, 95% CI:1.052-11.16,p = 0.04), anti-dsDNA antibodies (OR:2.2, 95% CI:1.074-4.5, p= 0.03) and BILAG category A arthritis (OR:2.4, 95% CI: 1.16-5.0, p = 0.01). Patients with HLADRB1*07 allele also revealed a positive correlation with low levels of C3 and C4 (OR: 5.1, 95% CI: 2.0-13.1, p = 0.0006).

Conclusion: DRB1*07:01 allele confer susceptibility to SLE in Indian lupus patients. We also found a protective association of HLADRB1*14 alleles with SLE. HLADRB1*07 allele also showed significant correlation with various lupus phenotypes and severe manifestations in the cutaneous, neuropsychiatric and cardio-respiratory BILAG domains.

  O10 Category: Systemic Lupus Erythematosus Top

Monocyte/macrophage related biomarkers in assessment of lupus nephritis activity

Ranjan Gupta, Akhilesh Yadav, Amita Aggarwal; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Background/Purpose: Macrophages are important players in pathogenesis of lupus nephritis (LN) and alternatively activated macrophages (CD163+) are the predominant subtype infiltrating the glomeruli. Monocyte/Macrophage markers like Monocyte Chemoattractant Protein-1 (MCP-1) and soluble CD163 (shed form of CD163; sCD163) in urine may reflect LN disease activity.

Methods: A total of 117 SLE patients with active nephritis (AN), active non-renal disease (ANR) and inactive disease (ID) were enrolled. AN patients were followed up every 3 months for 1 year. At all visits, urine and plasma samples were collected. Twenty urine samples each from healthy subjects (HC) and rheumatoid arthritis (RA) patients served as controls. MCP-1 and sCD163 in plasma and urine was measured using ELISA. Urinary values were normalized for creatinine excretion. Variables are expressed as median (range) and non-parametric tests were used for statistical analysis.

Results: Baseline uMCP-1 was significantly higher in AN as compared to ANR, ID, HC and RA. uMCP-1 correlated modestly with rSLEDAI (r=0.5;p<0.001), SLEDAI (r=0.45;p<0.001), protein:creatinine ratio (r=0.43;p<0.001) but not with corresponding plasma levels (r=0.17;p=ns) Similarly, baseline uCD163 wasalso significantly higher in AN as compared to other groupsand correlated modestly with rSLEDAI (r=0.48;p<0.001), SLEDAI (r=0.31;p<0.001), protein:creatinine ratio (r=0.56;p<0.001) but not with corresponding plasma levels (r=0.23;p=ns) (Table 1). To differentiate AN from ANR patients, on ROC analysis, uMCP-1 (AUC=0.737) and uCD163 (AUC=0.757) performed better than their corresponding plasma levels, C3, C4, and anti-dsDNA antibodies. On follow up,uMCP-1 and uCD163 decreased significantly at all visits in AN patients. Plasma levels also decreased significantly but showed an erratic and irregular trend (Table 2). Also, uMCP-1 and uCD163 rose before conventional markers in 4 patients who relapsed within 1 year whereas plasma levels did not.

Conclusion: Urinary MCP-1 and sCD163 aregood biomarkers of LN disease activityas they are also produced locally in the kidney.

  O11 Proinflammatory cytokines (IL6, TNFα and interferon γ) in patients with systemic lupus erythematosus and their clinical correlation Top

S. Sriram, S. Rajeswari; Madras Medical College and RGGGH, India

Aim: To study the levels of proinflammatory cytokines (IL6, TNFα, IFN-γ) in systemic lupus erythematosus(SLE) patients as compared to healthy control volunteers and to correlate the levels of cytokines with clinical features in Indian patients

Materials And Methods: After obtaining Institutional ethical clearance and written informed consent, 88 consecutive SLE patients(newly diagnosed and those in remission) who satisfied SLICC 2012 ACR/EULAR criteria and 60 age and sex matched healthy controls were taken for the study, which was conducted between June to December 2015 in a tertiary care centre. Patients who had overlap syndromes, Mixed connective tissue disorder, antiphospholipid antibody syndrome, secondary Sjogrens syndrome, Lupus flare due to infections and offending drugs,were excluded. A thorough history, clinical examination, baseline biochemical and immunological investigations were done. Serum IL6,TNFα,IFN-γ were estimated in all patients and controls by ELISA. Statistical methods were done using SPSS software.

Results: Serum interferon γ levels were higher in patients (mean±SD=25.65±64.81pg/ml; median 8) than the controls (mean±SD=2.95±10.28pg/ml, median-0) which was statistically significant (p=0.0080). Serum IL6 levels were also higher in patients (mean±SD=143.01±64.94 pg/ml) than controls (mean±SD=69.33±11.7pg/ml), which was statistically significant (p<0.0001). Serum TNF-α were also elevated in patients (mean±SD=427.13±206.49pg/ml; median 384.5) than controls (mean±SD=236.05±23.53pg/ml; median 238) which was also statistically significant (p<0.0001). Interferonγ levels were significantly higher in females, lower in patients with lymphadenopathy and significantly higher in lupus nephritis class III,positively correlated with thrombocytopenia and negatively correlated with ESR, dsDNA, C3, C4. IL6 and TNF α were significantly associated with oral ulcer and alopecia respectively. Both showed a positive correlation with ESR, dsDNA, C3, C4.Cytokines didn't correlate with SLEDAI.

Conclusion: IL6 and TNF α are a good and reliable markers of disease activity, but lack significant clinical correlation and stand behind the conventional markers for correlating with internal organ involvement.


  O12 Category: Osteoarthiritis Top

Comparison of intra articular autologous platelet rich plasma with intra articular depot steroids in osteoarthritis knee: A Prospective Randomized comparative interventional study.

Arjun MN, Vivek Vasdev, Arun Hegde, Gautham Dhar Choudhary, Kunal Kishore, Abhishek Kumar; Department of Rheumatology & Clinical Immunology, Army Hospital Research & Referral, Delhi Cantt, India

Background: Platelet Rich Plasma (PRP) is rich in growth factors, which augments the process of healing and cartilage regeneration . It has become a promising treatment option for osteoarthritis knee. This study compares the clinical response of intra-articular PRP and depot steroids (Depomedrol, Pfizer) in two groups of patients affected by knee Osteoarthritis (OA) and differences in their outcomes at 6, 12 and 24 weeks post injection.

Methods : A total of 60 patients affected by clinically and radiographically documented osteoarthritis knee were included (Kellgren-Lawrence radiographic classification scale ≤3). The patients were randomized into 2 study groups in a 1:1 ratio with both groups comparable in baseline characteristics. Group A (n=30) received 2 intra-articular (IA) injections of PRP (6 ml), 3 months apart and Group B (n=30) patients received 2 IA injections of Depomedrol (80 mg/2 mL). All patients were evaluated with visual analog scale (VAS) and the Western Ontario and McMaster (WOMAC) score at baseline. 6, 12, and 24 weeks post treatment.

Results : Statistically significant improvement in all WOMAC parameters was noted in group A within 2 weeks that persisted until final follow-up at 24 weeks. The mean WOMAC scores (pain, stiffness, physical function, and total score) at baseline for group A were 12.18, 4.32, 47.56, 64.06, respectively and for group B, were 11.62, 4.50, 45.10, and 61.22.At final follow-up meantotal WOMAC scores showed significant improvement in Group A (28.60 vs 59.86, p<0.001)where the clinical outcomes were better compared with the corticosteroids (Group B).

Conclusion: Treatment with PRP showed a significantly better clinical outcome compared with depot IA steroids, with sustained lower WOMAC scores. PRP is an effective modality for improvement in functional status and pain in moderate knee osteoarthritis and a minimum of two injections are appropriate.

  O13 Category: Rheumatoid Arthritis Top

In early RA, serum angiogenic markers of inflammation is better predicted by PDUS synovitis grade compared to disease activity index.(DAS 28)

Sanchaita Misra, Sumantro Mondal, Pradyot Sinhamahapatra, Alakendu Ghosh, Aharna Guin Paul, Sampurna Roychowdhury Majumder; Department of Rheumatology, Institute of Post Graduate Medical Education And Research, Kolkata, India

Background : Pathophysiology of RA is characterized by synovial cells hypoxia, angiogenesis and abnormal fibroblast proliferation. PDUS can detect both synovial proliferation and increased vascularity in early stage. The aim of this study was to compare relationship of PDUS synovitis grading and RA disease activity index with serum angiogenic markers in early RA patients.

Methods : 50 consecutive early RA patients (< 6 months) [ACR, 2010 criteria] were included in this study. DAS28,CRP was calculated and PDUS synovitis grading (0-3) was done. Patients were categorized into different DAS activity subsets. PDUS assessments were categorized accordingly. Serum level of inflammatory cytokines (TNF-α, IL-6) and angiogenic markers (Ang-1, VEGF) were measured between these two groups.

Results: Of 50 patients (24 Moderate activity and 26 high activity) were included. Patients with grade 3 PDUS score, even with moderate DAS value showed a significant rise in angiopoietin 1, VEGF, IL6 level compared to grade 2 PDUS patient but of high DAS values (Table 1). VEGF level showed significant correlation with CRP (p=0.03). IL-6,Tnf-α also correlated well with Ang-1 and VEGF.

Conclusion: The study suggests that in early RA patients, PDUS synovitis grading better reflects internal angiogenic/cytokines involved in inflammation and acute phase reactants than disease activity index.

  O14 Category: Rheumatoid Arthritis Top

Major Histocompatibility Antigen HLA-DQ6.1 (DQA1*0103/DQB1*0601) Increases Rheumatoid Arthritis Risk Independent of Shared Epitope Among Indians

Able Lawrence1, Swayam Prakash2, Uddalak Bharadwaj2, Amita Aggarwal1, Ramnath Misra1, Suraksha Agrawal2 ;1 Department of Clinical Immunology and2 Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Background/Purpose : The HLA-DRB1 alleles (SE) are classified into neutral (Sx), high (S2, S3P) and low risk (S1, S3D) . Unlike HLA-DR antigens, HLA-DQ is polymorphic at both alpha and beta chains. DQA1*0103 and DQB1*0601 that form the DQ6.1 heterodimer are autoimmune prone and are common in Asia but rare outside. We studied the association of HLA-DQ6 isoforms with RA after controlling for SE.

Methods: 181 patients with RA fulfilling ACR 1987 criteria were along with 250 healthy controls from the same ethnic and regional background. HLA-DRB1, HLA-DQA1 and HLA-DQB1 alleles were typed using PCR and SSOP. Logistic regression was used to study association. Subjects were risk-stratified based on SE genotype and adjusted Odds Ratio was estimated using random effects meta-analysis. STATA and Meta-Analyst software were used.

Results : The mean age of patients were 37.2(+10.2) years at onset and 74% were female. 76.1% were RF positive and 16.5% had extra-articular manifestations. 43(23.8%) of RA patients had DQ6.1 against 33(13.3%) controls (Odds ratio 2.01, P=0.007). DQ6.3(DQA1*0103/DQB1*0603) was present in 3(1.7%) patients against 16(6.4%) controls (OR 0.37, P=0.037). High risk SE alleles S2 or S3P were present in 84/179 (47%) patients and 73/249 (29%) controls (OR 2.1, P<0.001). Low risk SE alleles S1 or S3P were present in 104/179(58%) of rheumatoid and 178/250 (81%) of controls (OR 0.70, P=0.016). On multivariate analysis, the OR for DQ6.1 increased to 2.76 (P<0.001) while high risk SE alleles S2/S3P had OR 1.99 (P=0.001). After adjustment for SE genotype by stratification and meta-analysis (Fig 1), OR for DQ6.1 further increased to 4.3(1.7-10.7 P=0.002). Both DQ6.1 and DQ6.3 (Fig 2) were in linkage with low risk SE alleles but not high risk alleles.

Conclusion: HLA-DQ6.1 (DQA1*0103/DQB1*0601) is an independent genetic risk factor for Rheumatoid Arthritis in North Indians especially those negative for high risk DRB1 shared epitope alleles.

  O15 Category: Rheumatoid Arthritis Top

Cytokine levels may assist in identifying rheumatoid arthritis patients achieving remission

Swetha J1, Chandrashekara S1, Deepak CL*1, Renuka Panchagnula2, Anupama KR1, Shuchismita Dey1 ; Chan Re Rheumatology & Immunology Center & Research, Bengaluru, India, ChanRe Diagnostic Laboratory, Bengaluru, India

Background/Purpose: Cytokines regulate a wide range of inflammatory processes implicated in the pathogenesis of rheumatoid arthritis (RA). Hence, they may serve as biomarkers for identifying RA patients on remission. The preliminary study evaluated the differences in cytokine levels of IL6, IL10 and TNF-α in RA patients who achieved remission.

Methods: Seventy-two RA patients who fulfilled the ACR/EULAR 2010 classification criteria were recruited for the study.Fifty-two patients were in remission (DAS28CRP ≤2.6), among whom 17 were in deep remission (≤1.6). Twenty patients were DMARD-naïve and had active disease (DAS28CRP >2.6). As per ACR Boolean criteria, 44 patients had remission and 28 had active disease. The demographic and clinical data of all the subjects were recorded, and the serum levels of IL6, IL10 and TNF-α were estimated by enzyme linked immune-sorbent assay (ELISA). The cytokine values obtained were classified as below detection values (BDL) and above detection values (ADL). Group differences for demographic variables and cytokine values were determined separately between the patients in remission and active disease classified based on DAS28CRP and ACR Boolean criteria. Correlation among the variables was also examined.

Results: The study subjects had a mean age (SD) of 46.54 (10.6) years and median (range) duration of illness of 45 (3-240) months. Marked differences in duration of illness, IL6 and IL10 levels were seen between the active and remission groups. Age, gender and TNF-α did not differ among the DAS28CRP groups. Strong positive correlation was observed between DAS28CRP and IL6. IL10 was positively correlated (moderate) and duration of illness was negatively correlated (moderate). RA patients classified according to ACR Boolean criteria showed similar results.

Conclusion: Cytokine (IL-6 and IL-10) levels may assist in differentiating patients in remission from those with active disease.

Keywords: IL6, IL10, TNF-α, ELISA, RA

  O16 Category: Rheumatoid Arthritis Top

Direct LPS recognition and activation of CD8+T cells via TLR4 in patients with rheumatoid arthritis.

Archana Tripathy1, Shweta Khanna1, Prasanta Padhan2, Shuchi Smita3, Sunil Raghav3 and Bhawna Gupta1 ; School of Biotechnology Kalinga Institute of Industrial Technology; Department of Rheumatology, Kalinga Institute of Medical Sciences; Institute of Life Sciences, Bhubaneswar, Odisha, India

Background: Rheumatoid arthritis (RA) is an autoimmune disease characterized by abnormal immune responses to self-antigens. Though the pathogenesis of RA is not yet fully elucidated, it is known to be induced by environmental factors on a genetically susceptible background. Toll-like Receptors (TLRs) have been established to recognize specific patterns of microbial components and lead to systemic immune responses in Rheumatoid arthritis (RA). TLRs are expressed by cells in inflamed joints of RA patients and variety of endogenous TLR ligands is present within those joints. This study suggests that the over expression of TLR4 in CD8+T cells from RA patients may contribute to the abnormal immune activation of pro inflammatory cytokines and enhance the acute inflammation.

Methods: Eighty seven RA patients and 70 healthy donors participated in this study. Clinical variations like disease duration, number of actively inflamed joints, number, and type of bones deformities, CRP, RF, Anti-CCP, ESR (Erythrocyte Sedimentation Rate), and therapeutic interventions were recorded for each patient and DAS 28 scores were calculated with the help of the clinician. We analyzed the expression of TLR4 in transcript level by real-time PCR and protein level by flow cytometry in CD8+T cells of RA patients. Different cytokines level was checked after stimulation of CD8+T cells in TLR4 agonist.

Results: A significant increased of TLR4 in both transcript level and protein level in patients with RA compared to healthy donors (p<0.001). We got a strong positive correlation between TLR4 expression and DAS 28 score (rs= 0.96). The ROC curve analysis confirmed the significance of TLR4 expression in RA patients (Area=0.77, p<0.01). We found that TLR4 ligand responsiveness significantly increased the mRNA expression of different inflammatory mediators in purified CD8+T cells of RA patients compared with healthy individuals after in vitro stimulation.

Conclusion: In summary, our data suggest an increased expression of TLR4 in CD8+T cells play a major role in inflammation of RA patients.

  O17 Category: Rheumatoid Arthritis Top

Assessment of hand arterial flow pattern and change in resistive index from proximal to distal arterial segments in Rheumatoid arthritis: a case control study

Sumantro Mondal, Rudra Prosad Goswami, Debanjali Sinha, Geeta Bali Sircar, Parasar Ghosh, Alakendu Ghosh; Department of Rheumatology, Institute of post graduate medical education and research. Kolkata, West Bengal, India

Background: Hand joint synovitis is one of the classical features of Rheumatoid arthritis (RA). Tissue inflammation is associated with change in local blood flow pattern which can be detected by colour Doppler ultrasound (CDUS). This study was intended to search for changes in blood flow parameters of hand arteries by CDUS, in RA patients

Materials and Methods: 109 RA patients (as per ACR/EULAR 2010 classification criteria) with hand joint synovitis were included in this study along with 90 age and sex matched controls. Both groups underwent CDUS of bilateral radial, ulnar, palmar and digital arteries. Resistive index (RI) and change in resistive index (ΔRI) from proximal to distal arteries were calculated and compared between patient and control group.

Results: Mean age of patient and control group were 40 ± 10.8 and 37 ± 7.6 years respectively. RI values of palmar arteries (case: 0.73 ± 0.08, control: 0.77 ± 0.06, p=0.001) and digital arteries (case: 0.68 ± 0.08, control: 0.76 ± 0.04, p= <0.001) were significantly lower in patient group. RI of radial and ulnar arteries did not show any statistically significant difference. The ΔRI for radial to palmar (case: 14.13 ± 7.82, control: 6.17 ± 4.8, p= <0.001), ulnar to palmar (case: 12.66 ± 8.11, control: 4.18 ± 3.86, p= <0.001) radial to digital (case: 20.11 ± 8.42, control), ulnar to digital (case: 18.7 ± 9.02, control: 6.61 ± 5.64,, p=<0.001) and palmar to digital (case: 6.89 ± 5.92, control: 1.07 ± 7.32, p=<0.001) were all statically significantly more in patient group.

Conclusion: In RA patient, palmar and digital arteries show low resistance flow pattern alongwith significant reduction in flow resistance from proximal to distal hand arteries. Change in resistive index from radial, ulnar to distal hand arteries could be an objective surrogate marker for underlying tissue inflammation.

  O18 Category: Rheumatoid Arthritis Top

Quantitative Metabolic Volumetric product on 18F-FDG PET-CT in assessing Treatment Response to disease-modifying anti-rheumatic drugs (DMARDs) in Rheumatoid arthritis: multi-parametric analysis integrating ACR-EULAR criteria

Santosh Nandigam, Yogesh Sejul, Ramesh Asopa, Sandip Basu; Radiation Medicine Center (BARC), Tata Memorial Hospital Annexe, Parel, Mumbai, India

Background/Purpose : The EULAR score for treatment response evaluation of RA using conventional DMARDs still remain investigatory with need for more practical objective assessment. The main objective of this study was to quantify the treatment response employing FDG-PET/CT andcompare with clinical and biochemical parameters.

Methods: Newly diagnosed patients of RA were prospectively evaluated with clinical symptoms, biochemical parameters as per 2010 ACR-EULAR criteria, FDG-PET/CT with calculation of standardized uptake value (SUVmax) and metabolic volumetric product (MVP) of the involved joints prior to starting DMARDs. Follow up evaluation was done with same parameters at 3 and 6 months post therapy. Correlation analyses were undertaken between biochemical, PET-CT parameters, and EULAR score with clinical outcome. Patients were grouped into 4 categories: complete response, good response, mixed response and no response to DMARD therapy using pre-defined criteria.

Results: Evaluation of treatment response in 10 patients at 3 months and in 9 patients at 6months showed a) agreement for MVP, biochemical parameters with clinical symptomatic assessment in all patients, b) while agreement for EULAR score was noted in only 3 patients and disagreement in 7 patients with clinical symptoms rEULAR (0.37) and at 6 months in only 3 patients and disagreement in 6 patients, rEULAR (0.52). The correlation factors at 3rd month and 6th months were respectively as follows: rMVP (0.67 & 0.75), rRA factor (0.54 & 0.74), rESR (0.81 & 0.73), rCRP (0.78 & 0.51), and rAntiCCPantibodies (0.33 & 0.54). The overall response to DMARD at 3 months was assessed with: good response in 4 cases (40%), mixed response in 1(10 %), no response in 5 (50 %) and complete response in none ( 0 %). Step-up therapy was initiated in 4 patients who showed non-response/progression on clinical symptomatic assessment at 3months. Among them, 1 patient showed good response, 1 mixed response and the remaining 2 continued to show non-response at 6 months. One patient who had minimal response at 3 months on FDG-PET/CT was continued on same DMARD in view of clinical symptomatic good response (at 3 months) but ultimately demonstrated disease progression in all scales and worsening of symptom (at 6 months).

Conclusion: FDG-PET/CT based assessment of inflammatory activity noted in the joints of RA with quantitative parameters (SUVmax/MVP) can be a promising approach for whole body assessment of RA disease activity and treatment response assessment especially in inconclusive cases and correlates well with other parameters.

  O19 Category: Basic Immunology Top

Phosphodiesterase-5 Inhibitors Attenuate Fibrotic Phenotype And Restore Anti-fibrotic Responses Of Cutaneous Fibroblasts In Patients With Scleroderma.

Mohit Kumar Rai, Vinita Agrawal, Vikas Agarwal; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Background/Purpose: Scleroderma is characterized by excessive fibrosis of skin and internal organs. There is no promising therapy available for treatment of fibrosis in Scleroderma. Herein, we hypothesize that Phosphodiesterase5 inhibitors (PDE5i) attenuate fibrotic phenotype of cutaneous fibroblasts in patients with scleroderma.

Methods: Primary fibroblast cultures from mid forearm skin of 13 Patients with scleroderma and 5 healthy individuals were established. To mimic disease condition fibroblasts were pre-stimulated with TGF-β1 (10 ng/ml) for 1 hour followed by incubation with TGF-β1 and PDE5i; Sildenafil (10μM) and Zaprinast (10μM), for 24 hours (Strategy 1). In another strategy, fibroblasts were pre-treated with PDE5i for 1 hour followed by incubation with TGF-β1 for 24 hours (Strategy 2). Expression of profibrotic genes; COL1A1, COL1A2, Fibronectin, ASMA1, CTGF, and antifibrotic genes; MMP2/TIMP were analyzed with real time PCR and Western Blot. Further, effect of PDE5i on TGF-β1 downstream signalling; canonical and non-canonical pathways, were analyzed with western blot.

Results: TGF-β1 significantly increased the expression of COL1A1, COL1A2, ASMA1, fibronectin, and CTGF at mRNA and protein levels compared to untreated fibroblasts. TGF-β1 induced fibrotic genes expression were significantly higher in SSc fibroblasts compared to healthy fibroblasts. In both Healthy and SSc fibroblasts, Sildenafil and Zaprinast treatment in both the strategies, significantly reduced the mRNA and protein expression of type 1 collagen, ASMA-1, fibronectin and CTGF compared to treatment with TGF-β1. Moreover, Sildenafil and Zaprinast treatment restored the levels of MMP2/TIMP1 in fibroblasts which were suppressed by TGF-β1 treatment. MMP2 level was significantly increased in culture supernatant of Healthy and SSc fibroblasts treated with PDE5i. Sildenafil and Zaprinast both reduced the phosphorylation of Smad3 (canonical) and Erk1/2 (non-canonical) in SSc fibroblasts.

Conclusion: PDE5i attenuate the pro-fibrotic gene expression and increase anti-fibrotic responses in TGF-β1 treated cutaneous fibroblasts in SSc patients. PDE5i affect both canonical as well non-canonical TGF-β1 mediated downstream signalling pathways.

  O20 Category: Basic Immunology Top

Treatment with spironolactone after the onset of collagen induced arthritis reduces joint inflammation, cartilage destruction and bone erosion

Inderjeet Verma1, Pawan Krishan1, Ashit Syngle2 ; Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala,2 Cardio Rheuma and Healing Touch City Clinic, Chandigarh, India, Rheumatologist Fortis Multi Specialty Hospital, Mohali, India

Background: Spironolactone possesses potent anti-inflammatory and immune modifying properties that might make it an excellent medical intervention for rheumatic diseases. However, the therapeutic impact of spironolactone (SPIR) in collagen-induced arthritis model has still not been investigated; this was the objective of the present study.

Materials and Methods: Mice (DBA/1) with collagen-induced arthritis (CIA) were treated SPIR (20, 40 and 80 mg/kg/day), methotrexate (MTX) and vehicle after the first signs (day 21) of arthritis until day 42. Arthritis was monitored visually, clinically and joint pathology was examined. Systemic tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) were measured by enzyme-linked immunosorbent assay, and oxidative markers like TBARS and serum nitric oxide were also measured.

Results: Treatment with SPIR after the onset of CIA significantly reduced the severity of CIA indicated by arthritis score (Fig. 1A), paw swelling (Fig. 1B) and oxidative markers. Histological analysis confirmed the suppression of joint inflammation and showed prevention of cartilage and bone destruction after SPIR (40 and 80 mg/kg/day and its effect was found comparable to that of MTX (Fig. 2). Systemic TNF-α and IL-6 levels were significantly reduced after SPIR.

Conclusion: Our data strongly indicate that spironolactone ameliorate of paw swelling, antioxidant properties, inflammatory mediators TNF-α and IL-6 and histopathological changes therefore it could provide an additional therapeutic strategy for RA. Spironolactone may be considered for use as a novel therapeutic treatment against human arthritis.

  O21 Category: Basic Immunology Top

Exposure to mycobacterial cord factor enhances in vitro IL6 production by peripheral blood mononuclear cells from patients with Takayasu arteritis

Nikhil Gupta, Jayakanthan Kabeerdoss, Hindumathi M, Ruchika Goel, Debashish Danda; Department of Rheumatology, Christian Medical College, Vellore, Tamil Nadu, India

Introduction: Association between Takayasu Arteritis (TA) and Tubcerculosis (TB) has been in vogue for years. Prevalence of TB in TA is reported to be higher. Scientific evidence for this association is limited. We aimed to study pro-inflammatory cytokine responses in patients with TA on exposure to Trehalose-6,6-dibehenate (TDB), a synthetic analogue of trehalose-6,6-dimycolate (TDM, also known as mycobacterial cord factor) in comparison with healthy controls.

Methods: Patients with type V TA satisfying 1990 ACR criteria and age and sex matched healthy controls were recruited. 10 ml blood were collected in heparin coated vacutainer tube. PBMCs were separated by density gradient centrifugation. PBMCs were cultured with and without 5μg/ml of TDB for 48 hours in RPMI medium at 5% co2 incubator. IL-6, TNF-α and IL-17 were measured in cell culture supernatant, which was separated from cells at the end of incubation period. T-tests was used to compare levels between the groups.

Results: Twenty two TA patients and 21 healthy controls were recruited. Baseline characteristic of cases included median (range) age: 26.5 years (15-49), ITAS-CRP2010: 7(1-26) and DEITAK: 7.5(1-21) and male: female (%) ratio of 5(22.72%):17(77.28%). Median age in controls was 31 years (24-45) and male: female ratio of 5(23.8%):16(96.1%). Both patients and controls showed response by secreting IL-6 and TNF-α upon stimulation by TDB. Relative induction of IL-6 was significantly higher in TA [31.88(0.74-168)] as compared to healthy controls [1.931(0.644-8.21); p<0.002] (figure-1). No difference was noted in TNF-α levels between TA (10.9(1-1030) and healthy controls [9.72(0.35-33.1); p=0.49]. IL-17 levels were undetectable in all subjects even on stimulation.

Conclusion: Stimulation with mycobacterial synthetic analogue lead to higher secretion of IL-6 by PBMCs of patients with TA as compared to healthy controls.

  O22 Category: Vasculitis Top

rs1205 polymorphism in CRP gene associated with Indian Takayasu arteritis patients

Aswin M Nair, Ruchika Goel, Hindhumathi M, Sumita Danda1, Krati Shah2, Puneet Chandana3, Jayakanthan K, George Joseph4, Debashish Danda; Department of Rheumatology, Christian Medical College, Vellore, India

Background/Purpose : An earlier pilot study of 13 single nucleotide polymorphisms (SNP) conducted by our centre in 54 Takayasu arteritis (TA) patients and 100 controls using Sequenom iPlexTM Gold Assay and MALDI-TOF platform showed rs1205 in CRP to be associated with TA. We therefore aimed to study this SNP in an extended cohort of our patients.

Methods : Genomic DNA of patients and sex matched healthy controls were extracted using Puregene Qiagen kit according to manufacturer's instructions. Genotyping was done by Taqman SNP genotyping assay in Stepone plus real-time PCR instrument. Chi-square test was used for comparison between 2 alleles and logistic regression for independent association of allele with TA.

Results : We recruited 104 TA (84 females) and 185 healthy controls (166 females). This included 100 controls studied in earlier study. Type 5 was the commonest (58.7%) followed by type 1 (15.4%), type 4 (13.5%). Minor allele frequency of T allele of rs1205 was lower in cases (57/208, 27%) compared to controls (139/370, 37.6%), p=0.013, OR= 0.632 irrespective of gender. Genotype CC was higher in cases (53.8%) than controls (37.3%), p=0.006. Blunted CRP response was observed in 14/48 (29.2%) patients with TT genotype as compared to 8/56 (14.3%) patients with other genotypes (p=0.064).

Conclusion : T allele of rs1205 in CRP gene was protective against TA in our patients. TT genotype tended to have a blunted CRP response which may explain normal CRP levels encountered in-spite of active disease in few patients of TA.

  O23 Category: Vasculitis Top

NMR-based Serum Metabolomics of patients with Takayasu Arteritis (TA): Relationship with disease activity

Avinash Jain, Dinesh Kumar, Anupam Guleria, Durga Prasanna Misra, Abhishek Zanwar, Durgesh Dubey, Umesh Kumar, C L Khetrapal, P A Bacon , Ramnath Misra; Department of Clinical Immunology, S.G.P.G.I.M.S, Lucknow, India,Centre of Biomedical Research, Lucknow India and1 Department of Rheumatology, Birmingham UK.

Introduction: NMR based s erum metabolomics revealed distinctive metabolic signatures in patients with TA compared to age/sex matched healthy controls. In this study we sought to investigate whether these distinctive metabolites correlated with disease activity.

Methods: Patients with TA fulfilling ACR criteria were assessed for disease activity by ITAS 2010, with a score of 4 or more, considered as active. Sera were analysed by 800 MHZ NMR spectrometer. The resulted NMR spectra were analyzed by PLS-DA based multivariate analysis (Figure 1) followed by univariate analysis using students t test.

Conclusion: NAG, glucose and NAG/Phosphocholine ratioare elevated and choline and LDL decreased in active TA patientssuggesting impairment of glucose oxidation and activation of self-repair mechanism under conditions of inflammation and oxidative stress.

  O24 Category: Vasculitis Top

High expression of S100 calgranulins genes in peripheral blood mononuclear cells of patients with Takayasu arteritis

Jayakanthan Kabeerdoss, Ruchika Goel, Hindumathi M, Debashish Danda; Department of Rheumatology, Christian Medical College, Vellore, Tamil Nadu, India

Introduction: Takayasu arteritis (TA) is inflammatory disorder that affects aorta and its branches. Human aorta has high expression of Toll-like receptors (TLR) 1-4. Activation of TLR4 caused transmural panarteritis in human temporal artery-SCID chimera model. However, ligand for TLR4 activation is not known in TA as yet. In this study, we studied expression of TLR4 and its endogenous ligands in peripheral blood mononuclear cells (PBMCs) of TA.

Methods: mRNA from PBMCs of 24 TA patients and 19 sex and age matched healthy controls was extracted. The expression of TLR4, RAGE and TLR4 ligands i.e. S100A8, S100A9, S100A12, heat shock protein 70, fibronectin-1, High mobility group box protein, tenascin and two downstream mediators interleukin-6 and Interleukin-8 were quantified in real time PCR using specific primers and SYBR Green qPCR master mix. Serum S100A12 levels was measured using commercial ELISA kits. S100A12 was measured in cell culture supernatant of un-stimulated and LPS stimulated PBMCs cultured for 4 hours. t-test was used to compare between the groups. P <0.05 was considered as statistically significant.

Results: Among TA, 18 were females [median age 25.5 (19-58) years], with 12 being treatment naïve. mRNA expression of TLR4, S100A8, S100A9 and S100A12 were significantly higher in TA compared to healthy controls. RAGE, HSP70 and IL-6 were expressed at lower levels in TA. Expression of tenascin was undetectable in all subjects. S100A12 levels tended to be higher in supernatants of un-stimulated PBMCs of TA patients as compared to controls but LPS stimulation led to a significant increased S100A12 levels only in controls as compared to TA. Serum S100A12 levels did not differ between TA and healthy controls.

Conclusion: TLR4 and its ligands S100A8, S100A9 and S100A12 are expressed at higher in PBMCs of patients with TA. This however did not translate to increased secretion of S100A12 in serum.

  O25 Category : Scleroderma Top

Helicobacter Pylori And Upper Gastrointestinal Dysfunction In Systemic Sclerosis - Eradicate Or Miss ?

Balaji Chilukuri, Rajeswari Sankaralingam, Bhuvanesh Mahendran, Saravanan Mayilsamy, Saranya Chinnadurai, Ramesh Ramamoorthy, Sivakumar Vengudusamy, Mythili Seetharaman; Institute of Rheumatology, Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai, India

Background: Immune dysregulation triggered by several environmental events have been implicated in the etiopathogenesis of Systemic sclerosis (SSc).Helicobacter pylori (H.pylori) is a pathogen that has been associated with several autoimmune diseases.Association of H.pylori with gastric ulcers is also well known. Role of H.pylori in SSc has not been widely reported.

Aim: To estimate the levels of anti-H.pylori IgG antibodies in SSc patients and analyse its clinical associations.

Method: 55 cases of SSc who satisfied ACR/EULAR 2013 classification criteria and 25 age and sex matched healthy controls were included in this study.Demographic, Clinical, laboratory and immunological parameters were recorded.Upper gastrointestinal endoscopy was done. Anti-H.pylori IgG levels (RU/ml) were estimated by ELISA method and results analysed by SPSS

Results: Baseline characteristics were comparable in both cases and controls. Anti-H.pylori IgG levels were high in SSc patients in comparison to controls (mean 65 RU/ml vs 25.3RU/ml ; p=0.003). Anti-H.pylori IgG levels showed no statistically significant difference between diffuse cutaneous SSc and limited cutaneous SSc (mean 72.9 RU/ml vs 54.1RU/ml, p=0.289).SSc patients with symptomatic gastrointestinal involvement had higher H.pylori levels than asymptomatic patients (mean 118.3 RU/ml vs 20.7 RU/ml, p<0.001).Oesophageal dysfunction was the most common gastrointestinal manifestation associated with high H.pylori levels .Patients with gastric ulcers had highest H.pylori levels (p=0.01).H.pylori levels showed no correlation with disease duration ,acute phase reactants - ESR and CRP,ILD,pulmonary hypertension and modified Rodnans Skin Score.

Conclusion: Anti-H.pylori IgG levels are high in SSc patients with symptomatic oesophageal dysfunction and gastric ulcers .Early H.pylori eradication regimens may help prevent symptomatic upper gastrointestinal complications of SSc.

  O26 Category: Scleroderma Top

Anti Annexin V Antibodiesas A Marker Of Digital Ischemia In Systemic Sclerosis"

Saranya Chinnadurai1, Rajeswari Sankaralingam1, Saravanan Mayilsamy1, Balaji Chilukuri1, Bhuvanesh Mahendran1, Vignesh Mantharam1, Mythili Seetharaman1 ;1 Institute of Rheumatology, Madras Medical College & Rajiv Gandhi Government General Hospital, Chennai, India

Background: Annexin V is an anionic phospholipid binding protein which has anticoagulant activity by inhibiting prothrombin activity. Anti-Annexin V antibodies have been found to be elevated in sera of patients with systemic sclerosis.


  1. To compare the serum levels of anti-Annexin V IgG antibodies in systemic sclerosis patients with healthy population.
  2. To find the correlation between serum anti-Annexin V IgG antibodies in Systemic sclerosis (SSc) patients withdigital ischemic changes.

Methods: 60 systemic sclerosis patients fulfilling 2013 ACR/EULAR classification criteria for scleroderma and 25 healthy age and sex matched controls were studied. Of the 60 patients, 16 had digital ulcers/gangrene, 33 had digital pitted scars and 11 had only Raynaud's phenomenon. Sera of patients and controls were analysed for anti-Annexin V IgG antibodies by ELISA.

Results: Baseline characteristics of patients and controls were comparable. Mean serum anti-Annexin V IgG antibodies in SSc patients were higher than in the healthy controls (14.78+6.74 U/ml vs 2.72+1.02 U/ml; p<0.0001). There was no significant difference in the serum anti-Annexin V IgG antibodylevels between diffuse(n=32) and limited cutaneous Systemic sclerosis(n=28)(mean 16.06+7.26 vs 13.32+5.89;p=0.117). Patients withdigital ulcers/gangrene(n=16) and digital pitted scars (n=33) had significantly highermean serum anti-Annexin V IgG antibodies than those with only Raynaud's phenomenon without these ischemic changes (n=11)(23.56+6.01U/ml& 12.33+3.11 U/ml respectively vs 9.36+2.8U/ml; p<0.00001).

Conclusion: Serum Anti-Annexin V IgG antibodiescan be used as a marker of digital ischemic changes in systemic sclerosis.

  O27 Category: Ctd Top

Salivary and serum levels of chemokine CXCL13 in primary Sjogren's Syndrome: still far from being a biomarker - Prospective observational study.

Santosh kumar Mandal1, Sandhya P1, Ramya J1, Mahasampath Gowri2, Jayakanthan K1, Debashish Danda1 ; Department of Clinical Immunology & Rheumatology,2 Department of Biostatistics,Christian Medical College, Vellore, India

Background: This study was done to evaluate salivary and serum levels of CXCL13 in primary Sjogren's Syndrome (pSS) and look for any association with clinical and serological parameters of disease activity.

Methods: Patients with pSS satisfying either AECG or ACR criteria and healthy controls were recruited from July 2014 and July 2015. All pSS cases were assessed by clinical evaluation, laboratory tests, ESSDAI and ESSPRI scoring. Three ml of blood and unstimulated saliva was collected by the spitting method from cases and controls. Salivary and serum CXCL13 levels were quantified by commercially available ELISA kits.

Results: The study included 46 patients with pSS and 42 healthy controls. The median (IQR) age of cases and controls were 40 (32 - 45) years and 32 (24.50 - 38.25) years respectively. The median level (IQR) of salivary CXCL13 in pSS [13.53 (5.38 - 40.70)] was similar to that of healthy controls [13.21 (5.65 - 25.79)]. The median levels of serum CXCL13 was significant higher in pSS as compared to healthy controls [ 78.38 (36.53 - 120.98) Vs 10.58 (5.39 - 45.43); p = 0.010]. Serum CXCL13 levels significantly correlated with globulin levels ( rho = 0.34; p = 0.035). Serum or salivary CXCL13 levels did not correlate with other parameters.

Conclusion: Serum CXCL13 but not salivary CXCL13 was elevated in pSS. Serum CXCL13 showed weak correlation with hyperglobulinemia.

  O28 Category: Ctd Top

A prospective study of renal involvement in patients with Primary Sjögren's syndrome

Ankit Jain, Dantis Emmanuel, Sonal Mehra, Jignesh Usdadiya, Chengappa KG, Gaurav Seth, Durga P Mishra, Vikram K jain, V S Negi; Department of Clinical Immunology, Jawaharlal Institute of Postgradute Medicine and Research, Pondicherry, India

Background/Purpose: Primary Sjögren's syndrome (pSS) is known to be associated with renal disease. However, few studies have prospectively evaluated renal involvement in pSS. The present study evaluated renal involvement in patients with pSS followed up prospectively for a period of one year.

Methods : Patients satisfying 2002 AECG criteria for pSS were included in the study and evaluated for renal involvement including renal function tests, urine examination, Arterial blood gases, Urine pH and urine acidification test (UAT) if indicated. Patients were followed up prospectively for one year for disease activity (ESSDAI), development of renal involvement and dysfunction eGFR (CKD-EPI). Patients were divided into two groups: those with renal involvement (renal group) and those without (non-renal group). Demographic, Clinical and laboratory parameters were compared between the two groups.

Results : One hundred and seventy eight patients were screened of which 71 fulfilling the inclusion criteria were enrolled. Twenty eight (39.4%) had renal involvement. They were significantly younger (35.2±9.75 vs. 42.3±10.79; p=0.006) and had fewer articular symptoms (42% vs 76%, p=0.004) than those without renal involvement. Of the 28 patients, 21 had renal tubular acidosis (RTA), 1 had chronic kidney disease(CKD), 1 had nephritis, 1 had proteinuria and 4 had subclinical RTA. All patients with RTA presented with hypokalemic paralysis except one who presented with renal calculi and was found to have RTA on UAT. Renal biopsy was performed on 14 patients. The most common histological finding was tubulo-interstitial nephritis. Two patients had features of IgA nephropathy. Both had RTA as presenting manifestation. There was mild but significant increase in eGFR in renal group (p=0.0373) compared to the non renal group (p=0.24).

Conclusion : Renal involvement in pSS is an under-recognized entity. These patients are younger and have less articular symptoms. Most common presentation is RTA. Without specific treatment, there is a gradual progressive decline of renal function. Renal biopsy is recommended in all patients with renal involvement.

  O29 Category: Miscellaneous Top

Neutrophil CD64 Expression Distinguishes Bacterial Infection From Disease Flare In SLE and ANCA associated vasculitis

Sajal Ajmani, Harshit Singh, Saurabh Chaturvedi, Mohit kumar Rai,VIkas Agarwal; Department of Clinical Immunology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Background/Purpose: Treating physician is often challenged to differentiate between disease activity vs. infection as the cause of fever in patients with SLE and ANCA associated vasculitis (AAV). Presently, there is no reliable clinical or serological biomarker for this purpose. We aimed to determine the utility of CD64 (FcγR1) expression on neutrophils and sTREM-1 (soluble triggering receptor expressed on myeloid cells) in serum in distinguishing bacterial infection from disease flare.

Methods: In this prospective, cross sectional, observational study 20 healthy controls and patients of SLE and AAV admitted to our unit either with disease flare or bacterial infection were recruited over a period of 1 year. Neutrophil CD64 expression was measured by flowcytometry and sTREM by ELISA from blood samples collected on the day of admission. Other parameters such as Total Leukocyte Count (TLC), ESR, CRP, C3 and C4 were noted.

Results: Among the 56 patients included in the study 32 (SLE-20 and AAV-12) had disease flare while 24 (SLE-20 and AAV-4) had infection . 67% had fever at presentation. Percentage of neutrophil with CD64 expression and their mean fluorescence intensity in patients with infection were significantly higher as compared to those without infection and healthy controls (p<0.05) (Table-1). CD64 expression as a marker for differentiation between disease flare and infection had sensitivity of 86% and specificity of 83% at cut off of 30% (percentage of neutrophils expressing CD64). Serum sTREM-1, TLC, ESR, CRP, C3, C4 levels were not significantly different between disease flare and infection group. On subgroup analysis patients of SLE with infection had a higher CRP and TLC compared those with disease flare, although they had a lower sensitivity and specificity than CD64 expression (p<0.5) (Table-2).

Conclusion: CD64 expression on Neutrophils is helpful in differentiating bacterial infection from disease flare in SLE and AAV.

  O30 Category: Rheumatoid Arthritis Top

Resistive index of hand arteries can accurately distinguish between disease activity states in patients with rheumatoid arthritis: a promising tool in development?

Rudra Prosad Goswami, Sumantro Mondal, Parasar Ghosh, Alakendu Ghosh; Department of Rheumatology, Institute of Post Graduate Medical Education and Research, Kolkata, India

Background: Musculoskeletal ultrasound (B mode and power Doppler (PDUS)) in rheumatoid arthritis (RA) provides information regarding synovitis and inflammation. Arterial resistive index (RI) is an objective marker of inflammation. Aim of the present study was to describe the utility of RI of hand arteries in identifying patients with subclinical synovitis.

Methods: Patients with RA, fulfilling the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Classification Criteria, were recruited from July 2015 to January 2016. Patients were classified as in remission (DAS28 <2.6 for 3 months with no US synovitis); subclinical synovitis (DAS28 <2.6 for 3 months with positive US synovitis); and active disease (DAS28 ≥2.6). A trained radiologist, blinded to subject status, did the Doppler studies: B-mode, PDUS and colour Doppler US (CDUS). RI of hand arteries (radial, ulnar, palmar arch and digital) was recorded. Delta (Δ) RI values were calculated: ΔRI = (RI Proximal artery - RI Distal artery) x 100/ RI (Proximal artery).

Results: One hundred and nine patients with RA (81/109 (74.3%) female, median age 40 years (19 - 65), median duration 24 months (3 - 180)) were studied; remission: 29/109 (26.6%), subclinical synovitis 24/109 (22%) and active disease 56/109 (51.4%). CDUS parameters varied significantly across disease activity groups except RI (Radial). In Tukey's post hoc test ΔRI (radial-digital), ΔRI(ulnar-digital) and ΔRI(palmar-digital) were significantly different in all pairwise comparisons. By ROC analysis, best discrimination of subclinical synovitis from active disease were by ΔRI (ulnar - digital) (area under curve (AUC): 0.793), ΔRI(radial - digital) (AUC: 0.702) and ΔRI(palmar - digital) (AUC: 0.646); the same between remission and subclinical synovitis was by ΔRI(ulnar - digital) (AUC: 0.805), ΔRI(radial - digital) (AUC: 0.746) and ΔRI(palmar - digital) (AUC: 0.718).

Conclusion: RI of hand arteries might provide quantitative measure of disease activity in patients with RA.

  O31 Category: Paediatric Rheumatology Top

Role of 'Serum Amyloid A' as a marker of disease activity in Juvenile Idiopathic Arthritis

Sharad Dev, Abhishek Agrawal, Late Prof. Nand kumar Singh1, Prof. Usha; Department of General Medicine,1 Division of Rheumatology, and2 Department of Pathology Institute of Medical Sciences, BHU, Varanasi, India

Background/Purpose : Although several studies have validated the use of serum amyloid A (SAA) protein as a biomarker for the disease activity in different rheumatoid conditions, it has not been extensively used in clinical practice. Moreover only one such study is available in relation with JIA.

Methods : A total of 50 newly diagnosed cases of JIA (modified ILAR criteria 2001), covering all subtypes and 40 healthy controls of same age and sex, were included in this study. Serum amyloid A (SAA), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured in both patients and healthy controls. Quantitative measurement of SAA level was done using standard human SAA ELISA kit. Disease activity was assessed by number of large joints affected, ie. USG score (Out of total 8 ;viz bilateral elbow, wrist, knee, ankle) as detected by the USG study as well as clinical examination in all patients.

Results : SAA levels were significantly higher in JIA patients versus healthy controls (p<0.001). Significant positive correlations were found between SAA and the presence of active joints (r=0.64, p<0.001) , ESR(r=0.39, p<0.05) and CRP(r=0.36, p<0.05). No significant correlations between ESR and the presence of active joints (r=0.21, p=0.225) and between CRP and the presence of active joints (rho=0.034, p=0.855) were demonstrated in JIA patients. The correlation between CRP and ESR was also significant (r=0.57, p=<0.001). The mean USG score of patients with increased SAA level was significantly higher than that of patients with normal SAA level (p<0.05).

Conclusion : We discovered a significant increase in SAA levels in JIA patients and strong positive correlation between SAA level and JIA disease activity. We also discerned SAA to be a more sensitive laboratory marker than ESR and CRP for evaluating the presence of active joints.


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