Autoimmune Phenomena Research Articles

12452 Unraveling An Intriguing Clinical Sequence: Thyrotoxicosis Antecedent To Stiff Person Syndrome

Abstract Disclosure: A. Jain: None. M.N. Rayan: None. Title: Unraveling an Intriguing Clinical Sequence: Thyrotoxicosis Antecedent to Stiff Person Syndrome Background: Stiff Person Syndrome (SPS) is an autoimmune phenomenon resulting in the progressive rigidity of limbs and trunk muscles. It is associated with GAD-positive antibodies in the CSF and serum and is linked to Type 1 Diabetes, Celiac disease, and other autoimmune diseases. Clinical Case: A 34-year-old female with no past medical history was brought into the ED by family for paranoia, suicidal ideations, and visual and auditory hallucinations. She was found to be tachycardic and altered in the ED. Endocrinology was initially consulted for concerns of hyperthyroid pathology due to lab work showing a TSH of <0.008 uIU/mL and free T4 of 4 pg/mL. Thyroid ultrasound revealed heterogeneous, hypervascular thyroid tissue. Further investigation revealed TRAB 4.05 IU/L (n 0-0.9 IU/L) and TSI 3 IU/L (n < 0.577 IU/L). A diagnosis of Graves’ disease was made, and she was started on methimazole 20mg daily and metoprolol 25mg daily. Due to a lack of response to methimazole, other organic causes were investigated including psychiatric and neurological etiology. The patient's symptoms continued to worsen, with new tremors of the upper and lower extremities. Thyroid labs showed improvement, and hence thyrotoxicosis was not thought to be the underlying etiology of her encephalopathy. Neurology was consulted, and EEG and MRI Brain were performed which were unrevealing. Lumbar puncture revealed elevated oligoclonal bands and GAD-65 antibodies, suggesting autoinflammatory encephalitis. High-dose steroids were started, with no improvement. Due to the failure of steroids to treat her symptoms, she was given 5 days of plasmapheresis and a dose of rituximab. Slowly, the patient began to improve and could follow commands and communicate with staff. A formal diagnosis of SPS was made at this time. Upon seeing her in follow-up 1 month after discharge, her TRAB and TSI antibodies were negative, and she was able to be titrated off of methimazole. Conclusion: SPS is strongly associated with autoimmune diseases, with up to 30-40% having T1DM. The association between hyperthyroidism and SPS, however, is exceedingly rare and the etiology remains unclear. Presentation: 6/1/2024

Investigating Concomitant RAG-2 and LRBA Mutations in SCID and Autoimmunity.

Inborn errors of immunity (IEI) are a large heterogenous group of diseases characterized by immunodeficiency, immune dysregulation, allergy, auto-inflammation and predisposition for malignancies. Most are inherited in an autosomal recessive trait. We studied a patient with severe combined immunodeficiency (SCID) and immune dysregulation who harbored two distinct bi-allelic IEI-associated genetic mutations. Clinical, immunological and genetic data were collected. Genetic investigation included whole exome sequencing on DNA extracted from skin fibroblasts. Family segregation was performed by Sanger sequencing. Immunological evaluation included absolute and functional evaluation of lymphocytes and chimerism analysis post hematopoietic stem cell transplantation (HSCT). Treg subsets, LRBA and CTLA4 expression levels were measured by flow-cytometric analysis. A nineteen-year-old female patient from a consanguine background underwent unconditioned matched sibling related HSCT during infancy due to clinical presentation of SCID with an Omenn phenotype. At that time her underlying genetic defect was not defined. Years after HSCT, severe auto-immune phenomena were noted, including a systemic lupus erythematosus-like syndrome and ophthalmic manifestations. Genetic evaluation revealed bi-allelic homozygous mutations in RAG-2 (c.685C>T, p.Arg229Trp) and a previously undescribed mutation in LRBA (c.3325G>T, p.Asp1109Tyr). LRBA and CTLA4 expression levels were normal, suggesting that the LRBA variant identified in these kindred is unlikely to be pathogenic. Multiple genetic defects causing complex IEIs may be identified in the same individual in highly consanguineous populations. Functional immunological testing is essential for evaluation of novel genetic variants.

Corona vaccination under immunosuppression

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to play a major role as a severe and potentially fatal airway infection, especially in vulnerable patient groups. In view of the thin data situation on the influence of treatment and response to vaccination, at the beginning of the corona pandemic it was a major challenge to predict the tolerability and effectiveness in patients with inflammatory rheumatic diseases under immunomodulation or immunosuppression. In the meantime, numerous studies have addressed the questions of response and tolerability, at least for the COVID-19 vaccination. Even in the first months of the vaccination campaign, a small study on a single center cohort could show that apart from patients with B‑cell depletion, all included patients showed a seroconversion after the first two vaccinations. This resulted in neither an increased occurrence of exacerbations of the underlying disease nor new autoimmune phenomena. Various studies have since then confirmed these data.

“Mechanic’s Hand” with Polyarthralgia and Transient Autoimmune Features after COVID Vaccination

Abstract Autoimmune diseases are now well reported with COVID vaccination. Rheumatological, neurological, cardiac, and hematological adverse events are observed globally. Dermatological adverse events are reported in a few cases but dermatological with rheumatological manifestation with reversible autoimmune phenomenon after COVID vaccination is not reported commonly in literature. “Mechanic’s hands” is blackish discoloration of palmar aspects of both hands and knuckles commonly reported in rheumatological autoimmune condition such as dermatomyositis. In this case report, a 28-year-old male presented with polyarthralgia with myalgia and fatigability after 1 month of COVID vaccination. His joint pain symptoms worsened over 4 weeks and developed blackish pigmentation of both hands predominantly involving palms to present as mechanic’s hands. Vasculitis workup was inconclusive and rheumatologic workup documented raised antinuclear antibody titers and rheumatoid factor. We have started him on steroid and hydroxychloroquine and observed satisfactory clinical response with near complete resolution of “mechanic’s hands” in 24 weeks. Mechanic’s hands with rheumatological syndrome which is a rare vaccine-related adverse event, reversible, and easily treatable with routinely available medicines, and importantly it is having excellent prognosis. Mechanic’s hand is first time reported in medical literature after COVID vaccination. Minimal systemic adverse events are known to occur with all viral vector vaccines, but its occurrence is rare and it should not impact on routine vaccinations, as vaccination is a key step in this pandemic to protect humankind.

A Comprehensive Review on the Intricate Interplay between COVID-19 Immunization and the New Onset of Pemphigus Foliaceus.

Autoimmune bullous diseases (AIBDs) are characterized by the formation of vesicles, bullous lesions, and mucosal erosions. The autoantibodies target the cellular anchoring structures from the surface of epidermal keratinocyte named desmosomes, leading to a loss of cellular cohesion named acantholysis. AIBDs are classified into intraepidermal or subepidermal types based on clinical features, histological characteristics, and immunofluorescence patterns. Pemphigus foliaceus (PF) is an acquired, rare, autoimmune skin condition associated with autoantibodies that specifically target desmoglein-1, leading to a clinical presentation characterized by delicate cutaneous blisters, typically sparing the mucous membranes. Several factors, including genetic predisposition, environmental triggers, malignancies, medication use, and vaccination (for influenza, hepatitis B, rabies, tetanus, and more recently, severe acute respiratory syndrome Coronavirus 2 known as SARS-CoV-2), can potentially trigger the onset of pemphigus. With the advent of vaccines playing a pivotal role in combatting the 2019 coronavirus disease (COVID-19), extensive research has been conducted globally to ascertain their efficacy and potential cutaneous adverse effects. While reports of AIBDs post-COVID-19 vaccination exist in the medical literature, instances of PF following vaccination have been less commonly reported worldwide. The disease's pathophysiology is likely attributed to the resemblance between the ribonucleic acid (RNA) antigen present in these vaccines and cellular nuclear matter. The protein produced by the BNT-162b2 messenger ribonucleic acid (mRNA) vaccine includes immunogenic epitopes that could potentially trigger autoimmune phenomena in predisposed individuals through several mechanisms, including molecular mimicry, the activation of pattern recognition receptors, the polyclonal stimulation of B cells, type I interferon production, and autoinflammation. In this review, we present a comprehensive examination of the existing literature regarding the relationship between COVID-19 and PF, delving into their intricate interactions. This exploration improves the understanding of both pemphigus and mRNA vaccine mechanisms, highlighting the importance of close monitoring for PF post-immunization.

P-363 Reproductive toxicity of new immunobiologic treatments for male patients with melanoma

Abstract Study question Do immunotherapy and targeted therapy for melanoma affect male fertility? Summary answer Immunotherapy and targeted therapy for melanoma affect sperm quality. However, the detrimental effects are only transient. Sperm quality recovers once the treatment is discontinued. What is known already Immune checkpoint inhibitors, such as anti-BRAF and anti-MEK inhibitor, are currently used in melanoma patients to modulate the immune system and promote its anti-cancer action. Since these agents do not have an anti-mitotic action, they should not cause damage to spermatogenesis. However, no specific studies on human fertility have been conducted before drug registration. In fact, based only on pre-clinical studies, fertility-lowering effect of the BRAF/MEK inhibitors cannot be excluded. Potential endocrine autoimmune-related adverse events which could alter the hypothalamic-pituitary-gonadal axis such as hypophysitis, could impair spermatogenesis. These potential harmful effects should not be overlooked when counselling patients. Study design, size, duration Male patients scheduled for immunotherapies for melanoma were prospectively recruited at National Cancer Institute in Milan, Italy, between March 2020 and April 2023. Patients were counselled by a reproductive medicine specialist and offered to cryopreserve semen before immunotherapies. A semen analysis was also proposed 6-8 months after the initiation and 6-8 months after the end of immunotherapies. The primary outcome was to compare semen variables before, during and after immunotherapies. Participants/materials, setting, methods All patients underwent therapy with Nivolumab or Dabrafenib for 12 months.Semen samples were all cryopreserved and analysed by a single biologist at the Infertility Unit of Policlinico in Milan. Data are reported as median [Interquartile range-IQR] or number (percentage). Main results and the role of chance Twenty-three men operated on for melanoma and scheduled for immunotherapy were recruited. The age of patients at cryopreservation was 33 years [29–39]. An average of 12 [10-12] sperm paillettes were cryopreserved per patient. Total sperm count and total progressive motile sperm count were 126 millions [75–246] and 90 millions [38–154], respectively. Three patients were lost to follow-up and two patients died after cryopreservation. Twelve patients (52%) returned for a semen analysis during oncological treatment. After a median time of 9 months [8-12] of immunotherapy, a reduction in all semen variables was noted, particularly in total sperm count (77 million [49-189], p = 0.05 compared to basal condition) and the total count of progressive spermatozoa (34 million [23-77], p = 0.02 compared to basal condition). No differences were observed in morphology. Ten (43%) patients returned after the end of immunotherapies. One patient died before completing the follow-up. A recovery of all sperm variables compared to the cryopreserved sample was observed. Total sperm count and total motile sperm count were 190 millions [107–320] and 79 millions [34–140], respectively (p=ns). Two patients thawed their cryopreserved semen for an IVF cycle during immunotherapy. No pregnancy was achieved. Limitations, reasons for caution Our study evaluates male fertility only in terms of semen quality. Alterations of the hypothalamic-pituitary-gonad axis, such as the increase of autoimmune phenomena, have not been studied. Furthermore, the small sample size of our study is a limit. Wider implications of the findings Our study evaluates male fertility only in terms of semen quality. Alterations of the hypothalamic-pituitary-gonad axis, such as the increase of autoimmune phenomena, have not been studied. Furthermore, the small sample size of our study is a limit. Trial registration number not applicable

Anti-LGI1 Autoimmune Encephalitis in a Patient with Rheumatoid Arthritis and MGUS.

Anti-leucine-rich glioma inactivated 1 limbic encephalitis (anti-LGI1 LE) is one of the most frequent autoimmune encephalitis, commonly coexisting with other autoimmune diseases. Rheumatoid arthritis (RA) and monoclonal gammopathy of unknown significance (MGUS) are commonly associated with autoimmune phenomena. However, neither RA nor MGUS have been described in the literature to date as coexisting with anti-LGI1 LE. We present the case of anti-LGI1 LE in a male patient with rheumatoid arthritis, who was also found to have an MGUS. The patient was initially treated with corticosteroids and IV immunoglobulin. After a mild relapse, his treatment was complemented with rituximab, resulting in complete regression of the disease symptoms. Our report provides evidence for the coexistence of anti-LGI1 LE with RA and/or MGUS, thus extending the differential diagnosis of patients suffering with these disease entities that present with neuropsychiatric symptoms suggestive of encephalitis. Moreover, this case raises challenges on the management of the coexistence of these diseases, given the lack of therapeutic guidelines and their potential interaction on a pathophysiological and a clinical level. In a patient with known autoimmune or malignant background who presents with neuropsychiatric symptoms, after excluding infectious encephalitis or central nervous system involvement in the primary disease condition, autoimmune limbic encephalitis (LE) should also be considered.In a patient diagnosed with anti-LGI1 LE there should be an extensive check for coexisting occult pre-malignant conditions, even for months after disease presentation.Clinical management and treatment options of anti-LGI1 LE when coexisting with other autoimmune or pre-malignant conditions can be challenging; thus, more research is needed towards that direction.

FusionVAC22_01: A phase I clinical trial evaluating a DNAJB1-PRKACA fusion transcript-based peptide vaccine combined with immune checkpoint inhibition for fibrolamellar hepatocellular carcinoma and other tumor entities carrying the oncogenic driver fusion.

TPS2702 Background: The DNAJB1-PRKACA fusion transcript is the driving force behind tumor development in fibrolamellar hepatocellular carcinoma (FL-HCC) and other tumor types, such as oncocytic neoplasms of the pancreas and bile ducts. Consequently, it serves as a versatile target for innovative cancer therapies. Recently, the DNAJB1-PRKACA fusion protein was recognized as a source of HLA-presented neoepitopes targetable by to T cell-based immunotherapy (1). The FusionVAC-22 neoepitope, derived from DNAJB1-PRKACA fusion, is computationally predicted to bind to 1,290 different HLA class II alleles. Furthermore, it includes embedded HLA class I ligands for 13 out of the 20 most common HLA class I alleles, covering 93.8% of the global population This broad coverage enables the widespread application of FusionVAC-22-based immunotherapies. The initial use of FusionVAC-22-based peptide vaccines, adjuvanted with the TLR1/2 agonist XS15 emulsified in Montanide ISA 51 VG, in two FL-HCC patients was well-tolerated and demonstrated the induction of robust and long-lasting T cell responses. Notably, T cell responses coincided with 32 months and 13 months of progression-free survival for the respective patients. Methods: Building on these promising outcomes, we have initiated a Phase I open-label, multicentric clinical trial to assess the immunogenicity, safety, toxicity, and initial signs of efficacy of the FusionVAC-22-based peptide vaccine combined with the immune checkpoint inhibitor (ICI) atezolizumab. The trial includes 20 patients with locally advanced or metastatic FL-HCC or other malignancies carrying the DNAJB1-PRKACA fusion transcript without available standard therapy. Key eligibility criteria involve the absence of autoimmune phenomena due to prior immunotherapy agents (≥ grade 3) and no history of tissue or organ allografts. The FusionVAC-22-based peptide vaccine is administered twice with a 4-week interval, with an option for a booster vaccination after 11 months. ICI administration begins on day 15 after the first vaccination and continues every 4 weeks for 1 year, followed by a 6-month follow-up. Primary trial objectives include assessing immunogenicity in terms of peptide-specific T cell responses up to 28 days after the second vaccination, as well as evaluating the safety and toxicity of the peptide vaccine in combination with ICI. Safety assessment is based on the frequency of adverse events according to CTCAE v5.0. Clinical efficacy is determined through iRECIST assessment on imaging. Additionally, disease control rate, quality of life, and overall and progression-free survival will be evaluated. So far, 3 out of 20 planned patients have been enrolled. 1. Bauer et al., Nat. Commun, 2022. Clinical trial information: NCT05937295 .

Spontaneous development of myasthenia gravis and myositis following treatment with pembrolizumab: a case report

BackgroundImmune checkpoint inhibitors are a relatively new advancement in the world of cancer therapy. As such, their adverse effects have yet to be fully understood, with only recent literature documenting autoimmune phenomena secondary to their utilization. Specific immune checkpoint inhibitors have recently been linked with the development of myasthenia gravis, which is classically known to manifest spontaneously in patients. Given the relative rarity of this presentation, the risk of misdiagnosis and subsequent mortality and morbidity is concerning.Case presentationWe discuss the case of a 73-year-old male who presented with clinical symptoms of myasthenia gravis and myositis shortly after beginning treatment with Pembrolizumab. The diagnosis of myasthenia gravis was initially missed at an outside hospital, which delayed initiation of proper treatment.ConclusionWhile the incidence of “de-novo” diseases secondary to immune checkpoint inhibitors might be increasing, guidelines regarding best treatment options do not yet exist, leaving many providers at a loss when faced with making clinical decisions surrounding patients with De novo myasthenia gravis. Thus, our goal is to underscore the importance of early recognition of this disease, and emphasize the need for a standard of care as immune checkpoint inhibitors usage becomes more prevalent.

COVID-19-Induced Rheumatoid Arthritis: Case Series and Systematic Review of the Literature.

COVID-19, caused by a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to severe infection and has been suggested to induce autoimmune phenomena. We report three cases of rheumatoid arthritis (RA) occurring after COVID-19 infection and we present a systematic review of the literature of cases of RA post COVID-19. Our findings suggest that RA may be trigged by COVID-19 infection in genetically predisposed individuals.

Possible Role of Cytomegalovirus in Gastric Cancer Development and Recurrent Macrolide-Resistant Campylobacter jejuni Infection in Common Variable Immunodeficiency: A Case Report and Literature Discussion.

Common variable immunodeficiency (CVID) is the most common symptomatic immunodeficiency in adults. It comprises a group of syndromes whose etiology involves genetic, epigenetic, microbiota, and environmental factors. We present the case of a 46-year-old Caucasian male patient with CVID and an immune dysregulation phenotype. The particular elements of the case consisted of an atypical clinical course, which undoubtedly demonstrates the great variability of clinical manifestations that these types of patients can suffer from, including bacterial and viral infections, autoimmune phenomena, and neoplasia. Notably, the patient suffered from recurrent gastrointestinal infection with macrolide-resistant Campylobacter jejuni and gastroduodenal disease and viraemia by cytomegalovirus (CMV). In addition, CMV was postulated as the main pro-oncogenic factor contributing to the development of early-onset intestinal-type gastric adenocarcinoma, for which the patient underwent gastrectomy. The patient's evolution was difficult, but finally, as a result of the multidisciplinary approach, clinical stabilization and improvement in his quality of life were achieved. Based on our brief literature review, this is the first reported case of this clinical complexity. Our experience could help with the management of future patients with CVID and may also update current epidemiological data on CVID.

NETosis and SARS-COV-2 Infection-Related Autoimmunity: A Narrative Review

Background: Neutrophil extracellular traps (NETs) are crucial for antimicrobial defense in sepsis, trapping and neutralizing pathogens while minimizing damage to host cells. Neutrophil extracellular traps, comprising nuclear chromatin, histones, and antimicrobial cytoplasmic granules, are significant. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) triggers multiple complications in patients. Decondensed NETs and associated proteins can become a critical source of autoantigens, presented to the immune system, thereby inducing hyperinflammation and autoimmunity in sepsis and viral diseases. Objectives: This study aimed to explore NETosis and its role in autoimmunity in coronavirus disease 2019 (COVID-19). Methods: We reviewed the PubMed database using keywords (autoimmune disease OR autoimmunity AND SARS-CoV-2 OR COVID-19 AND NETosis OR NETs) to enhance understanding of NETosis in autoimmune diseases and COVID-19, ultimately analyzing 55 articles. Results: Neutrophil extracellular traps play a pivotal role in host defense against pathogens. However, their overproduction can lead to self-tolerance failure and immune system activation, contributing to autoimmunity. Autoimmune phenomena have been observed in many COVID-19 patients, with a pathophysiology similar to other viral infections that induce NET formation. Conclusions: SARS-CoV-2 infections may cause immune system hyperactivation and subsequent autoimmunity. Like in other viral infections, NETosis could play a significant role in the autoimmunity associated with SARS-CoV-2. Modulating NET formation and degradation could potentially reduce the severity of the disease.

Hydralazine use can be associated with IgM-dominated immune complex-mediated glomerulonephritis

ABSTRACT Context IgM-dominant immune complex-mediated glomerulonephritis (IgM-dominant ICMGN) is a rare renal entity, characterized by a membranoproliferative pattern by light microscopy, dominant IgM staining by immunofluorescent staining, and subendothelial deposits by electron microscopy. This study was to investigate if some of IgM-ICMGN were associated with autoimmune disorders induced by hydralazine. Design Seven IgM-dominant ICMGN cases were identified over 8 years. Their pathologic phenotypes and clinical scenarios were analyzed in detail. Results Patients’ ages ranged from 47 to 87 years old with 5 women and two men. Six of seven patients had drug-induced autoimmune phenomenon (hydralazine-induced positive ANCA and ANA). All of them had renal dysfunction and some proteinuria. Most pathologic features showed a membranoproliferative pattern of glomerulonephritis with dominant IgM deposits at subendothelial spaces. IgM nephropathy (a variant of focal segmental glomerulosclerosis), chronic thrombotic microangiopathy, and cryoglobulinemic glomerulopathy were ruled out in the cases. Conclusion The hydralazine-induced autoimmune phenomenon can be seen in IgM-dominant ICMGN, which should be classified as a subtype of membranoproliferative glomerulonephritis.

Characteristics of emerging new autoimmune diseases after COVID-19 vaccination: A sub-study by the COVAD group.

Despite the overall safety and efficacy of COVID-19 vaccinations, rare cases of systemic autoimmune diseases (SAIDs) have been reported post-vaccination. This study used a global survey to analyze SAIDs in susceptible individuals' post-vaccination. A cross-sectional study was conducted among participants with self-reported new-onset SAIDs using the COVID-19 Vaccination in Autoimmune Diseases (COVAD) 2 study dataset-a validated, patient-reported e-survey-to analyze the long-term safety of COVID-19 vaccines. Baseline characteristics of patients with new-onset SAIDs and vaccinated healthy controls (HCs) were compared after propensity score matching based on age and sex in a 1:4 ratio. Of 16 750 individuals, 74 (median age 52 years, 79.9% females, and 76.7% Caucasians) had new-onset SAID post-vaccination, mainly idiopathic inflammatory myopathies (IIMs) (n = 23, 31.51%), arthritis (n = 15; 20.53%), and polymyalgia rheumatica (PMR) (n = 12, 16.40%). Higher odds of new-onset SAIDs were noted among Caucasians (OR = 5.3; 95% CI = 2.9-9.7; p < .001) and Moderna vaccine recipients (OR = 2.7; 95% CI = 1.3-5.3; p = .004). New-onset SAIDs were associated with AID multimorbidity (OR = 1.4; 95% CI = 1.1-1.7; p < .001), mental health disorders (OR = 1.6; 95% CI = 1.3-1.9; p < .001), and mixed race (OR = 2.2; 95% CI = 1.2-4.2; p = .010), where those aged >60 years (OR = 0.6; 95% CI = 0.4-0.8; p = .007) and from high/medium human development index (HDI) countries (compared to very high HDI) reported fewer events than HCs. This study reports a low occurrence of new-onset SAIDs following COVID-19 vaccination, primarily IIMs, PMR, and inflammatory arthritis. Identified risk factors included pre-existing AID multimorbidity, mental health diseases, and mixed race. Revaccination was well tolerated by most patients; therefore, we recommend continuing COVID-19 vaccination in the general population. However, long-term studies are needed to understand the autoimmune phenomena arising post-vaccination.

Vaccinoprophylaxis of infections and activity of immuno-inflammatory rheumatic diseases: pro et contra

In modern conditions, patients with immuno-inflammatory rheumatic diseases (IIRD) are at significant risk of influenza, pneumococcal and herpes viral infections, as well as COVID-19, in some cases fatal. The most effective way to prevent infectious diseases and reduce mortality from them is vaccination, which is recommended in the inactive phase of IIRD. However, a number of patients with IIRD have a refractory course of the disease, and achieving remission in them turns out to be a difficult task, and therefore the problem of vaccination of such patients against the background of an active inflammatory process is very relevant. The review analyzes data on the use of vaccine prophylaxis for the above infections in the active phase of IIRD. In the vast majority of cases, vaccination was safe and did not lead to an exacerbation of IIRD or the development of new autoimmune phenomena.

Mastitis granulomatosa

Granulomatous mastitis is a chronic, benign and inflammatory disease of the breasts from idiopatic etiology. It usually appears in women until 5 years after giving birth. The main hypothesis explains an autoimmune phenomenon as a result of expelled antigens from the breast-feeding period.Its clinical expression varies a lot, ranging from mastitis, fistulas or nodules. Usually it is seen as a hard nodule in any of the breast quadrants.Due to the fact that granulomatous mastitis clinically resembles inflammatory breast cancer, the diagnosis becomes challenging, needing different radiological tests as well as histiopatological samples for the final diagnosis. The treatment is not well established, and the two main options are complete escision of the breast or corticoesteroids with methotrexate. Even with this treatment, in half of cases the disease chronifies.

Joint-related manifestations of leprosy: A case report

Leprosy is a chronic granulomatous disease in which the musculoskeletal system has been described as the third most commonly affected system. Leprosy infections may manifest with various autoimmune phenomena reminiscent of classic autoimmune diseases. Among the leprosy factors affecting the prognosis of the disease, early diagnosis was reported to be the most effective. A 46-year-old married woman was referred to the hospital with initial articular symptoms. The patient also had deep folds, increased thickness of the skin in the forehead area, and dryness of the skin with a progressive course. The finger deformities and swelling are certainly misleading, but they may constitute an unsuspected inaugural form of leprosy, especially in its lepromatous form. The skin smear and biopsy confirmed leprosy, and treatment consisting of multi-drug therapy, as suggested by the WHO, was prescribed for the patient. According to these findings, it seems that one of the major symptoms of leprosy is musculoskeletal involvement and rheumatological manifestations, which may obscure and mislead diagnostic and treatment plans.

Abstract 1177: The chronology of immune-related adverse events (irAEs)-mechanistic implications

Abstract Immune Oncology (IO) is a novel component of the oncology armamentarium given its distinct mechanism of action, and by extension, unique mechanisms of toxicity (Tx). To recognize these unusual Txs, the term irAEs was popularized in clinical trials. Most organs have been involved by irAEs and autoimmunity has been implicated commonly by practicing oncologists. The onset of irAEs has not been studied well, however. We reasoned that autoimmune phenomena would be expected early after IO, since this is the timeframe within which T-cells expand to exert their effects on tumor and other ‘self’ tissues. It follows that if autoimmunity is the sole mechanism of irAEs, such toxicities should be reported early. Mechanism(s) of irARs may prove important for IO duration discussions. In some cases, tumor antigenic epitopes may mimic self-tissues, and in such cases irAEs develop early after initiation of IO. We hypothesized that irAEs have distinct chronology: earlier events representing autoimmunity (unavoidable); later events reflecting an intercurrent exposure to an antigen (e.g., virus) and therefore are avoidable by limiting duration of IO. Methods: We reviewed published IO monotherapy trials if individual patient data (swimmers’ plot) were reported. We derived the timing and frequency of Tx. We used therapy discontinuation without progressive disease as a surrogate for Tx if reported before the planned 24 months IO therapy.Results: Table depicts the data on included clinical trialsConclusion: The emergence of irAEs after IO extends over a protracted periods with 86% of events occurring beyond 4 months of IO. Though responses occasionally develop late after IO, for Tx consideration, T-cell expansion starts within days of IO initiation, and if autoimmunity is the mediator of Tx, irAEs would emerge only early. Our results suggest dual mechanisms and provide one more impetus to consider shortening IO duration. Tumor Author Discontinued IO (n) Months of IO Discontinuation 0-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16 17-18 19-20 21-22 NSCLC Topalian 12 1 1 4 1 1 3 1 Dart 11 3 4 3 1 Warburton 56 2 2 7 8 7 22 1 3 1 2 1 Melanoma Topalian 13 4 1 2 1 2 2 1 Weber 2 1 1 Demetriou 66 8 4 6 5 6 10 6 10 6 5 RCC Topalian 3 1 2 Total 163 14 10 15 25 14 38 9 15 10 11 2 8% 6% 9% 15% 8% 23% 5% 9% 6% 7% 1% Citation Format: Farah Mazahreh, Haya Safar, Liyan Mazahreh, A. Mazin Safar. The chronology of immune-related adverse events (irAEs)-mechanistic implications [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1177.

Trajectories

The decades I have traversed have taught me greater humility and a better quality of listening, which results in emotional support in the face of pain and moderation in the use of anti-inflammatories and biological drugs. While immunosuppression has been the therapeutic substrate for autoimmune phenomena, as is obvious, its excess leads to catastrophic results and undesirable effects that make the path more daunting.

Late-onset and long-lasting neutropenias in the young: A new entity anticipating immune-dysregulation disorders.

This study identifies a new chronic form of immune neutropenia in the young with or without detectable indirect anti-neutrophil antibodies, characterized by mild/moderate neutropenia low risk of severe infection (14%), tendency to develop autoimmune phenomena over the course of the disease (cumulative incidence of 58.6% after 20 years of disease duration), leukopenia, progressive reduction of absolute lymphocyte count and a T- and B-cell profile similar to autoimmune disorders like Sjogren syndrome, rheumatoid arthritis, and systemic lupus erythematosus (increased HLADR+ and CD3 + TCRγδ cells, reduced T regulatory cells, increased double-negative B and a tendency to reduced B memory cells). In a minority of patients, P/LP variants related to primary immuno-regulatory disorders were found. This new form may fit the group of "Likely acquired neutropenia," a provisional category included in the recent International Guidelines on Diagnosis and Management of Neutropenia of EHA and EUNET INNOCHRON ACTION 18233. The early recognition of this form of neutropenia would help clinicians to delineate better specific monitoring plans, genetic counseling, and potentially targeted therapies.