anti-dsDNA Research Articles

Systemic lupus erythematosus presenting as lupus erythematosus tumidus and lupus nephritis: a case report

BackgroundLupus nephritis and lupus erythematosus tumidus (LET) are uncommon manifestations of systemic lupus erythematosus (SLE), and their coexistence as the initial presentation of SLE is exceedingly rare. Here, we report such a case, emphasizing the diagnostic challenges and therapeutic implications of this unusual association.Case reportA 38-year-old North African woman presented in Nephrology department with a history of lower extremity edema, fatigue, and weight loss of 3 kg in 4 weeks. Physical examination revealed LET lesions on the chest and the Neck. Laboratory investigations showed lymphopenia, low C3 and C4 complement levels, positive antinuclear antibodies, anti-dsDNA antibodies, and anti-SSA/Ro antibodies. Renal function tests showed normal serum creatinine and nephrotic proteinuria. Renal biopsy revealed Class V lupus nephritis. Skin biopsy confirmed the diagnosis of LET, with the presence of lymphohistiocytic infiltrates and dermal mucin. The patient was diagnosed with SLE based on the 2019 EULAR/ACR criteria and treated with prednisone (1 mg/kg/day) and hydroxychloroquine. She showed significant improvement in her cutaneous and renal symptoms at 6 and 12 months follow-up.ConclusionThe rarity of the coexistence of LET and lupus nephritis as the initial manifestation of SLE, especially in the North African population, underscores the need for further research to elucidate the immunopathogenic mechanisms and prognostic factors associated with this association.

#3740 AFTER ALL A TYPICAL HUS

Abstract Background and Aims Typical Hemolytic Uremic Syndrome (HUS) is a thrombotic microangiopathy (TMA) characterized by the triad of acute renal failure, hemolytic anemia and thrombocytopenia. TMAs are classified into: Inherited or primary acquired (atypical HUS), secondary or infection associated. Infection with Shiga-toxin–producing Escherichia coli (E. coli), mainly of serotype O157:H7, is the most common cause of typical HUS, but other serotypes have been rarely associated such as Enteroagregative Escherichia coli (EAEC) serotype O104:H4. Method Case Report Results We report a case of a 51-years-old male with past medical history of arterial hypertension (treated with Perindopril) and IgGk Multiple Myeloma (MM) diagnosed 10 years prior submitted to two bone marrow autotransplants (9 and 4 years prior) and multiple chemotherapy agents including Carfilzomib-Pomalidomide-Dexamethasone (last cycle 4 days before the onset of symptoms). One week after returning from a trip to Brazil, he was admitted to the emergency department with a two-day history of non-bloody diarrhea (4-5 liquid stools per day) and asthenia, with similar positive familiar epidemiology. He denied abdominal pain, fever, nausea or vomiting. At physical examination, he was hypertensive (177/90 mmHg), anuric (12,5 ml/h), dehydrated and apyretic. Abdominal palpation was painless and there were no signs of peritoneal irritation. Laboratory tests showed hemoglobin 10.5 g/dl, new onset thrombocytopenia (261 000/uL » 21 000/uL), kidney disfunction (serum creatinine (sCr) 0.74 mg/dL to 9 mg/dL and serum urea (sU) 41 mg/dL to 260 mg/dL), hyperkaliemia (6 mEq/L) and metabolic acidosis (pH 7,39 and bicarbonate 18.4 mEq/L). LDH was 1949 U/L, C-reactive protein 30.6 mg/L, procalcitonin 3.77 ng/mL, haptoglobin <0.07 g/L and with normal complement levels (C3 and C4). Schistocytes were present in peripheral blood smear. The diagnosis of Acute Kidney Injury related with TMA was established and the patient was transferred to the Nephrology ward and urgent hemodialysis was started. Exhaustive study was performed showing normal renal ultrasound, non-nephrotic proteinuria (1.6 g/g), urinalysis showed leukocyturia and erythrocyturia. Autoimmune study including PR3-ANCA, MPO-ANCA, anti-GBM antibody, Anti-dsDNA antibody, anti-beta 2-glycoprotein I antibodies, anticardiolipin antibodies, anti-ADAMTS13 antibodies and ADAMTS13 activity, as well as study of complement C5, C'3, C'4, factor B, H and I, anti-factor H ac, AH 50 and CH50b were unremarkable. Blood and urine culture and antistreptolysin O titers were negative. Specific stool cultures for E. coli O157, Shigella, Salmonella, Yersinia and Campylobacter were negative. Stool evaluation for parasites were also negative. Viral serology for HIV, HBV, HCV and Plasmodium tests were negative. PCR stool was required due to high suspicion of E.coli infection. The suspicion of a Carfilzomib induced TMA was also raised, while molecular techniques results were awaited. MM was stable and treatment was held until recovery of kidney function. During hospitalization the patient recovered diuresis and creatinine decreased. On the 11th day of hospitalization, he was discharged but still depended on hemodialysis. Finally, stool PCR techniques identified aatA and aggR genes associated with EAEC O104:H4 allowing the diagnosis of acquired infectious HUS rather than drug-related TMA. One week after discharge, the dialysis was stopped due to sCr 3 mg/dL. Four months later, he resumed Carfilzomib and kidney function remained stable with sCr 0.9 mg/dL, despite sustained proteinuria of 1.2 g. Conclusion The authors emphasize the importance of considering other causes of TMA when E.coli O157 infection is excluded, namely drug-related causes (as Carfilzomib) or less frequent infectious agents such as EAEC O104:H4. This case reveals the importance of requesting PCR in the stool even when the E.coli test is negative. This is of particular relevance in immunosuppressed patients. This diagnosis allowed continuing MM treatment.

#5414 CLINICAL UTILITY OF SEROLOGICAL TEST AT TIME OF BIOPSY

Abstract Background and Aims It is common practice to order serological tests at time of renal biopsy, but the diagnostic value in different clinical settings is largely unknown. We utilized data from the national Swedish Renal Biopsy Registry to analyze the positive and negative post-test likelihood of four common diagnoses depending on the results of frequently used serological tests. Method Data on all biopsies performed during the period 2015-01-01 – 2020-12-31 was retrieved from the Swedish Renal Biopsy Registry. All biopsies are classified into one of the following five biopsy indications: the nephrotic syndrome (nephrosis), acute/subacute nephritic syndrome (nephritis), other acute kidney injury (AKI), chronic kidney disease stage 1-2 (CKD 1-2), and CKD 3-5. Biopsy results are given as SNOMED codes by the pathologist and a clinical diagnosis using the ERA coding system by the nephrologist. Results from the following serological tests were analyzed: C3, C4, ANA, anti-dsDNA, ANCA (PR3 and/or MPO-ANCA) and anti-phospholipid antibodies. Pre-test likelihood, positive post-test (PPL) and negative post-test likelihood (NPL) for the diagnoses IgA nephropathy (IgAN), diabetic nephropathy (DN), ANCA-associated vasculitis (AAV) and lupus nephritis (LN) were analyzed. The diagnostic yield was defined as the ratio between the PPL and NPL. Results Out of a total of 3165 individuals that had undergone kidney biopsy, there were 694 (21.9%) patients assigned a diagnosis of IgAN, 378 (11.9%) with DN, 342 (10.8%) with AAV and 117 (3.7%) with LN. The proportion of patients being tested varied from 17% for anti-phospholipid antibodies to 77% for ANCA. The highest diagnostic yield was found for ANCA in AAV were the PPL/NPL ratio was 154. In patients with nephrosis the ratio went up to 290 mainly because of a very low NPL (0.2%). The next best diagnostic yield was seen in SLE were both ANA and anti-dsDNA exhibited a PPL/NPL ratio of 26. The best yield for ANA was found when the biopsy indication was nephrosis where the PPL was 33% and the NPL 0.54% and the ratio 61. For anti-dsDNA the best yield was in AKI with a ratio of 46 (PPL 55%, NPL 1.1%). The best test to make a diagnosis less likely was anti-phospholipid antibodies in diabetic nephropathy. The test was never positive in any of the 42 patients with this diagnosis, however the same result slightly increased the likelihood of AAV. A positive result for C3(reduced levels) also reduced the likelihood av diabetic nephropathy, the PPL / NPL ratio was 13. C4 and ANCA being, on the other hand, reduced the likelihood for IgAN with a ratio in the same range. Conclusion While the utility of ANCA, ANA and anti-dsDNA is well known, it is less known when a positive test substantially reduced the likelihood of a disease. Here we present data showing that a positive test for C3 decreases the likelihood of DN, while the likelihood is much less affected by C4. The opposite Is seen for IgAN.

#4323 A RARE CASE OF MEMBRANOUS NEPHROPATHY AS THE INITIAL PRESENTATION OF SJöGREN SYNDROME

Abstract Introduction Primary Sjögren's syndrome (pSS) is an autoimmune disorder characterized by lymphocytic infiltrates in exocrine glands, most commonly manifesting as dry eyes and mouth. Even though extra glandular involvement can occur in Sjögren, renal involvement is rare. It affects less than 10% of the patient population, with tubulointerstitial nephritis being the usual presentation. Glomerular involvement and, in particular, membranous nephropathy are not commonly encountered. We describe a rare case of membranous nephropathy as the initial presentation of Primary Sjögren's syndrome. Case history A 21-year-old female with a history of sickle cell trait presented to our emergency department with one week history of anasarca. Vital signs were unremarkable, and the physical exam was significant for a 2+ pitting edema of bilateral upper and lower extremities. Initial investigation revealed acute kidney injury (Creatinine 2.9 mg/dl from normal baseline), nephrotic range proteinuria of 6 grams on 24-hour urine collection, and hypoalbuminemia (serum albumin 1.5 mg/dl). Immunological workup showed positive ANA (speckled), strongly positive anti-SSA, borderline elevated anti-SSB, negative anti-PLA2R, negative cryoglobulins, negative anti-dsDNA, and negative anti-Smith antibody (Figure 1). Renal biopsy (Figure 2) revealed membranous nephropathy with acute tubular necrosis (ATN). PLA2R staining was negative. We attributed acute kidney injury to ATN and proteinuria to membranous nephropathy. Negative serologies and renal biopsy findings ruled out systemic Lupus. The patient was therefore diagnosed with membranous nephropathy secondary to pSS. The patient was started on Mycophenolate mofetil and steroid taper with an improvement of proteinuria and anasarca and currently follows at our clinic. Discussion Glomerular involvement is rare, and when involved, it is membranoproliferative glomerulonephritis (MPGN) associated with B-cell activation and positive cryoglobulins. Membranous nephropathy is rare with primary Sjögren syndrome. In our patient, a negative anti-PLA2R goes against primary membranous nephropathy. A negative anti-dsDNA and anti-Smith and biopsy findings essentially rule out Lupus nephritis, leaving Sjögren induced secondary membranous nephropathy as the most likely diagnosis. A literature search revealed few described cases of membranous nephropathy as the presenting feature of pSS with later development of sicca symptoms and progression of renal disease to MPGN. Interestingly, our patient had no sicca symptoms at the presentation time. Occult salivary gland involvement has been described in some of these patients; however, our patient deferred salivary gland biopsy. The management of renal disease in pSS has yet to be well described because of its rarity. Rituximab has shown the most benefit in patients with pSS who have positive cryoglobulins and associated MPGN. Steroids and mycophenolate mofetil (MMF) are other possible agents that can be tried. Given that experience, we started on steroids and MMF with an excellent response to treatment indicated by improvement in proteinuria. Conclusion This case adds to the limited available literature on membranous nephropathy as the initial manifestation of pSS. Although the European Alliance of Associations for Rheumatology (EULAR) criteria strongly emphasizes sicca symptoms and glandular involvement in pSS, the possibility of a small subset of pSS patients who present with early renal involvement with latent glandular findings needs to be recognized.

#4852 LATE REFERRAL OF PATIENTS WITH AN UNKNOWN CAUSE OF CHRONIC KIDNEY DISEASE AND MALIGNANT HYPERTENSION

Abstract Introduction Systemic sclerosis (SS) is a rare connective tissue disorder characterized by widespread vascular dysfunction and progressive skin and internal organ fibrosis. Scleroderma renal crisis (SRC) is a life-threatening complication of SS. The estimated incidence of SSc is approximately 20 cases per million per year, and SRC affects about 5-15% of those patients. Case Description A 32-year-old female was admitted to the hospital with dyspnea, edema, HTN, COPD. 4 months before the hospitalization, she had an abrupt onset of HTN (230/120 mm/Hg) and seizures (no abnormal waveforms on EEG). Vital signs: HR 90’, RR 22’, BP 197/121 mmHg, SpO2 90% on room air. PEx: severe jugular venous dilation, crackles in both lungs, 3+ pitting edema bilaterally. The skin appeared abnormal with a modified Rodnan score “9” out of “51” with puffy hands, sclerodactyly, telangiectasia, and Raynaud's phenomena. Lab: creatinine 406 mcmol/L, urea 20.8 mmol/L, T.Ca 2.04 mmol/L, P 1.71 mmol/L, PTH 255.5 pg./mL, Alb 33 g/L, LDH 596 U/L. Urinalysis: UPCR of 4.169 mg/mg creat. microhematuria ANA were positive for centromere pattern with a titer of >400 AU/mL (N <40), CENP-B +++, negative for anti-Scl70, anti-dsDNA, ANCA, Anti-GBM, anti-CCP, RF, anti-Jo1 and anti-Smith antibodies. A kidney biopsy showed acute tubular injury in the early stage, and later stages of interstitial fibrosis and tubular atrophy; chronic active thrombotic microangiopathy (TMA), vascular abnormalities including intimal accumulation of myxoid material, thrombosis, fibrinoid necrosis consistent with Scleroderma Renal Crisis (Fig.3; 4; 5; 6; 7) The patient started treatment with losartan 100mg. 3 months later she started hemodialysis due to diuretic refractory overhydration with severe pulmonary edema resulting in multiple hospital readmissions. Discussion SRC is a dreaded complication of systemic sclerosis that is characterized by new-onset malignant hypertension and progressive acute renal failure, often with associated microangiopathic hemolytic anemia and thrombocytopenia, occurring in ≈ 5–15% of cases, of which 2% occur with the Limited cutaneous systemic sclerosis (lcSS) and 12% in the Diffuse cutaneous systemic sclerosis (dcSS). Histopathologically SRC can be divided into narrowly defined nd-SRC and SSc-associated TMA: nd-SRC is a typical type of SRC, which shows acute renal failure and abrupt onset of moderate-to-significant hypertension. The pathology of nd-SRC shows injured endothelial cells and subsequent intimal thickening in the arcuate and interlobular arteries. The pathology of SSc-TMA shows abnormalities in the capillary wall which eventually leads to microvascular thrombosis. Our case demonstrates severe damage to the kidney, presenting with combined nd-SRC and SSc-TMA, inevitabley leading to irreversible changes resulting in CKD. Notably, until the kidney histopathology workup, neither clinical presentation nor lab tests revealed typical TMA. SRC was at one time almost uniformly fatal, with death often occurring within a few weeks. With the development of ACE-I, survival has improved dramatically, but death rates remain unacceptably high. Unfortunately, some will require chronic dialysis. However, when timely and appropriately managed, renal function can improve considerably, although it may take several months to years, allowing for discontinuation of dialysis. Conclusion SSc should be considered in any patient presenting with malignant hypertension and AKI. SRC can occur in patients without evidence of skin thickening or other manifestations of SSc. Early diagnosis improves outcome. Kidney biopsy should be gold standard in all patients with ``unknown'' causes of the CKD. ACEi remains the cornerstone of the treatment. Renal Transplantation: to discuss after two years after start of dialysis.

Decipher the Immunopathological Mechanisms and Set Up Potential Therapeutic Strategies for Patients with Lupus Nephritis.

Lupus nephritis (LN) is one of the most severe complications in patients with systemic lupus erythematosus (SLE). Traditionally, LN is regarded as an immune complex (IC) deposition disease led by dsDNA-anti-dsDNA-complement interactions in the subendothelial and/or subepithelial basement membrane of glomeruli to cause inflammation. The activated complements in the IC act as chemoattractants to chemically attract both innate and adaptive immune cells to the kidney tissues, causing inflammatory reactions. However, recent investigations have unveiled that not only the infiltrating immune-related cells, but resident kidney cells, including glomerular mesangial cells, podocytes, macrophage-like cells, tubular epithelial cells and endothelial cells, may also actively participate in the inflammatory and immunological reactions in the kidney. Furthermore, the adaptive immune cells that are infiltrated are genetically restricted to autoimmune predilection. The autoantibodies commonly found in SLE, including anti-dsDNA, are cross-reacting with not only a broad spectrum of chromatin substances, but also extracellular matrix components, including α-actinin, annexin II, laminin, collagen III and IV, and heparan sulfate proteoglycan. Besides, the glycosylation on the Fab portion of IgG anti-dsDNA antibodies can also affect the pathogenic properties of the autoantibodies in that α-2,6-sialylation alleviates, whereas fucosylation aggravates their nephritogenic activity. Some of the coexisting autoantibodies, including anti-cardiolipin, anti-C1q, anti-ribosomal P autoantibodies, may also enhance the pathogenic role of anti-dsDNA antibodies. In clinical practice, the identification of useful biomarkers for diagnosing, monitoring, and following up on LN is quite important for its treatments. The development of a more specific therapeutic strategy to target the pathogenic factors of LN is also critical. We will discuss these issues in detail in the present article.

A comparison of the chemiluminescence immunoassay and Crithidia luciliae immunofluorescence test in detecting anti-dsDNA antibodies and assessing the activity of systemic lupus erythematosus.

This study aimed to compare the YHLO chemiluminescence immunoassay (CLIA) with the Crithidia luciliae immunofluorescence test (CLIFT) to detect anti-dsDNA antibodies and its correlation with disease activity in systemic lupus erythematosus (SLE). In total, 208 patients diagnosed with SLE, 110 other autoimmune patients, 70 infectious disorders patients, and 105 healthy people were enrolled in this study. Serum samples were tested using CLIA in a YHLO chemiluminescence system and CLIFT. The overall agreement between YHLO CLIA and CLIFT was 76.9% (160/208), with a moderate correlation (kappa = 0.530, p < 0.001). The sensitivity of YHLO CLIA and CLIFT were 58.2% and 55.3%, respectively. The specificity of YHLO CLIA and CLIFT were 95.1% and 99.3%, respectively. The sensitivity of YHLO CLIA was increased to 66.8% with a specificity of 93.6% when the cut-off value was set at 24IU/mL. Spearman's correlation coefficient between the quantitative results of YHLO CLIA and the titers of CLIFT was 0.59 (p < .01). A significant correlation was found between the anti-dsDNA results detected by YHLO CLIA and the SLE Disease Activity Index 2000 (SLEDAI-2K). Spearman's correlation coefficient between YHLO CLIA and SLEDAI-2K (r = 0.66, p < .01) was higher than that of CLIFT (r = 0.60, p < .01). Good correlation and agreement were found between YHLO CLIA and CLIFT. In addition, there was a significant correlation between YHLO CLIA and the SLE Disease Activity Index, which was superior to that of CLIFT. The YHLO chemiluminescence system is recommended for the assessment of disease activity.

Performance of two multiplex flow cytometric assays for antibody detection in Egyptian patients.

Autoantibodies are vital biomarkers for the diagnosis, assessment and prognostic determination of various autoimmune disorders. This study aimed to evaluate the performance of the two AtheNA Multi-Lyte® systems for the detection of various autoantibodies. A total of 105 systemic lupus erythematosus patients, 35 patients with other autoimmune diseases (diseased controls), and 30 healthy volunteers (healthy controls) at Zagazig University Hospitals, Zagazig city, Al Sharqia governorate were tested for anti-double-stranded DNA (anti-dsDNA) antibodies using indirect immunofluorescence (IIF) and the AtheNA Multi-Lyte® anti-nuclear antibodies-II system between May 2020 and April 2022. Seventy-five patients with clinically suspected autoimmune vasculitis (AIV) and 25 healthy volunteers were also tested for anti-myeloperoxidase and anti-proteinase 3 antibodies using IIF, the AtheNA Multi-Lyte® AIV system, and enzyme-linked immunosorbent assay (ELISA). The AtheNA anti-dsDNA test (98.5%) was more specific than IIF (96.9%) for diagnosing systemic lupus erythematosus, but both tests had the same sensitivity (38.1%). Combining both methods increased sensitivity to 47.6%, while increasing the cut-off of the AtheNA anti-dsDNA test to 134 international units/mL increased specificity to 100%. The AtheNA Multi-Lyte AIV system exhibited substantial agreement with IIF regarding anti-myeloperoxidase testing (κ = 0.65) and almost perfect agreement with ELISA (κ = 0.85). The AtheNA Multi-Lyte® AIV system exhibited perfect agreement with IIF (κ = 1) and substantial agreement with ELISA for anti-proteinase 3 testing (κ = 0.63). AtheNA Multi-Lyte® systems appear to be reliable for anti-dsDNA, anti-myeloperoxidase, and anti-proteinase 3 screening and may be an optimal choice for monitoring anti-dsDNA levels. It is necessary to evaluate various autoantibodies detection assays to increase both sensitivity and specificity of autoimmune diseases diagnostic approaches. AtheNA Multi-Lyte® systems appear to be reliable for anti-dsDNA, anti-myeloperoxidase, and anti-proteinase 3 screening and may be an optimal choice for monitoring anti-dsDNA levels.

Immunological disease activity parameters at conception are risk factors for preterm birth and low birth weight in patients with systemic lupus erythematosus.

This study aimed to identify which disease activity parameters may be risk factors for preterm birth (PB) and low birth weight (LBW) in patients with systemic lupus erythematosus (SLE). We also analyzed the extent to which these parameters affected PB and LBW. We collected the SLE Disease Activity Index (SLEDAI), the rate of lupus low disease activity state (LLDAS) attainment, complement levels, and the titer of anti-double stranded DNA (dsDNA) antibody as disease activity parameters. We retrospectively analyzed the associations of these parameters with PB and LBW. Sixty pregnancies were included in this study. C3 levels and anti-dsDNA antibody titers at conception were strongly associated with PB (p = 0.03 and p = 0.01, respectively), whereas C3 and CH50 levels were associated with LBW (p = 0.02 and p = 0.03, respectively). A logistic regression analysis showed that the cutoff values of C3 and anti-dsDNA antibody for PB were 62.0mg/dl and 5.4IU/ml, respectively. The cutoff values of C3 and CH50 for LBW were 87.0mg/dl and 41.8U/ml, respectively. The risk of PB or LBW was increased when divided by the cutoff value, and the combination of these cutoff values showed a significantly higher risk of PB and LBW (p = 0.01 and p < 0.01, respectively). PB and LBW are strongly associated with disease activity parameters in patients with SLE. Therefore, strictly monitoring and controlling these disease activity parameters, with or without clinical manifestation, is important for women who want to become mothers.

T-bet-expressing B cells contribute to the autoreactive plasma cell pool in Lyn-/- mice.

Systemic Lupus Erythematosus (SLE) is characterized by pathogenic autoantibodies against nucleic acid-containing antigens. Understanding which B-cell subsets give rise to these autoantibodies may reveal therapeutic approaches for SLE that spare protective responses. Mice lacking the tyrosine kinase Lyn, which limits B and myeloid cell activation, develop lupus-like autoimmune diseases characterized by increased autoreactive plasma cells (PCs). We used a fate-mapping strategy to determine the contribution of T-bet+ B cells, a subset thought to be pathogenic in lupus, to the accumulation of PCs and autoantibodies in Lyn-/- mice. Approximately, 50% of splenic PCs in Lyn-/- mice originated from T-bet+ cells, a significant increase compared to WT mice. In vitro, splenic PCs derived from T-bet+ B cells secreted both IgM and IgG anti-dsDNA antibodies. To determine the role of these cells in autoantibody production in vivo, we prevented T-bet+ B cells from differentiating into PCs or class switching in Lyn-/- mice. This resulted in a partial reduction in splenic PCs and anti-dsDNA IgM and complete abrogation of anti-dsDNA IgG. Thus, T-bet+ B cells make an important contribution to the autoreactive PC pool in Lyn-/- mice.

The role of hsa_circ_0008945 in juvenile-onset systemic lupus erythematosus

Backgroundcircular RNAs (circRNAs) play a crucial role in many physiological and pathological processes including juvenile-onset systemic lupus erythematosus (JSLE). The aim of this study is to investigate the role of circRNA hsa_circ_0008945 in JSLE and evaluate its significance as diagnosing biomarker.MethodsRT-qPCR was applied to detect the level of circ_0008945 in JSLE and controls. The Spearman correlation test assessed the correlation between circ_0008945 and clinical variables. The receiver operating characteristic (ROC) curve was calculated for evaluating the diagnostic value. Overexpression or knockdown of circ_0008945 in primary peripheral blood mononuclear cells (PBMCs) was performed to further examine its function in apoptosis.ResultsRT-qPCR revealed that there were significantly higher levels of hsa_circ_0008945 in PMBCs from JSLE patients (p < 0.001) compared to healthy controls. In addition, there were significant associations between hsa_circ_0008945 level and the level of C3, C4, anti-ds DNA, IgG, CRP and ESR (p < 0.05) but not associated with the level of Ig A and Ig M. ROC curve of the circ_0008945 showed that the AUC was 0.790 and it may potentially be used as a novel biomarker for the diagnosis of JSLE. The results showed that overexpression of circ-0008945 increased the apoptosis of PBMCs while knockdown of circ-0008945 by siRNA decreased the apoptosis of PBMCs, supporting that circ-0008945 promoted the apoptosis in PBMCs and contributed to the pathogenesis of JSLE.ConclusionThe role of circ_0008945 was first investigated in JSLE and proposed herein their possible contribution to the pathogenesis of JSLE. This study provides not only novel insight into the pathological mechanisms but also the potential value as a useful biomarker for JSLE.

Lupus-like phenotypes emerge from loss of macrophage derived Dnase1L3

Abstract One leading cause of death in women is autoimmunity. One prominent autoimmune disease is Systemic Lupus Erythematosus (lupus). During lupus, inflammation is driven by autoantibodies that target cell-free DNA. Cell-free DNA is degraded by two serum endonucleases, Dnase1 and Dnase1L3. The loss of Dnase1L3 causes lupus in humans and mice, but the amount of Dnase1L3 necessary to prevent lupus onset is unknown. Since DnaselL3 is secreted by macrophages and dendritic cells, we hypothesized that loss of macrophage-derived DnaselL3 is sufficient to cause lupus-like phenotypes in mice. We generated conditional knockout (cKO) mice lacking DnaselL3 expression in macrophages. Sera was collected weekly from these mice until 50 weeks of age. To measure autoantibody induction, total IgG, total IgM, anti-dsDNA and anti-nuclear antibody levels were analyzed at 4, 20, 30 and 50 weeks. Sandwich ELISA was used to quantitate antibody levels in control and cKO mice. Homogeneous and peripheral anti-nuclear antibodies were detected by immunofluorescence, consistent with anti-dsDNA antibodies. Total IgG, anti-ds DNA antibody levels increased in cKO mice. We conclude that SLE-like phenotypes arise in mice due to the loss of macrophage Dnase1L3. This suggest that macrophage derived DnaselL3 is critical to controlling lupus. Plains Bridges to the Baccalaureate Program (PBB) (NIH 2R25GM83730-B)

Systemic Lupus Erythematosus in Men: Brief Description of Clinical and Laboratory Findings

Background: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by the presence of nuclear autoantibodies, which can cause autoimmune complex formation and inflammation of multiple organs. It is known to affect women more frequently than men and is typically diagnosed during reproductive age, where the female-male ratio has been reported as high as 12:1. The etiology of SLE is not fully understood, but both genetic predisposition and environmental triggers are believed to be involved. Because of the multitude of presentations, manifestations, and serological abnormalities in patients with SLE, diagnosis can be challenging. Chronic discoid lupus and photosensitivity have been found in men with SLE as far as skin findings are concerned, there is less joint involvement in these patients, however, severe systemic findings predominate, such as serositis, pleurisy, central nervous system involvement with the presence of seizures. , thrombotic events and lupus nephropathy of the acute proliferative glomeruonephritis variety, serologically there is no consensus yet, nor in the specific clinical characteristics but the presence of anti-dsDNA anti-Sm antibodies and anticardiolipin antibodies is also frequently found. Therapeutic approaches predominantly involve immunomodulation and immunosuppression and are targeted to be the specific organ manifestation, with the aim of achieving low disease activity. Conclusion: We considered that although male patients with lupus are not commonly seen, the manifestations are life threatening, and timely diagnosis and treatment of the disease will lead to a better outcome for these patients.

Type 1 interferons promote anti-RBC antibody responses in interferon-dependent lupus mice

Abstract Red blood cell (RBC) transfusion can induce anti-RBC antibodies that promote hemolytic events. Patients with systemic lupus erythematosus (SLE) have an increased frequency of RBC alloimmunization, and two-thirds of patients express a type 1 interferon (IFNα/β) gene signature. We previously reported that IFNα/β induces RBC alloimmunization in the IFNα/β-dependent pristane lupus mouse model. However, it is unclear whether the lupus-like phenotype or IFNα/β directly promoted alloimmunization. Thus, we examined alloantibody responses in MRL/lpr mice, which have an IFNα/β-independent lupus-like phenotype. MRL/lpr mice produced anti-dsDNA lupus antibodies. However, unlike pristane-treated WT mice, IFNα/β-stimulated genes (ISGs) were not elevated in MRL/lpr mice. After transfusion with allogeneic RBCs, untreated WT and MRL/lpr mice produced minimal levels of anti-RBC antibodies, compared to elevated levels produced by pristane-treated WT mice. To determine whether IFNα/β can induce alloimmunization in MRL/lpr mice, WT and MRL/lpr mice were treated with recombinant IFNα (rIFNα) or the IFNα/β stimulus, poly(I:C), prior to transfusion. While rIFNa and poly(I:C) induced RBC alloimmunization in WT mice, they failed to induce alloimmunization in MRL/lpr mice. Thus, MRL/lpr mice are resistant to IFNα/β-induced alloimmunization due to a currently explored mechanism. These findings also illustrate that allogeneic transfusion induces alloimmunization in an IFNα/β-dependent lupus model, but not in an IFNα/β-independent model. Thus, the lupus-like phenotype is not sufficient to induce alloimmunization. Collectively, these findings warrant investigation of the role of IFNα/β in RBC alloimmunization in patients with SLE. NIH (R01 HL165169-01); NIH (R03 HL158637-01); NIH (K08 HL141446-03)

Phenotypic Evaluation of TREX1 Null Mice as a Model for Lupus-Like Autoimmune Disease

Abstract TREX1 (DNase III) is the major mammalian 3’-5’ DNA exonuclease and thought to play a major role in cell death and genomic DNA degradation. Dysfunction of Trex1 has been suggested to activate immune response by self DNA, as TREX1 null mice develop inflammatory myocarditis similar to autoimmune cardiomyopathy and produce type 1 IFN. TREX1 D18N causes a monogenic cutaneous form of lupus called familial chilblain lupus and exhibits dysfunctioned dsDNA-degrading activity, providing a link between dsDNA degradation and nucleic acid-mediated autoimmune diseases. Using CRISPR-Cas9, we generated a Trex1 −/−mouse by knocking out exon 2 and performed comprehensive phenotypic analyses to evaluate the loss of function of TREX1 and its potential application in SLE research. Both female and male TREX1 null mice showed dramatically increased post-wean morbidity and significantly increased serum ALT, AST and LDH levels, compared to wildtype and heterozygotes from 6 to 24 weeks of age, indicating liver and heart injuries. Pathohistological analysis showed inflammatory immune cell infiltration in liver, heart, spleen, kidney, lung and skin among TREX1 null mice. Serum anti-dsDNA antibody levels were significantly increased and remained high from 7 to 25 weeks of age, consistent with Trex1’s being the major DNA exonuclease. Urine protein to creatinine ratio was dramatically increased at 28 weeks of age among TREX1 null mice. In conclusion, the Trex1 −/−mice we generated in this work showed lupus-like inflammatory autoimmune responses in multiple organs, providing an urgently needed tool to study Trex1-mediated autoimmunity and to evaluate potential therapeutic treatments for lupus.

Sex disparities in pathological features and autoimmunity in high fat diet associated lupus mouse model

Abstract Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that is more common in women than men. SLE has been reported with diverse clinical phenotypes of varying severity, which may be caused by sex hormones and environmental factors. Our recent studies showed that high-fat diet (HFD) exacerbated lupus development in MRL/lpr lupus-prone mice. Here we explored the gender difference in lupus progress and autoimmune response to HFD. Twenty male and twenty female MRL/lpr mice were evenly grouped and fed with a regular diet (RD, 10% fat) or HFD (60% fat) for 14 weeks. Body weights were recorded weekly. SLE progression was monitored by skin lesions, urine protein, titers of anti-dsDNA antibody in serum. Kidney and skin from the dorsum of the neck were embedded for H&amp;E, PAS, and Masson’s staining quantified as kidney index and skin score. Immune cells in the spleens were identified by immunofluorescence staining and flow cytometry. HFD induced a greater weight gain in female mice than male mice (p&amp;lt;0.01). Skin rash showed up as early as week 6 in female HFD group with a greater histopathological skin score (p&amp;lt;0.01). Splenomegaly, proteinuria, and anti-dsDNA level were increased only in male HFD group. Kidney pathological changes were more severe in male HFD mice with significant increase of kidney index (p&amp;lt;0.05). Significant increases of germinal center B cells, plasma cells, and T follicular helper cells were observed in HFD mice (p&amp;lt;0.05). SLE progression is sexually dimorphic in lupus-prone mice in response to HFD. Our results parallel many known clinical lupus phenotypes and sexual dimorphism in which male patients are more likely to have severe disease (such as nephritis) than female lupus patients who may have a broader range of lupus symptoms. None

Fetal and Neonatal Outcomes of Maternal Rheumatic diseases in a tertiary care centre of Lahore, Pakistan

Background: Pregnancy may worsen underlying autoimmune rheumatologic illnesses. The trans-placental transmission of autoantibodies can harm the foetus or newborn. Aim: To determine the impact of maternal rheumatological disorders on fetal and newborn outcomes. Methods: A descriptive longitudinal study was conducted at Fatima Memorial Hospital enrolling 32 pregnant women with rheumatologic disorders by consecutive sampling. Data was collected regarding maternal demographics, diagnosis, serum markers, Fetal &amp; neonatal outcome factors (IUGR, Fetal distress, Umbilical Doppler findings, Fetal Echo, Place of birth, Mode of delivery, discharge status, Term/pre-term birth, Gender, Low Birth Weight, Cardiac defect, NICU stay, the reason for NICU stay) Results: The diagnosis of 50% of the subjects was SLE. 25%subjects were suffering from RA. Regarding serum markers, 50% of the mothers were Anti ds DNA positive followed by ANA with 34.4% &amp; Lupus anticoagulant with 21.9% positivity. IUGR was recorded in 9.4%, fetal distress in 28.1%, abnormal umbilical doppler in 9.4%, and 12.5% of a newborn could not survive. Pre-term delivery was recorded in 31.3% of cases, low birth weight in 34.4%, cardiac defects in 6.3%, thrombocytopenia in 6.3%, NICU stay was required in 31.3%, EOS was reason in 12.5% and RDS in 25%. Conclusion: Prevalence of IUGR, fetal distress, low birth weight, preterm delivery, cardiac defects and admission to NICU was high in autoimmune rheumatological pregnant females. Pre-term delivery, fetal distress and LBW were significantly associated with SLE. Keywords: Pregnancy outcome, rheumatic disease outcome, fetus, neonate, SLE

Effects of Hyperbaric Oxygen on Anti-dsDNA Antibodies and IL-6 in BALB/c Mice with Pristane-Induced Lupus Nephritis

Effects of Hyperbaric Oxygen on Anti-dsDNA Antibodies and IL-6 in BALB/c Mice with Pristane-Induced Lupus Nephritis

Chorea as the Initial Manifestation of Antiphospholipid Syndrome (P9-5.020)

<h3>Objective:</h3> To discuss a rare case of chorea presenting as the initial manifestation of autoimmune disease. <h3>Background:</h3> Autoimmune chorea, including paraneoplastic, post-infectious, and idiopathic etiologies, is one of the leading causes of adult-onset chorea behind Huntington’s and vascular diseases.¹ In particular, in primary antiphospholipid syndrome (APS) and systemic lupus erythematosus, chorea is the initial manifestation of disease in 0.9 to 2% of cases.^1,2 <h3>Design/Methods:</h3> Verbal and written consent were obtained from the patient. <h3>Results:</h3> 73-year-old female with PMH of ITP, left MCA ischemic stroke, SDH, and DVT on anticoagulation who presented initially to ED with choreoathetoid movements starting 3 days prior to admission. History was unremarkable for triggering factor. Head imaging was unremarkable for acute intracranial process. B12, folate, TSH, electrolytes, RPR, serum copper, ANA, anti-dsDNA, SS-A, SS-B, Smith, and RNP antibodies negative. Lupus anticoagulant, β2 glycoprotein, and anti-cardiolipin antibodies positive. EEG unremarkable. Pelvic ultrasound negative. Genetic testing for Huntington’s negative. LP normal with exception of positive Coxsackie B1–B6 and A24 antibodies. After five-day course of IVIg, movements improved and she was discharged on no immunosuppression. Five weeks later, patient returned to ED with worsening of choreoathetoid movements. Repeat head CT again negative for acute pathology. Repeated spinal was unremarkable. Patient received Solumedrol 1g for four days with significant improvement in symptoms, and discharged on Prednisone 60 mg daily with recommendation to follow-up with rheumatology and neurology. On follow-up several months later, patient maintained on Prednisone 5 mg daily with no recurrence of choreoathetoid movements. <h3>Conclusions:</h3> While chorea is not the most commonly reported movement disorder in the context of autoimmune disease, it is often a delayed diagnosis, resulting in recurrent admissions and healthcare costs. Laboratory testing for autoimmune disorders should be included in the initial work-up of new-onset chorea to establish the diagnosis and properly treat as to prevent development of fulminant disease. <b>Disclosure:</b> Ms. Alayon has nothing to disclose. Mrs. Goodis has nothing to disclose. Dr. Feinberg has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Acadia. Dr. Feinberg has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Catalyst. Dr. Feinberg has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for eisai. Dr. Feinberg has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Argenx. Dr. Feinberg has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Abbvie. Dr. Feinberg has stock in Amarin. Stuart N. Kieran, MD has nothing to disclose. Dr. Wirkowski has nothing to disclose.

E027 An outlandish presentation of IgG4-related disease

Abstract Background/Aims IgG4-related sclerosing disease is a systemic disease characterized by extensive IgG4-positive plasma cells and T-lymphocyte infiltration of various organs and tumour-like involvement of one or more exocrine glands or other extranodal sites. The major involved organs are the salivary glands, lacrimal glands, pancreas and retroperitoneal space. Cardiac masses in IgG4 disease include hematoma, tumours, vegetations, calcific lesions and other rare conditions. Cardiac tumours are rare and have a variety of benign and malignant entities. We herein report the case of a patient with antiphospholipid antibody syndrome with a mass lesion in the right atrium, histologically proven as IgG4-related disease. Methods A 52-year-old female, a known case of primary antiphospholipid antibody syndrome for 14 years, with five first trimester abortions and positive lupus anticoagulant, on anticoagulation with vitamin K antagonist, presented with: shortness of breath, bilateral lower limb swelling and exertional dyspnoea- grade 3, since one week before admission, associated with orthopnoea, without any h/o decreased urine output or facial puffiness. On examination, she had hypertension with raised JVP and loud P2 possibilities of myocarditis, hypertensive heart failure, and severe PAH with CCF were considered. Investigations showed iron deficiency anaemia, normal complements, and negative anti-dsDNA antibodies. she was treated with diuretics, PDE inhibitors and antihypertensives, 2D echo showed haziness in the right atrium, possible thrombus (1.5 × 2.3 cm), CTPA - showed enhancing mass lesion in right atrium wall, neoplastic origin was considered. Results To further evaluate the mass in the right atrium, a PET scan was performed, which showed a metabolically active isolated mass lesion in the right atrium, Cardiac MRI showed an ill-defined lobulated T1 hypointense, T2/STIR isointense lesion involving the right atrial wall, possible lymphoma/sarcoma. Planned for excision/debulking via sternotomy approach, intraoperative trans oesophageal echo showed right atrial mass of 25 cms possibility of lymphoma/sarcoma, during surgery mass could not be excised but a biopsy was taken and sent for histopathological analysis. The report was suggestive of IgG4 disease, plasma cells stain positive for IgG4 with ratio of IgG4 to IgG of 0.4. IHC results showed no evidence of malignancy. Serum IgG4 levels was 145mg/dl (&amp;lt;135mg/dl). Diagnosis of IgG4 disease was made and the patient was started on steroids, repeat 2D echo after 6 months showed that the mass in the right atrium had resolved and the patient was asymptomatic. Conclusion In conclusion, this was a rare case of primary antiphospholipid antibody syndrome, presenting as a cardiac mass which was difficult to distinguish from malignant lymphoma by a pathological examination alone, hence a biopsy was done to analyze the clonality of the cardiac tumour and accurate diagnosis of IgG4-RD was made. Disclosure K. Yerram: None. P. Devarasetti: None. L. Rajasekhar: None.