Alpha-1 Antitrypsin Levels Research Articles

Bridging from Intramuscular to Limb Perfusion Delivery of rAAV: Optimization in a Non-human Primate Study

Phase 1 and phase 2 gene therapy trials using intramuscular (IM) administration of a recombinant adeno-associated virus serotype 1 (rAAV1) for replacement of serum alpha-1 antitrypsin (AAT) deficiency have shown long-term (5-year) stable transgene expression at approximately 2% to 3% of therapeutic levels, arguing for the long-term viability of this approach to gene replacement of secreted serum protein deficiencies. However, achieving these levels required 100 IM injections to deliver 135 mL of vector, and further dose escalation is limited by the scalability of direct IM injection. To further advance the dose escalation, we sought to bridge the rAAV-AAT clinical development program to regional limb perfusion, comparing two methods previously established for gene therapy, peripheral venous limb perfusion (VLP) and an intra-arterial push and dwell (IAPD) using rAAV1 and rAAV8 in a non-human primate (rhesus macaque) study. The rhesus AAT transgene was used with a c-myc tag to enable quantification of transgene expression. 5 cohorts of animals were treated with rAAV1-IM, rAAV1-VLP, rAAV1-IAPD, rAAV8-VLP, and rAAV8-IAPD (n = 2–3), with a dose of 6 × 1012 vg/kg. All methods were well tolerated clinically. Potency, as determined by serum levels of AAT, of rAAV1 by the VLP method was twice that observed with direct IM injection; 90 μg/mL with VLP versus 38 μg/mL with direct IM injection. There was an approximately 25-fold advantage in estimated vector genomes retained within the muscle tissue with VLP and a 5-fold improvement in the ratio of total vector genomes retained within muscle as compared with liver. The other methods were intermediate in the potency and retention of vector genomes. Examination of muscle enzyme (CK) levels indicated rAAV1-VLP to be equally safe as compared with IM injection, while the IAPD method showed significant CK elevation. Overall, rAAV1-VLP demonstrates higher potency per vector genome injected and a greater total vector retention within the muscle, as compared to IM injection, while enabling a much greater total dose to be delivered, with equivalent safety. These data provide the basis for continuation of the dose escalation of the rAAV1-AAT program in patients and bode well for rAAV-VLP as a platform for replacement of secreted proteins.

Comparative evaluation of serum alpha-1antitrypsin levels in patients with oral squamous cell carcinoma and in subjects with tobacco habit without carcinoma.

Aim/Objectives:To evaluate serum levels of Alpha-1 antitrypsin in patients with oral squamous cell carcinoma and compare them with that of healthy subjects with and without tobacco habits.Materials and Method:The sample of 83 subjects was divided into three groups: 30 subjects with oral squamous cell carcinoma formed Group A. The age, sex, habit matched 23 healthy subjects with tobacco habit formed Group B and 30 healthy without history of consumption of tobacco formed Group C. Analysis of the samples was done using Alpha 1 antitrypsin kit and spectrophotometer.Results:There was a 2.33-fold rise in serum levels of Alpha 1 antitrypsin in Group A compared to Group B, 3.71-fold rise in Group A compared to Group C and 1.59-fold rise in Group B compared to Group C (P < 0.001). A definite rise in serum Alpha 1 antitrypsin levels in patients with oral squamous cell carcinoma as compared with healthy subjects with and without tobacco habits was observed.Conclusion:Alpha1-antitrypsin can be used as an adjunct to various diagnostic procedures implied for the evaluation of oral squamous cell carcinoma.

Detection of alpha-1 antitrypsin gene mutations by polymerase chain reaction in patients with chronic obstructive pulmonary disease

Introduction. The alpha-1 antitrypsin deficiency is the best described genetic cause of chronic obstructive pulmonary disease. The study of the alpha-1 antitrypsin deficiency, as the most important genetic risk factor for chronic obstructive pulmonary disease, is an important step in developing a strategy for the prevention and treatment of this disease. The aim of the study was detection of homozygous and heterozygous deficient gene alleles (protease inhibitor Z and protease inhibitor S) for alpha-1 antitrypsin in the group of patients with chronic obstructive pulmonary disease with the predominance of lung emphysema, as well as determination of a positive correlation between the serum levels of alpha-1 antitrypsin and the corresponding alpha-1 antitrypsin genotype. Material and Methods. The study included 90 patients, mutually unrelated individuals, hospitalized due to lung emphysema. The control group included 10 subjects, with no clinical signs of lung emphysema, but with a family history of chronic obstructive pulmonary disease. We attempted to identify the most common deficient alleles (protease inhibitor Z and protease inhibitor S) and the concentration of alpha-1 antitrypsin in the serum of the examinees. The polymorphism between the two allelic forms, protease inhibitor Z and protease inhibitor S, was detected by real-time polymerase chain reaction. Results. Protease inhibitor MM genotype alpha-1 antitrypsin was present in all 90 patients with the diagnosis of pulmonary emphysema, and the serum levels of alpha-1 antitrypsin were within the range of reference values. In the control group, there were two cases with mutated protease inhibitor MZ genotype, and in these 2 subjects the serum level of alpha-1 antitrypsin was at the lower limit of reference values. Conclusion. In patients diagnosed with lung emphysema, protease inhibitor MM genotype of alpha-1 antitrypsin and normal serum alpha-1 antitrypsin levels, the genetically- determined deficiency of alpha-1 antitrypsin is not responsible for the development of chronic obstructive pulmonary disease.

Rare Post-Infectious Autoimmune Hepatitis-Induced Liver Failure: A Consequence of HAV Infection

Autoimmune Hepatitis (AIH) is a chronic liver hepatitis of unclear etiology. Rarely AIH can be triggered by viral hepatitis, especially Hepatitis A virus(HAV), Hepatitis B, Hepatitis C and Hepatitis E virus(HEV). We present a case of AIH which developed in a patient with recent HAV infection. 45-year-old female from Mexico with past history of traumatic brain injury presented with progressive yellowish discoloration of eyes, headache and confusion. She had been diagnosed with acute Hepatitis A in Mexico 1 month prior to her presentation and had full recovery with supportive management. On presentation her vital signs were normal. She was confused, icteric, and had asterixis. Her ALT and AST were 2869 U/L and 1469 U/L respectively. Total bilirubin was 15.1 gm/dL, with a direct bilirubin of 6.2 gm/dL, INR 1.6 and Ammonia 55 μmol/L. Her initial MELD (Model for End-Stage Liver Disease) was 22. Work up for etiologies of chronic liver disease showed a ferritin of 1657 ng/mL and IgG 2580. Her ANA, anti-mitochondrial antibody (AMA), anti-smooth muscle antibody, P-ANCA, C- ANCA, Anti-LKM1 antibody were negative. Ceruloplasmin and Alpha-1 antitrypsin levels were normal. Anti HAV IgM, HEV IgG and IgM were positive, but HEV RNA was undetectable. Abdominal ultrasound and CT scan showed no significant abnormality. Transjugular liver biopsy was performed revealing a portosystemic gradient of 7mmHg and histologic consistent with autoimmune hepatitis (panlobular hepatitis with abundant portal and perivenular lymphoplasmacytic infiltrate). She was started on oral prednisone and azathioprine. Her liver enzymes and liver function improved. After 1-week MELD score improved to 16. She was discharged on a prednisone taper. At 6 months follow-up she had normal liver enzymes and synthetic function, and HEV IgM and IgG remained positive. HAV infection is common but development of post viral hepatitis AIH is unusual. We describe a patient with acute autoimmune hepatitis after HAV infection. HAV infection can rarely act as a trigger for autoimmune hepatitis by initiating a self-perpetuating immune-mediated liver inflammation and can present acutely after resolution of viral hepatitis. Although other viral hepatitis markers were positive(HEV) raising the concern for coinfection, she had no HEV viremia. It is crucial to differentiate between acute viral hepatitis and AIH since their treatment is different and recognize the potential for immune mimicry in acute immunologic flares.

SERPINA1 Hepatocyte-Specific Promoter Polymorphism Associate with Chronic Obstructive Pulmonary Disease in a Study of Kashmiri Ancestry Individuals

Different mutations in coding and non-coding sequences of the SERPINA1 gene have been implicated in the pathogenesis of COPD. However, - 10T/Cmutation in the hepatocyte-directed promoter region has not been associated with COPD pathogenesis so far. Here, we report an increased frequency of - 10C genotype that is associated with decreased levels of serum alpha1-antitrypsin (α1AT) in COPD patients. The quantification of serum α1AT was done by ELISA, the phenol-chloroform method was used for DNA extraction, PCR products were directly sequenced. The IBM SPSS Statistics v21 software was used for statistical analyses of the data. The mean serum α1AT level was found to be 1.203+0.239 and 3.162+0.160 g/L in COPD cases and in control, respectively. The - 10C allele is associated with an increased risk of COPD [OR, 3.50 (95%CI, 1.86-6.58); p < 0.001]. The combined variant genotype (TT+CC) was significantly found associated with an increased risk of COPD [OR, 3.20 (95% CI, 1.47-6.96); p = 0.003]. A significant association of the family history with COPD (overall p value= 0.0331) suggests that genetics may play an important role in the pathogenesis of COPD. The polymorphism associated with hepatocyte-specific promoter region (- 10T/C) is likely to be associated withthe pathogenesis of COPD. It is quite possible that the change of the base in thehepatocyte-specific promoterof the SERPINA1 gene can modulate its strength, thereby driving the reduced expression of α1AT.

Hepatic-targeted RNA interference provides robust and persistent knockdown of alpha-1 antitrypsin levels in ZZ patients

Alpha-1 antitrypsin deficiency (AATD) is a genetic disorder causing pulmonary and liver disease. The PiZ mutation in AAT (SERPINA1) results in mis-folded AAT protein (Z-AAT) accumulating in hepatocytes, leading to fibrosis and cirrhosis. RNAi-based therapeutics silencing production of hepatic Z-AAT might benefit patients with AATD-associated liver disease. This study evaluated an RNAi therapeutic to silence production of AAT. Part A of this double-blind first-in-human study randomized 54 healthy volunteers (HVs) into single dose cohorts (two placebo: four active), receiving escalating doses of the investigational agent ARC-AAT from 0.38 to 8.0 mg/kg or placebo. Part B randomized 11 patients with PiZZ (homozygous for Z-AAT) genotype AATD, who received up to 4.0 mg/kg of ARC-AAT or placebo. Patients with baseline FibroScan® >11 kPa or forced expiratory volume in one second (FEV1) <60% were excluded. Assessments included safety, pharmacokinetics, and change in serum AAT concentrations. A total of 36 HVs received ARC-AAT and 18 received placebo (part A). Seven PiZZ individuals received ARC-AAT and four received placebo (part B). A dose response in serum AAT reduction was observed at doses ≥4 mg/kg with similar relative reductions in PiZZ patients and HVs at 4 mg/kg and a maximum reduction of 76.1% (HVs) vs. 78.8% (PiZZ) at this dose. The time it took for serum AAT to return to baseline was similar for HV and PiZZ. There were no notable differences between HV and PiZZ safety parameters. The study was terminated early because of toxicity findings related to the delivery vehicle (ARC-EX1) seen in a non-human primate study. PiZZ patients and HVs responded similarly to ARC-AAT. Deep and durable knockdown of hepatic AAT production based on observed reduction in serum AAT concentrations was demonstrated. Accumulation of abnormal proteins in the livers of patients with alpha-1 antitrypsin deficiency may lead to decreased liver function and potentially liver failure. Therapeutics targeting the production of these abnormal proteins may be used to prevent or treat liver disease in patients with alpha-1 antitrypsin deficiency. NCT02363946.

Alpha-1 antitrypsin (AAT) and C-reactive protein (CRP) in interstitial lungs diseases

Deficiency of Alpha-1 Antitrypsin deficiency (AAT) and higher CRP level are known biomarker for Lungs diseases. The purpose of this investigation was to estimate probable relations of AAT and CRP levels in the Lungs diseases. The sera of 27 patients of Emphysema, 20 patients with Chronic Obstructive Pulmonary Disease (COPD) and 17 patients of asthma along with 28 healthy volunteers were analysed. Age of patients and healthy volunteers was between 23 to 46 and male and female percentage was 71% and 29 % respectively. Serum AAT in asthma (0.401 ± 0.340), COPD (0.556 ± 0.310) and of emphysema (0.421 ± 0.311) is significant (P<0.001) lower than healthy control (1.01± 0.17). Serum CRP in asthma (3.930 ± 0.906), COPD (3.830 ± 0.666) and of emphysema (3.996 ± 1.049) is higher than healthy control (1.01 ± 0.17). Thus, serum AAT and CRP measurement can be helpful in predicting asthma control and treatment response.

The patient profile of individuals with Alpha-1 antitrypsine gene mutations at a referral center in Brazil.

ABSTRACTObjective:The clinical, functional, radiological and genotypic descriptions of patients with an alpha-1 antitrypsin (A1AT) gene mutation in a referral center for COPD in Brazil. Methods:A cross-sectional study of patients with an A1AT gene mutation compatible with deficiency. We evaluated the A1AT dosage and genotypic, demographic, clinical, tomographic, and functional characteristics of these patients. Results:Among the 43 patients suspected of A1AT deficiency (A1ATD), the disease was confirmed by genotyping in 27 of them. The A1AT median dosage was 45 mg/dL, and 4 patients (15%) had a normal dosage. Median age was 54, 63% of the patients were male, and the respiratory symptoms started at the age of 40. The median FEV1 was 1.37L (43% predicted). Tomographic emphysema was found in 77.8% of the individuals. The emphysema was panlobular in 76% of them and 48% had lower lobe predominance. The frequency of bronchiectasis was 52% and the frequency of bronchial thickening was 81.5%. The most common genotype was Pi*ZZ in 40.7% of participants. The other genotypes found were: Pi*SZ (18.5%), PiM1Z (14.8%), Pi*M1S (7.4%), Pi*M2Z (3.7%), Pi*M1I (3.7%), Pi*ZMnichinan (3.7%), Pi*M3Plowell (3.7%), and Pi*SF (3.7%). We did not find any significant difference in age, smoking load, FEV1, or the presence of bronchiectasis between the groups with a normal and a reduced A1AT dosage, neither for 1 nor 2-allele mutation for A1ATD. Conclusions:Our patients presented a high frequency of emphysema, bronchiectasis and bronchial thickening, and early-beginning respiratory symptoms. The most frequent genotype was Pi*ZZ. Heterozygous genotypes and normal levels of A1AT also manifested significant lung disease.

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Enhancement of Alpha 1-antitrypsin Production in Pichia pastoris by Designing and Optimizing Medium Using Elemental Analysis.

Background: Human alpha 1-antitrypsin (AAT) is a monomeric glycosylated protein; it is the potent inhibitor of a whole range of serine proteases and protects tissues against their destructive effects. The human plasma-derived AAT, which is currently used to augment the AAT level in patients, is limited due to high cost and source limitation. Recombinant production of AAT can be considered as a potential alternative. Objectives: This study aims to develop and optimize a new chemically defi ned medium based on an elemental analysis of the yeast Pichia pastoris for an effi cient culture of the recombinant yeast-producing secretory AAT. Materials and Methods: An elemental analysis of Carbon (C), Hydrogen (H), Nitrogen (N), Sulfur (S); CHNS in its abbreviated form, and metallic elements was performed to determine the exact molecular constituent of the P. pastoris. The medium components were selected according to the obtained formula; they were optimized by the response surface methodology (RSM). The grown yeast cell was measured at the end of 18 h glycerol batch culture. The amounts of AAT production and elastase inhibitory capacity (EIC) were measured at the end of three days' methanol feeding. Results: The optimized medium compositions consist of glycerol (40 g.L-1), KH2PO4 (24.78 g.L-1), NaCl, (0.88 g.L-1), MgSO4 .7H2 O (1.95 g.L-1), (NH4 )2 SO4 (22.76 g.L-1), and trace elements (20 mL.L-1). The presented quadratic models show that KH2 PO4 and (NH4)2 SO4, are the most abundant ones in the P. pastoris biomass and have the greatest effect on the cell growth, EIC, and AAT protein production responses. Conclusions: According to the results of this study, it can be concluded that the characterizing cell composition formula could be considered as an appropriate method to design culture media in order to improve cell growth and productivity. Compared to the common P. pastoris chemically defi ned media, FM22 and BSM, production of AAT protein increased by 1.5 and 1.4 times, respectively, in this new medium.

Evaluation of Alpha-1 Antitrypsin Levels and SERPINA1 Gene Polymorphisms in Sickle Cell Disease.

Alpha-1 antitrypsin (AAT) is an inhibitor of neutrophil elastase and a member of the serine proteinase inhibitor (serpin) superfamily, and little is known about its activity in sickle cell disease (SCD). We hypothesize that AAT may undergo changes in SCD because of the high oxidative stress and inflammation associated with the disease. We have found high AAT levels in SCD patients compared to controls, while mutant genotypes of SERPINA1 gene had decreased AAT levels, in both groups. AAT showed negative correlation with red blood cells, hemoglobin (Hb), hematocrit, high-density lipoprotein cholesterol, urea, creatinine, and albumin and was positively correlated with mean corpuscular Hb concentration, white blood cells, neutrophils, Hb S, bilirubin, lactate dehydrogenase, ferritin, and C-reactive protein. Patients with higher levels of AAT had more infection episodes (OR = 1.71, CI: 1.05–2.65, p = 0.02), gallstones (OR = 1.75, CI: 1.03–2.97, p = 0.02), and had more blood transfusions (OR = 2.35, CI: 1.51–3.65, p = 0.0001). Our data on AAT association with laboratory indices of hemolysis and inflammation suggest that it may be positively associated with SCD severity; the negative correlations with renal parameters suggest a cytoprotective mechanism in SCD patients. In summary, AAT may need to be included in studies related to SCD and in the discussion of further therapeutic strategies.

Déficit de Alfa-1-antitripsina y su tratamiento

Alpha-1 antitrypsin deficiency (AATD) is a genetic disorder caused by a mutation in the codifying gene for the alpha-1 antitrypsin (AAT) protein, which has anti-elastase activity. While there is extensive genetic variability, the most common genotypes associated with AATD are PI*Z y PI*S. Most clinical manifestations are pulmonary (i.e. emphysema) and hepatic, though other pathologies, such as panniculitis and Wegener’s granulomatosis, can also present with this disorder. To date, there is no cure for AATD, and treatment options are focused on reducing the frequency of exacerbations and relieving symptoms; among these, augmentation therapy,&#x0D; which raises AAT levels through serum injections of the protein to correct the deficit, has been the most effective. Novel findings of this therapy are discussed, along with research efforts that explore new treatment options based on gene therapy or the use of protein chaperones, for instance. In Chile, no epidemiological studies on AATD have been conducted, so it is unknown exactly how many individuals are affected or if they receive adequate treatment.

Alpha-1 antitrypsin augmentation therapy decreases miR-199a-5p, miR-598 and miR-320a expression in monocytes via inhibition of NF\u03baB

Alpha-1 antitrypsin (AAT) augmentation therapy involves infusion of plasma-purified AAT to AAT deficient individuals. Whether treatment affects microRNA expression has not been investigated. This study’s objectives were to evaluate the effect of AAT augmentation therapy on altered miRNA expression in monocytes and investigate the mechanism. Monocytes were isolated from non-AAT deficient (MM) and AAT deficient (ZZ) individuals, and ZZs receiving AAT. mRNA (qRT-PCR, microarray), miRNA (miRNA profiling, qRT-PCR), and protein (western blotting) analyses were performed. Twenty one miRNAs were differentially expressed 3-fold between ZZs and MMs. miRNA validation studies demonstrated that in ZZ monocytes receiving AAT levels of miR-199a-5p, miR-598 and miR-320a, which are predicted to be regulated by NFκB, were restored to levels similar to MMs. Validated targets co-regulated by these miRNAs were reciprocally increased in ZZs receiving AAT in vivo and in vitro. Expression of these miRNAs could be increased in ZZ monocytes treated ex vivo with an NFκB agonist and decreased by NFκB inhibition. p50 and p65 mRNA and protein were significantly lower in ZZs receiving AAT than untreated ZZs. AAT augmentation therapy inhibits NFκB and decreases miR-199a-5p, miR-598 and miR-320a in ZZ monocytes. These NFκB-inhibitory properties may contribute to the anti-inflammatory effects of AAT augmentation therapy.

Noninvasive Resolution of Vanishing Lung Syndrome

SESSION TITLE: Obstructive Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Vanishing lung syndrome, also known as idiopathic giant bullous emphysema, is defined by large bullae that occupy at least one third of the hemi thorax with resultant compression of surrounding lung parenchyma. Rarely do the bullae resolve spontaneously. We report a case of spontaneous resolution of giant bullae in a female patient with a remote smoking history and undiagnosed chronic obstructive lung disease (COPD). CASE PRESENTATION: A 75-year-old woman presented to the emergency department (ED) with a four-week history of non-productive cough and one-week of progressive dyspnea. Medical history included NASH-cirrhosis, hepatocellular carcinoma, and tobacco use. The patient had a 46 pack-year smoking history however quit 19 years prior to presentation. The patient recently underwent trans arterial chemoembolization (TACE) and ablation of a residual hepatocellular tumor on the liver. In the ED, pulse oximetry was 93 % breathing ambient air. Computed tomography (CT) of the chest confirmed interval development of large bullae and severe volume loss of the left lung without pneumothorax as well as emphysematous changes throughout the right lung (Figure 1) when compared with CT from two months prior. Patient was admitted to the hospital for further monitoring. Pulse oximetry was measured during ambulation, oxygen level dropped to 83% while breathing ambient air. Supplemental oxygen was supplied along with antitussives, oral steroids, azithromycin, nebulized albuterol and ipratropium. Home oxygen, albuterol, fluticasone-salmeterol inhalers and antitussives were prescribed upon discharge. Two months later, follow-up CT of the chest revealed almost complete resolution of the bullae (Figure 2). The patient’s symptoms were much improved and she no longer required supplemental oxygen. DISCUSSION: Vanishing lung syndrome primarily affects the upper lung lobes, and is more prevalent in young males who are heavy smokers and in those with alpha-1 antitrypsin (A1AT) deficiency. These giant bullae are usually persistent and often require lung-volume reduction surgery or bullectomy. In this case, bullae were attributed to persistent coughing (possibly related to recent TACE/ablation procedure) - this is rare. There was no pneumothorax or infection. The patient tested negative for connective tissue disorders and A1AT level was normal. She had no environmental exposures such as coal mining, gold mining or to cotton textile dust. Resolution occurred with symptom control and administration of bronchodilators. CONCLUSIONS: Spontaneous resolution of giant bullae is rare, even more so in females. Intensifying bronchodilator therapy and symptom control should be attempted before invasive procedures are considered. Reference #1: Ladizinski, B. and Sankey, C. N Engl J Med. 2014; 370:e14 February 27, 2014 Reference #2: Byrd, R.P. and Roy, T.M. Austin J Pulm Respir Mws. 2014;1(4):1017 Reference #3: Sharma N., Justaniah A.M., Kanne J.P., Gurney J.W., and Mohammad T.L. J Thoracic Imaging. 2009 Aug;24(3):227-30 DISCLOSURE: The following authors have nothing to disclose: Stephanie Cull, Garrett Rampon, Abhishek Krishna, Setu Patolia No Product/Research Disclosure Information

Diffuse Large B-Cell Lymphoma Presenting as Acute Pancreatitis and Mediastinal Mass

SESSION TITLE: Disorders of the Mediastinum 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acute pancreatitis is an extremely rare presentation of diffuse large B-cell lymphoma (DLBCL). We present the case of a 19 year old female with recurrent pancreatitis secondary to DLBCL. CASE PRESENTATION: A 19 year old female with a prior history of cholecystectomy and no alcohol use presented to the emergency department with epigastric pain and vomiting. She had recently been admitted twice for acute pancreatitis with no etiology identified. Lipase was 3,334 U/L (normal 23-300 U/L). Ultrasound showed no biliary duct dilation. Magnetic resonance cholangiopancreatography five days prior had shown pancreatic edema but no common bile duct obstruction. A CT had shown only pancreatic edema. Extensive workup for the etiology of her pancreatitis was done: calcium, triglycerides, hepatitis panel, EBV, CMV and HIV serology, alpha-1 antitrypsin, ANA, and IgG4 levels were normal. On review of systems, she had a one-month history of dry cough and dyspnea on exertion. Chest X-ray revealed a right upper lobe (RUL) infiltrate. CT chest/abdomen/pelvis was done and showed a 13 x 3.4 cm mediastinal mass (Fig. 1) causing compression of the superior vena cava and RUL bronchus, right hilar adenopathy, and pericardial and bilateral pleural effusions. The pancreas was diffusely swollen with peripancreatic induration and retroperitoneal adenopathy. Pathology from CT-guided biopsy of the mediastinal mass revealed DLBCL. She was treated with 6 cycles of R-CHOP and has been in remission for five years with no further episodes of pancreatitis. DISCUSSION: Primary pancreatic lymphoma often presents as pancreatitis, but it is very rare for DLBCL to present as acute pancreatitis from secondary involvement of the pancreas. Our case is even more unusual as there was no discrete pancreatic mass on imaging. To our knowledge, only two other cases of DLBCL involving the pancreas have been reported in which there was no discrete mass1,2. Notably, in all cases reported in the literature, imaging has demonstrated either lymphadenopathy or masses involving other organs in addition to the pancreas. Therefore, these findings should raise suspicion for malignant etiologies in the patient with otherwise routine-appearing pancreatitis. Our case demonstrates the value of repeat imaging upon recurrent episodes of pancreatitis when no etiology has been found, as her lymphadenopathy and masses did not appear on initial imaging. CONCLUSIONS: Lymphoma must be considered in the differential diagnosis of acute pancreatitis after the usual causes are excluded. Repeat imaging is valuable in cases of recurrent pancreatitis of unknown etiology since new findings may develop rapidly and lead to the diagnosis. Reference #1: To C, et. al. Masquerade without a mass: an unusal cause of severe acute pancreatitis. J Gastrointest Oncol 2013;4(1):114-117. Reference #2: Saif M, et al. Secondary pancreatic involvement by a diffuse large B-cell lymphoma presenting as acute pancreatitis. World J Gastroenterol 2007;13(36):4909-4911. DISCLOSURE: The following authors have nothing to disclose: Zachary Wolfe, Lydia Winnicka, Bradley Lash No Product/Research Disclosure Information

Alpha-1 Antitrypsin-Deficient Macrophages Have Increased Matriptase-Mediated Proteolytic Activity.

Alpha-1 antitrypsin (AAT) deficiency-associated emphysema is largely attributed to insufficient inhibition of neutrophil elastase released from neutrophils. Correcting AAT levels using augmentation therapy only slows disease progression, and that suggests a more complex process of lung destruction. Because alveolar macrophages (Mɸ) express AAT, we propose that the expression and intracellular accumulation of mutated Z-AAT (the most common mutation) compromises Mɸ function and contributes to emphysema development. Extracellular matrix (ECM) degradation is a hallmark of emphysema pathology. In this study, Mɸ from individuals with Z-AAT (Z-Mɸ) have greater proteolytic activity on ECM than do normal Mɸ. This abnormal Z-Mɸ activity is not abrogated by supplementation with exogenous AAT and is likely the result of cellular dysfunction induced by intracellular accumulation of Z-AAT. Using pharmacologic inhibitors, we show that several classes of proteases are involved in matrix degradation by Z-Mɸ. Importantly, compared with normal Mɸ, the membrane-bound serine protease, matriptase, is present in Z-Mɸ at higher levels and contributes to their proteolytic activity on ECM. In addition, we identified matrix metalloproteinase (MMP)-14, a membrane-anchored metalloproteinase, as a novel substrate for matriptase, and showed that matriptase regulates the levels of MMP-14 on the cell surface. Thus, high levels of matriptase may contribute to increased ECM degradation by Z-Mɸ, both directly and through MMP-14 activation. In summary, the expression of Z-AAT in Mɸ confers increased proteolytic activity on ECM. This proteolytic activity is not rescued by exogenous AAT supplementation and could thus contribute to augmentation resistance in AAT deficiency-associated emphysema.

Disturbed Inflammatory/Anti-inflammatory Milieu and Activation of Primary Phase Reactants may Underlie Development and Recurrence of First trimester Pregnancy Loss.

Objective: Estimation of serum levels of tumor necrosis factor-a (TNF-a), interleukin (IL-) 6 and 10 and alpha-1 antitrypsin (AAT) in pregnant women with current pregnancy loss (CPL) and non-pregnant women with history of recurrent PL (RPL) compared versus women with normal pregnancy (NP).Patients & Methods: All studied women underwent clinical and vaginal ultrasonographic examination for assurance of inclusion criteria and then gave blood samples for ELISA estimation of studied parameters.Results: Patients of CPL and RPL groups showed significantly high serum TNF-a and IL-6 levels with significantly lower serum IL-10 levels than women of NP group with significant difference between CPL and RPL groups. Serum AAT levels were significantly lower in CPL group than RPL and NP groups with significantly lower levels in RPL than NP group. High serum TNF-a and low AAT levels showed high positive predictive value (PPV) and sensitivity, respectively, for possibility of presence or recurrence of PLConclusion: Disturbed serum levels of pro- and anti-inflammatory cytokines could diagnose CPL with high PPV and persistence of their disturbed levels may predispose to RPL. Activation of primary phase reactant system may underlie, accompany or initiate PL, so low serum AAT during 1st trimester and its persistently low serum levels during inter-pregnancy intervals could be used as screening test for presence or liability for development of PL.

PROTEIN-LOSING ENTEROPATHY AFTER INFECTIOUS ENTEROCOLITIS IN CHILD – A CASE REPORT AND A REVIEW OF THE LITERATURE

Protein-losing enteropathy (PLE) represents an abnormal protein loss at the level of the digestive tract mucosa, being in most of the cases secondary to other gastrointestinal or extraintestinal pathologies. Nevertheless, there also are primary causes, genetic ones associated with PLE. We present the case of a small female child, 1 year and 1 month-old, with a history of infectious enterocolitis determined by Escherichia coli enteropathogenic, who presented palpebral edemas, especially in the morning for approximately 1 week. The laboratory tests revealed hypoalbuminemia, type A and G hypogammaglobulinemia, leukocytosis with eosinophilia, and anemia. The test for the detection of occult hemorrhages from feces was positive, likewise the fecal calprotectin and level of alpha-1 antitrypsin. We identified also allergy to cow’s milk protein, which we interpreted as being secondary to the intestinal pathology. Thus, we established the diagnosis of protein losing enteropathy after an episode of acute enterocolitis caused by E. coli enteropathogenic, and we administered substitutive treatment with human albumin and steroids, with favorable evolution. The particularity of the case consists in diagnosing a severe case of protein-losing enteropathy in a small child, with palpebral edema, predominantly during the morning, and decreased levels of serum albumin, after an episode of acute enterocolitis caused by E. coli enteropathogenic, which remitted without etiologic treatment.

Association of elevated alpha-1 antitrypsin with advanced clinicopathologic features of hepatocellular carcinoma.

289 Background: Alpha-1 Antitrypsin (A1AT) is a circulating liver derived protease inhibitor. There is an evolving evidence that elevated level of A1AT stimulate tumor cell proliferation, and invasion in different cancers. Despite A1AT well-known involvement in hepatic fibrosis, its role in hepatocellular carcinoma (HCC) pathogenesis is not well characterized. The current study aimed to investigate the association between A1AT and clinicopathologic features and prognosis of patients with HCC. Methods: Between 2001 and 2014, total of 766 HCC patients from MD Anderson Cancer Center were enrolled. Under IRB approval, baseline patients’ clinical characteristics were retrieved from medical records. The normal level of plasma A1AT was defined based on the Mayo clinic reference value (1 – 1.9 mg/ml). Survival analysis included Kaplan Meier statistic and Cox regression analysis. Multivariate Hazard Ratio (HR) and 95% Confidence interval (CI) were estimated to determine the independent effect of A1AT on HCC prognosis. Results: The mean and standard deviation of plasma A1AT level was 2.7 ± 0.98 mg/mL. All patients were categorized into 2 groups: group 1 (N = 156) with normal serum level ( ≤ 1.9) and group 2 (N = 610) with higher values ( &gt; 1.9). Median survival (months), 95% CI were 24.4 (18.02 – 30.7) and 11.6 (9.6 – 13.6) in group 1 and 2 respectively, (P &lt; .0001). Patients in group 2 experienced poor clinical characteristics than group 1. The estimated multivariate HR (95% CI) for A1AT is 1.4 (1.1 – 1.7) after adjustment for age, sex, race, cirrhosis, AFP, TNM staging, and treatment exposure. Conclusions: High plasma level of A1AT is associated with higher α-feto protein, advanced TNM and Barcelona clinic liver cancer (BCLC) staging and poor survival of HCC patients. Recent preliminary studies suggested that changes in glycosylaion of production of A1AT by HCC cells correlates with the microenvironment inflammatory and proteolytic activities, which are probably linked to advanced clinicopathologic features and poorer survival. Future excremental studies are warranted to understand the mechanistic pathways of potential A1AT involvement in HCC initiation and progression.

State-of-the-art testing for alpha-1 antitrypsin deficiency

Alpha-1 antitrypsin deficiency (AATD) is a genetic condition characterized by low serum levels of the protein alpha-1 antitrypsin. Because there are no unique clinical symptoms that point to a definitive diagnosis of AATD, laboratory testing is crucial to differentiate this disease from others. To summarize advances in laboratory techniques used to test for AATD. Data were sourced from a nonsystematic literature review of MEDLINE and the author's personal literature collection, and by checking reference lists of sourced articles. Since the original description of AATD by Laurell and Eriksson in 1963, testing methods have undergone major changes. Currently, alpha-1 antitrypsin protein is quantified by immunologic measurement in serum, and the phenotype is characterized by isoelectric focusing and/or targeted genotyping of predefined mutations. In addition, whole-gene sequencing of the gene SERPINA1 can be undertaken. However, this is costly and generally used only if targeted genotyping cannot conclusively identify the variant. The introduction of next-generation sequencing (NGS), which enables rapid and accurate sequencing of large quantities of DNA fragments in a single reaction, may help reduce costs. With its increasing availability, NGS may begin to appear in testing protocols. Clinical guidelines recommend that patients are tested for AATD if they have chronic irreversible airflow obstruction, especially those with early onset disease or a positive family history of AATD. Despite this, AATD is still underrecognized, and significant delays exist between symptom onset and diagnosis. Traditional testing practices have limitations. Screening programs that incorporate NGS are the most comprehensive methods available for accurate diagnosis of AATD.