Prolonged Immunosuppressive Therapy Research Articles

Paroxysmal Cold Hemoglobinuria: Mild to Catastrophic-Spectrum of a Rare Hemolytic Anemia of Childhood.

Paroxysmal cold hemoglobinuria (PCH) is among the rarest forms of autoimmune hemolytic anemia, most often seen in young children. PCH is caused by a biphasic immunoglobulin G antibody that binds to red cells at low temperatures and causes complement-mediated lysis as the temperature is raised. Diagnosis is based on high clinical suspicion followed by confirmation of the presence of Donath-Landsteiner antibodies. We have described 3 cases diagnosed with PCH over a span of 1 year, 2 cases presented with acute kidney injury with variable severity and needed hemodialysis. Another case showed prompt recovery with supportive treatment, suggesting variable severity of PCH. This report intends to generate awareness of this rare condition which is often misdiagnosed as nonspecific autoimmune hemolytic anemia and leads to unnecessary prolonged immunosuppressive therapy. It also emphasizes the rare possibility of the need for prompt renal replacement therapy in an otherwise benign self-limiting disorder.

Activation of the inflammasome and pyroptosis cascade in podocytes of patients with minimal change disease.

In contrast to childhood minimal change disease (MCD), adult-onset MCD frequently recurs and requires prolonged immunosuppressive therapy. Accordingly, an investigation of the pathogenesis of adult MCD is required. MCD is usually accompanied by severe dyslipidaemia. Oxidized low-density lipoprotein (ox-LDL) is known to function in a damage-associated molecular pattern (DAMP) through CD36, triggering the NOD-like receptor thermal protein domain-associated protein 3 (NLRP3) inflammasome and programmed cell death called pyroptosis. However, the relationship between MCD pathogenesis and NLRP3 inflammasome/pyroptosis activation via CD36 is not fully understood. We conducted comprehensive histological and clinical evaluations by analysing renal biopsy (RBx) specimens and urine samples obtained from 26 patients with MCD. These samples were compared with control kidneys from 15 transplant donors and urine samples from 15 healthy volunteers. The number of podocytes was lower in the MCD group than in the control group. Urinary ox-LDL levels were higher in the MCD group than in the control group. Immunofluorescence staining revealed that NLRP3 and CD36 were upregulated in MCD podocytes. Urinary interleukin (IL)-18 levels increased in patients with MCD. Steroid therapy performed before RBx appeared to maintain the podocyte number and reduce urinary ox-LDL and IL-18 levels. In MCD, the NLRP3 inflammasome and pyroptosis cascade seem to be activated via upregulation of CD36 in podocytes, associated with increased urinary ox-LDL. Elevated urinary IL-18 levels suggest that pyroptosis may occur in MCD. Further research is required to confirm the significance of the podocyte NLRP3 inflammasome/pyroptosis in MCD.

Study protocol for a randomised, phase II, double-blind, experimental medicine study of obinutuzumab versus rituximab in ANCA-associated vasculitis: ObiVas

IntroductionRelapses in ANCA-associated vasculitis (AAV) increase the incidence of end-organ damage and their prevention requires prolonged immunosuppressive therapy. Rituximab, a type I anti-CD20 B cell depleting monoclonal antibody, is the...

A Case of Disseminated Cryptococcus in an HIV-Positive Patient

A 69-year-old male with a history of untreated Human Immunodeficiency Virus (HIV) was admitted to the emergency department for symptoms such as cough, shortness of breath, lethargy, and weight loss. His physical examination revealed severe wasting, oral thrush, and hypoxia. Chest imaging revealed cavitary lesions and blood work showed an absolute CD4 count of 23 cells/mm3. An IR-guided biopsy revealed abundant necrosis and scattered narrow-based fungal organisms consistent with Cryptococcus neoformans infection. The patient was treated with liposomal amphotericin B and flucytosine. Due to the increased risk of Immune Reconstitution Inflammatory Syndrome (IRIS), HIV treatment was deferred. The patient deteriorated, transitioned to comfort care, and unfortunately expired. INTRODUCTION Cryptococcus neoformans is a ubiquitous environmental yeast and a leading cause of invasive fungal infection in humans with significant morbidity and mortality that affects both immunocompetent and immune-compromised hosts.1,2 Globally, there are approximately 1 million cases of AIDS-related cryptococcosis each year, leading to over 600,000 deaths. This represents a prevalence of 6.0% (95% CI 5.8–6.2) among people with a CD4 cell count of less than 100 cells per uL.2 The transmission mode is by inhalation of microscopic fungus (desiccated yeast or spores). Immunosuppression is the strongest risk factor for disease development, including HIV infection, stem cell and solid organ transplantation, prolonged immunosuppressive therapy, invasive medical procedures, hematological malignancies, advanced age, and prematurity.1,2,3 Treatment usually involves a fungicidal regimen of IV liposomal amphotericin B, plus flucytosine followed by oral fluconazole.4,5 Overall, 90-day all-cause mortality in patients with cryptococcal infection is 19.4%. Mortality rates are significantly higher in HIV/transplant patients at 90 days (41.7% versus 8.3%, p = 0.017) and one year (41.7% versus 12.5%, p = 0.047).6,7 This case describes a 69-year-old HIV-positive patient who presented with multisystemic manifestations and cavitary lung lesions with blood and cerebrospinal fluid (CSF) findings of cryptococcal antigen and positive fungal culture and lung biopsy confirmation of Cryptococcus.

A burning heart: combined therapy of checkpoint-inhibitors and prednisolone in a patient with sarcoidosis

Patients with prior autoimmune diseases such as sarcoidosis require special care when treated with checkpoint inhibitors (CPIs), given the risk for reactivation of inflammation. Here, we address the clinical dilemma of initiating CPIs for recurrent metastatic carcinoma in a patient with extensive sarcoidosis, controlled after prolonged immunosuppressive therapy when the tumor recurrence was detected. To achieve the best possible outcome, the case was discussed by an interdisciplinary team comprising specialists in rheumatology, oncology, and CPI-related myocarditis. Literature on this topic was very limited. Based on the pharmacodynamics of CPIs and the pathophysiology of CPI-related autoimmune diseases, we concluded that initiating CPIs alongside low-dose prednisolone would effectively suppress any reactivation of sarcoidosis without interfering with CPIs in a relevant way.

Acquired Hemophilia A Diagnosed Based on Gross Hematuria: A Case Report and Literature Review

Acquired hemophilia A (AHA) is an acquired bleeding disorder caused by neutralizing antibodies (inhibitors) against Coagulation Factor VIII (FVIII:C), causing sudden hemorrhagic symptoms (i.e., subcutaneous bleeding, intramuscular bleeding, and hematuria). Herein, this study is aimed at presenting a case of AHA diagnosed based on hematuria and reviewing patients who were diagnosed with AHA due to hematuria. A 67‐year‐old woman was referred to Atsugi City Hospital with painless gross hematuria that began 4 weeks before presentation. Contrast‐enhanced computed tomography (eCT) revealed an approximately 2 cm mass in the right renal pelvis, and the patient’s activated partial thromboplastin time (APTT) was elevated (61.4 s). The day after the endoscopic biopsy, the patient was in shock due to a large retroperitoneal hematoma. Although her condition stabilized after intravenous radioembolization, she underwent emergency surgeries several times because of rebleeding within the next 3 weeks. At that time, APTT was more prolonged at 106.4 s, and the FVIII:C level was 2%. Mixing tests showed an upwardly convex curve after 2‐h incubation, indicating the presence of an inhibitor. Factor VIII inhibitor titer was ≥5.1 Bethesda unit (BU)/mL. A combined product of Plasma‐Derived Factors VIIa and X (pd‐FVIIa/FX), as second‐line hemostatic therapy, as well as cyclophosphamide (CYP), were administered after Recombinant Activated Factor VIIa (rFVIIa) had been ineffective. Following this, the Factor VIII inhibitor titer was undetectable, FVIII:C levels were restored, and APTT decreased to within the normal range. Gross hematuria was significantly alleviated. However, the patient died of cytomegalovirus and fungal infections due to prolonged immunosuppressive therapy. Although AHA diagnosed based on hematuria may have a better prognosis than others, there have been occasional cases with severe outcomes. APTT, detected upon initial hematological testing in patients with hematuria, may be a potential indicator of an existing AHA.

The Evaluation and Management of Coronary Artery Disease in the Lung Transplant Patient.

Lung transplantation can greatly improve quality of life and extend survival in those with end-stage lung disease. In order to derive the maximal benefit from such a procedure, patients must be carefully selected and be otherwise healthy enough to survive a high-risk surgery and sometimes prolonged immunosuppressive therapy following surgery. Patients therefore must be critically assessed prior to being listed for transplantation with close attention paid towards assessment of cardiovascular health and operative risk. One of the biggest dictators of this is coronary artery disease. In this review article, we discuss the assessment and management of coronary artery disease in the potential lung transplant candidate.

Long-term efficacy of tailored prolonged immunosuppressive therapy in biopsy-proven virus- negative myocarditis: a single center propensity weighted study

Abstract Background The efficacy of immunosuppressive therapy (IT) in biopsy-proven (BP) myocarditis was proved by small trials in lymphocytic myocarditis with heart failure (HF) presentation. Aim To evaluate the efficacy of IT in a single center cohort of BP myocarditis patients, irrespective of histological type and clinical presentation. Methods Consecutive BP myocarditis patients were included and, in the absence of contraindications, were treated with IT according to current guidelines on top of standard care. IT patients were compared with a propensity score-weighted control group of non-IT patients, considering age, gender, ejection fraction (EF), NYHA class and histological type (Fig. 1A). The primary outcome was a composite of death or heart transplant (HTx), and the secondary outcome a composite of variation of biventricular function, NYHA class and myocarditis relapse. Results 87 IT patients were compared with 265 without IT. IT patients were older (44 vs 39 years, p=0.035), and more frequently had a systemic immune-mediated disease (34% vs 10%, p<0.001), and HF (59% vs 46%, p=0.048) or fulminant presentation (9% vs 2 %, p=0.002). IT patients had lower baseline left ventricular (LV) EF both on echocardiography (35±15% vs 43±15%, p=0.001) and cardiac magnetic resonance (26±16 % vs 45.5±15 %, p=0.0013), lower right ventricular (RV) fractional area change (FAC: 34±11 % vs 41±11 %, p<0.001) and higher frequency of lymphocytic, eosinophilic and giant cell myocarditis (71% vs 58%, 11% vs 1 %, and 7% vs 2%, p<0.001 respectively) compared to non IT patients. IT was indicated because of unremitting HF (62%) and recurrent chest pain (14%), and mainly involved prednisone (PDN) and azathioprine as first-line (61%) and PDN and mycophenolate mofetil as second-line therapy (62%). IT lasted on average 24 months. No difference was observed in the primary outcome between the two groups (5 years survival 88% in IT vs 91% in non-IT patients, p=0.8, Fig. 1B), while relapse incidence was higher in IT patients (p<0.001, Fig.2B). At long-term follow up (54 months, IQR 21.4-96.45), LVEF and RV FAC were within the normal range in both groups, and propensity score weighting analysis showed that IT patients presented LVEF values of only 3% lower than non-IT (p=0.013, Fig. 2). In addition, IT patients had a similar probability of presenting the same NYHA class as non-IT patients at last follow up (p=0.46). Conclusions Our study shows for the first time the efficacy of prolonged tailored IT in BP lymphocytic and non lymphocytic autoimmune myocarditis, with or without HF and with or without RV dysfunction. IT patients, despite having lower biventricular function and a higher risk profile at baseline as well as a higher frequency of relapses, at long-term follow up showed normalized biventricular function and a similar survival compared to their propensity-score weighted controls. Thus, autoimmune myocarditis responds to IT, even when the disease relapses.Figure 1.Figure 2.

Descent into Mania: A Case of Tacrolimus-Induced Psychosis

Background: Tacrolimus has historically been used as an effective immunosuppressant in solid organ transplants. Although it is standard care in most organ transplants, it is accompanied by a vast number of side effects, including headache, fatigue, and even psychosis. The neurotoxic side effects that accompany tacrolimus are usually apparent at supratherapeutic doses and resolve after dose adjustment or discontinuation. Case Presentation: We present a case of a 68-year-old male who sustained tacrolimus-induced mania post- transplant, refractory to both medication tapering and removal. He ultimately required the use of prolonged antipsychotic therapy. Conclusion: This study highlights the necessity for thorough psychiatric evaluations in patients undergoing organ transplantation as well as the continued need for further research and interventions in patients undergoing prolonged immunosuppressive therapy. This report may signify a novel mechanism of dose-independent neurotoxicity secondary to tacrolimus.

Invasive fungal infection in ANCA-associated vasculitis: Between the Devil and Deep blue sea. Case series and review of the literature.

Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are susceptible to opportunistic infections, including invasive fungal infections (IFI). This is due to many factors, including prolonged immunosuppressive therapy. The treatment of AAV with such IFIs is challenging. A descriptive analysis of 5 patients with AAV complicated by concomitant invasive fungal infections was performed. We also have done a comprehensive literature review of IFIs in AAV using PubMed and Google Scholar databases. All 5 patients initially received immunosuppressive medication but subsequently acquired IFI. One patient had sphenoid sinus involvement, and four had lung parenchymal involvement. Aspergillus infection was diagnosed in three patients, Cryptococcus infection in one patient and mixed infection with Aspergillus and Mucor infection in one patient. All our patients were on low doses of corticosteroids for several months to years or had received high-dose pulse steroids with cyclophosphamide in the last few weeks before being diagnosed with IFI. It was difficult to distinguish disease activity from IFI in all the cases. Two of the five patients died despite antifungal therapy. The literature review revealed a prevalence of IFIs ranging from 1 to 9.6% (excluding pneumocystis pneumonia). Aspergillosis was the predominant type of IFI, affecting 46 of 86 patients. Most of these patients (40/46) had pulmonary involvement. The prognosis for patients with IFI was consistently poor, as evidenced by 19 deaths out of 29 reported outcomes. Overall, IFIs have a poor prognosis in patients with AAV. Differentiating disease activity from IFI is difficult because of similar organ distribution, imaging lesions, and histopathological characteristics. A high suspicion index and good-quality microbiology are needed for early treatment and prevention of mortality.

Generalized edema as presenting feature of anti-NXP2 positive Juvenile dermatomyositis: A case report and review of literature

Juvenile Dermatomyositis (JDM) is a rare childhood inflammatory disease. Clinical manifestations include muscle weakness and skin rashes. However, generalized edema is uncommon in JDM. Treatment is based on prolonged immunosuppressive therapy. Only few case reports of edematous JDM has been described. Here we aim to describe a case of edematous JDM with review of literature.

Generalized actinomycosis of the pelvic organs. Clinical case

Here, a clinical case of generalized actinomycosis of the pelvic organs occuring very rarely usually observed in immunocompromised patients is presented. Patient T. referred to the women's clinic with complaints of prolonged genital discharge, itching, burning, and occasional sub-fever. The patient had a history of prolonged hormonal immunosuppressive therapy. After a thorough examination, the patient was consulted by two oncologists. Preliminary diagnosis: suspicio cancer coli; suspicio cancer vaginae. In order to clarify the diagnosis, an in-hospital multifocal scalpel biopsy was performed. The biological material obtained was sent out for intravital pathological and anatomical examination; no signs of malignancy were found. To prevent complications during surgery, the patient underwent separate diagnostic scraping of the uterine cavity and cervical canal after repeated sanitation of the vagina and additional patient examination; hysteroscopy; vulval biopsy; colpocentesis. The final diagnosis was made after obtaining the results of in-surgery microbial culture on nutrient media. Active growth of actinomycetes was detected in the material obtained. The final clinical diagnosis was pelvic actinomycosis, generalized form. Patient T was discharged in satisfactory condition after antibacterial treatment according to the diagnosis for further under gynecologist observation at the women's clinic.

Performance of high-frequency ultrasound in the evaluation of skin involvement in cutaneous chronic graft-versus-host disease: A preliminary report

To the Editor: Cutaneous chronic graft-versus-host disease (cGVHD) is the most frequent manifestation of cGVHD, developing a few months/years after allogeneic hematopoietic stem cell transplants. Cutaneous cGVHD can be clinically classified as sclerotic or nonsclerotic. Sclerotic manifestations are commonly observed during the late phase of cGVHD, inducing significant morbidity, functional impairment, and prolonged immunosuppressive therapy.1 An objective, noninvasive, and early detection of skin sclerodermatous changes is essential for preventing the irreversible sequela and for monitoring treatment response.

Predictors and outcomes of flares in chronic graft-versus-host disease.

Chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic cell transplantation (HCT) requires prolonged immunosuppressive therapy (IST), often requiring slow tapering with patients experiencing cGVHD flares and treatment failure. In 145 adult recipients developing cGVHD after matched sibling or umbilical cord blood donor HCT from 2010 to 2018, 2-year cumulative incidence of flares after cGVHD diagnosis was estimated at 60% (95% CI, 51-70%), with median time-to-first flare of 188 days (range, 16-751). Of 88 patients experiencing a flare, 32 (36%) had multiple flares (range, 2-4). First flare treatment consisted of an increase in prednisone dose in 77 patients (88%), plus topical therapy in 8 (9%) or another systemic IST in 43 patients (49%). Higher flare risk was associated with quiescent type of cGVHD at onset (HR 1.8; 95% CI: 1.1-2.7; p = 0.04). Patients without a flare required a shorter duration of IST and were more likely to achieve a durable discontinuation of systemic IST (86% vs. 31% for ≥6 consecutive months). Flares were associated with protective effect on relapse (HR 0.2, 95% CI: 0.1-0.3), however not with worsened 2-year NRM or OS. Flares of cGVHD identify a group needing better approaches to limit the duration of IST and thus the morbidity of cGVHD.

The use of tacrolimus in the management of checkpoint inhibitor immunotherapy-induced hepatitis.

Immune-mediated hepatitis is recognised as a frequently occurring complication with the use of checkpoint inhibitor immunotherapy drugs. The mainstay of treatment involves the use of immunosuppressive agents, such as corticosteroids. Mycophenolate mofetil is added when steroid resistant. However, there are limited data to guide further management when the hepatitis remains refractory to these therapies. We present two patients who developed severe immunotherapy-induced hepatitis and required prolonged immunosuppressive therapy with three agents in combination before resolution was achieved. We demonstrate that the addition of tacrolimus can be successful when other drugs fail. We also illustrate how a subsequent wean off immunosuppression can be safely performed and highlight the use of concordant antimicrobial prophylaxis to mitigate against opportunistic infections.

Oral Kaposi sarcoma following cord blood transplantation.

A 50-year-old man developed acute myeloid leukemia while receiving antiretroviral therapy for human immunodeficiency virus (HIV) infection. Following three courses of chemotherapy, he received cord blood transplantation (CBT) in the first complete remission. The patient developed mild skin acute graft-versus-host disease after CBT. In addition, he developed organizing pneumonia 1 month after CBT, which responded to steroid therapy, but repeatedly relapsed during steroid tapering. Thus, he had been receiving prolonged immunosuppressive therapy. Thirteen months after CBT, bluish-red elevated lesions developed on the hard palate of the oral cavity (Figure 1A). Biopsy samples obtained from the palate lesions confirmed the diagnosis of Kaposi sarcoma (KS). His HIV viral load was undetectable, and there were no signs of leukemia relapse. To improve the immunosuppression status, immunosuppressive therapy was attenuated. This led to the increase in CD4+ count from 0.26 × 109/L to 0.68 × 109/L and regression of the KS (Figure 1B, 18 months after CBT). However, the patient succumbed to heart and kidney failure 18 months after CBT. Despite its rarity, KS should be considered as a differential diagnosis when hematopoietic stem cell transplantation recipients develop bluish-red or purple lesions. The authors declare no conflict of interest. N.I., M.A., A.I., M.M, H.N., and H.I. were involved in the management of the patient. N.I., H.N., and H.I. wrote the manuscript. N.I., M.A., and A.I. prepared the figure. All authors reviewed and approved the manuscript. Informed consent was obtained from the patient.

Two Individuals with Rare Blocked Antigen Phenomenon and Coinciding Warm Autoantibody Mimicking Alloanti-Jk3 Resolved with JK Analysis

Abstract Introduction/Objective Kidd antigens can bind complement (C3) as well as Kidd specific warm autoantibodies (WAAb). An 838G>A single nucleotide variant (SNV) defines JK*01 and JK*02 which codes the antithetical Jka and Jk b, respectively. Both alleles translate the high prevalence (>99%) Jk3 (JK3). The 130G>A is associated with weak Jka and weak Jkb expression. In vivo binding of non-agglutinating globulins can cause false-negative phenotypes by means of the blocked antigen phenomenon (BAP). Methods/Case Report Transfusions were requested for a 74-year-old Caucasian (CA) female with Evan’s Syndrome, and an 85-year-old African American (AA) female with metastatic uterine cancer. Both had a history of nonspecific WAAb. Direct antiglobulin testing (DAT) detected moderate in vivo sensitization of IgG and C3. They phenotyped Jk(a- b-) with untreated and EDTA glycine-acid (EGA) treated IgG DAT-negative cells. Their serum contained anti-Jk3 reactivity, while a panreactive WAAb in the eluate reacted with Jk3- donor and EGA treated DAT-negative autologous cells. Weak anti-Jka and anti-Jkb reactivity remained in the alloadsorbed serum of the antithetical adsorbing cells. Genetic testing of the CA revealed JK*01W.01(130A)/02 alleles, while cDNA confirmed the alleles would be transcribed into mRNA. Sequencing of the AA detected 130G/A, and 838G/A as well as other silent mutations predicting either a Jk(a+wb+) or Jk(a+b+w) phenotype. The CA received one compatible JK:-3 transfusion, and both individuals benefited from multiple least incompatible transfusions of Jk a+ and/or Jk b+ donors with expected hemoglobin increases (1 g/dL per transfusion). The CA serologically phenotyped Jk(a-b+) 132 days later following prolonged immunosuppressive therapy while a normocytic normochromic anemia and the WAAb persisted. No follow up evaluations of the AA are available. Results (if a Case Study enter NA) NA Conclusion Unexpected BAP can confound immunohematology testing and lead WAAbs mimicking alloanti-Jk3 to be mischaracterized as allogeneic. By predicting phenotypes, genetic analysis can aid serological techniques in antibody characterization and help circumvent complications searching for rare JK:-3 donors.

Foremost Concepts in Mechanisms of De Novo Post-Liver Transplantation Malignancy

In liver transplant patients, solid tumors and post-transplant lymphoproliferative disorders (PTLD) have emerged as significant long-term mortality causes. Additionally, it is assumed that de novo malignancy (DNM) after liver transplantation (LT) is the second-leading cause of death after cardiovascular complications. Well-established risk factors for PTLD and solid tumors are calcineurin inhibitors (CNIs), tacrolimus (TAC), and cyclosporine, the cornerstones of all immunosuppressive (IS) therapies used after LT. The loss of immunocompetence facilitated by the host immune system due to prolonged IS therapy leads to cancer development, including in LT patients. Hindering DNA repair mechanisms, promoting tumor cell invasiveness, and hampering apoptosis are critical events in tumorigenesis and tumor growth in LT patients resulting from IS administration. This paper aims to overview the refined mechanisms of IS-induced tumorigenesis after LT and the loss of immunocompetence facilitated by the host immune system due to prolonged IS therapy. In addition, we also discuss in detail the mechanisms of action in different types of IS regimen used after LT, and their putative effect on DNM.

AB0411 CHALLENGES IN THE MANAGEMENT OF MIXED CONNECTIVE TISSUE DISEASE: A RETROSPECTIVE ANALYSIS OF THE MCTD COHORT IN A TERTIARY REFERRAL CENTRE

Background:As a rare, complex, and heterogeneous disease, mixed connective tissue disease (MCTD) represents a challenge for clinical practice.Objectives:We aimed to unravel potential pitfalls including correct referral diagnosis, fulfilment of diagnostic criteria, distinction from other CTDs, disease course and activity, and treatment modalities.Methods:We analysed the prospectively collected MCTD cohort at our tertiary referral centre. The patients’ medical histories were investigated for fulfilment of Sharp’s (1), Kasukawa’s (2), and Alarcón-Segovia’s (3) diagnostic MCTD criteria. We defined overlap syndromes as simultaneous fulfilment of clinical as well as immunological criteria of two defined rheumatic diseases. Disease conversion was defined as emergence of new symptoms and autoantibodies consistent with another rheumatic disease. Remission was defined by simultaneous systemic lupus erythematosus disease activity index 2000 (SLEDAI-2 K) of 0 and European League Against Rheumatism scleroderma trial and research (EUSTAR) activity index <2.5. Disease phenotype and disease activity were monitored over time and all patients were evaluated for fulfilment of classification criteria of various connective tissue diseases.Results:Out of 85 patients initially referred as MCTD, only one third fulfilled the diagnostic MCTD criteria. Most of the remaining patients had undifferentiated CTD (29%) or overlap syndromes (20%). In our final cohort of 33 MCTD patients, 6 (48%) also met the classification criteria of systemic sclerosis, 13 (39%) those of systemic lupus erythematosus (SLE), 6 (18%) those of rheumatoid arthritis, and 3 (9%) those of primary myositis. Over the median observation period of 4.6 (1.6, 9.9) years, only two patients (6%) underwent disease conversion from MCTD to SLE and no patient converted towards other diseases. The number of patients in remission increased from 6 (18%) to 15 (45%) due to introduction of immune modulatory treatment. Combination therapy was favoured in most cases (17 patients, 52%), whereas monotherapy was less frequent (12 patients, 36%), and only 4 (12%) patients remained without immune modulators until the end of the follow-up period. Hydroxychloroquine, prednisone, and methotrexate were the most frequently used medications in our cohort.Conclusion:Our study showed a high risk for misdiagnosis for patients with MCTD. Phenotype conversion was a very rare event. As a multi-organ disease, MCTD required prolonged (combined) immunosuppressive therapy to achieve remission. The establishment of an international registry with longitudinal data from observational multi-centre cohorts might represent a first step to address the many unmet needs of MCTD.

Interaction of tacrolimus through hedgehog signaling pathway: An in vitro evaluation using rat hepatocytes.

Tacrolimus (TAC) is the drug of choice in immunosuppressive therapy for organ transplantation; however, adverse effects are still a major concern. The current study aims to decipher the short-term exposure of TAC on rat hepatocytes in relation to activation of hedgehog (HH) signaling pathway. Time dependent study was conducted using primary rat hepatocytes treated with TAC (36 µM) for 6, 12, 24 and 48 h. Western blot analysis was performed using cell lysate in order to analyze the regulation of HH pathway proteins including HHIP, SMO, PTCH, IHH, SHH, and GLI transcription factors. The study revealed change in protein expression of HH signaling molecules with activation of HH pathway, due to downregulation of HHIP, and enrichment of HH ligands with activation of SMO and GLI transcription factors. It is therefore, concluded that short term TAC exposure leads to upregulation of HH pathway in liver, which may initially act to repair the liver damage but can worsen the condition in case of prolonged immunosuppressive therapy. This insight could lead to understand association of off target effects of immunosuppressive drugs and occurrence of other liver diseases in transplant patients when it comes to long term immunosuppressive therapy. These findings also illuminate a novel direction that use of HH inhibitor might provide a therapeutic strategy for immune suppression related liver disorders.