FACTORS ASSOCIATED WITH ADHERENCE TO ANTI TNF-Α THERAPY DURING THE COVID-19 PANDEMIC IN PATIENTS WITH RHEUMATOID ARTHRITIS

BackgroundRheumatoid Arthritis (RA) patients are effectively treated with anti-TNF-α therapy. However, pharmacological non-adherence limits the achievement of the therapeutic objective. This is a multifactorial behavior where factors such as the route of administration, frequency, tolerance, perception of improvement, polypharmacy and social factors are involved [1,2].ObjectivesTo explore the factors associated with non-adherence to anti TNF-α in RA patients during the COVID-19 pandemic.MethodsThis is a cohort of RA patients treated with anti TNF-α in Medicarte SAS, a Colombian center for Immune-Mediated Diseases, between January to December 2021. The program implements strategies such as pharmacotherapeutic support, informed dispensing, phone calls, text messages and home care services to increase adherence. Adherence was defined as dispensing at least 10/12 (>0.80) prescribed monthly doses for 1 year. Sociodemographic characteristics, time in the program, DAS28-CRP, HAQ and treatment were included as exposure variables. For continuous variables, median and interquartile range (IQR) were calculated. Adjusted Odds Ratio (AOR) with logistic regression were calculated, and a p-value <0.05 was considered as statistically significant.Results565 patients were included, 85.8% (n=485) were women, median age 56 years (IQR: 49-65), disease evolution time 13.7 years (IQR: 7.7-20.8), 51% (n=288) had been in the program for more than 3 years, the median time in treatment with anti TNF-α was 3 years (IQR: 1-3) and DAS-28-CRP 2.4 (IQR: 1.6-3.4). The most frequently anti TNF-α prescribed was etanercept 46.0% (n=260), followed by adalimumab 23% (n=130), subcutaneous golimumab 13.3% (n=75), certolizumab 11.0% (n=62) and intravenous golimumab 6.7% (n=38). At the admission, 18.2% (n=103) of the patients had high activity, 38.6% (n=218) mild activity, 9.2% (n=52) low activity and 34% (n=192) were in remission. At the end of follow-up, 6.4% (n=36) of patients had high activity, 18.2% (n=103) mild activity, 14.3% (n= 81) low activity and 61.1% (n= 345) were in remission. The 51.5% (n=291) did not have pharmacological adherence. The use of etanercept (AOR 0.36 CI95% 0.23- 0.58, p < 0.001) and adequate functionality measured through HAQ (AOR 0.64 CI95% 0.42- 0.97, p < 0.04) were associated with a lower risk of non-adherence. Higher DAS28-CRP at the end of follow up was associated with non-adherence (AOR 1.29 CI95% 1.12 - 1.48, p < 0.001).ConclusionDuring COVID-19 pandemic, the implementation of strategies in the home care patient program guaranteed adherence close to 50% in our cohort. Higher values of DAS28-CRP were associated with non-adherence, whilst etanercept use and a normal HAQ value were associated with a higher probability of adherence.References[1]Marengo MF, Suarez-Almazor ME. Improving treatment adherence in patients with rheumatoid arthritis: what are the options? Int J Clin Rheumtol. 2015 Oct 1;10(5):345-356.[2]Smolen JS, Gladman D, McNeil HP, Mease PJ, Sieper J, Hojnik M, et al. Predicting adherence to therapy in rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis: a large cross-sectional study. RMD Open. 2019 Jan 11;5(1):e000585.Acknowledgements:NIL.Disclosure of InterestsWilmer Gerardo Rojas Zuleta Speakers bureau: Pfizer, Jannsen Cilag, Bristol Myers Squibb, Amgen, Eli lilly, Mario Barbosa: None declared, Oscar Jair Felipe Díaz Speakers bureau: Pfizer, Jannsen Cilag, Bristol Myers Squibb, Amgen, Eli lilly, Adelis Enrique Pantoja Marquez: None declared, Jeixa Canizales: None declared, Carolina Becerra-Arias: None declared, Jorge Hernando Donado Gómez: None declared, Natalia Duque Zapata: None declared.

RETROSPECTIVE STUDY OF VITAMIN D DEFICIENCY IN RHEUMATOLOGIC PATIENTS DURING THE COVID-19 PANDEMIC IN POLAND

BackgroundBefore the COVID-19 pandemic it was estimated that nearly 70% of the population is deficient in vitamin D - 25(OH)D <20ng/ml in Poland [1]. The percentage was expected to increase due to indoor isolation during the COVID-19 pandemic. Vitamin D has a positive effect on the condition of the bones, affects the course of autoimmune diseases, the course of neurological diseases, in type 2 diabetes, vitamin D supplementation improves glucose tolerance and reduces insulin resistance [2,3,4].ObjectivesThe aim of the retrospective study was to determine what percentage of rheumatology clinic patients suffer from vitamin D deficiency and whether this condition is effectively treated.MethodsIn January 2023, a retrospective analysis of the documentation of 172 patients treated at the Rheumatology Outpatient Clinic in Bełżyce (Poland) in 2022 was conducted.ResultsResults: The mean age of the 172 patients whose documentation was analyzed was 60.43 years (min 19, max 88). There were 132 women (76.8%) and 40 men (23.2%) in this group. The mean concentration of vitamin D was 25.57ng/ml±SD11.9 (min 5.7, max 75, Me 22.8). Vitamin D deficiency was found in 44% (serum concentration <20mg/ml), suboptimal concentration (20-30ng/ml) in 31%, optimal concentration (30-50ng/ml) in 21%, and high concentration (>50ng/ml) ml) in 4%. All those with a deficit or deficiency (75 people) were prescribed cholecalciferol in a dose of 20,000 units orally, 1 capsule twice a week after breakfast for 2 months [5]. Patients with optimal vitamin D levels were advised to take a dose of 2,000 units per day. Among the patients with deficit or deficiency, 48 people came for a follow-up visit to check the level of vitamin D (64% of the group with too low vitamin D concentration;28% of the entire group whose documentation was analyzed). In the follow-up examination, the mean concentration of vitamin D was 37.14±9.8ng/ml (min 28, max 84, Me 35.3). Therefore, a statistically significant increase in the concentration of vitamin D in the blood was noted (p<0.05). In the group of people who came for the follow-up examination, there were 35 women, whose mean age was 60.7 years and 13 men (mean age 68.2 years).Conclusion:1. During the COVID-19 pandemic in the group of outpatient rheumatology patients, 75% had a deficiency or suboptimal level of vitamin D.2. Treatment with cholecalciferol in a dose of 20,000 IU twice a week orally for 2 months is effective treatment of vitamin D deficiency.3. Too low percentage of patients diagnosed with vitamin D deficiency come for visits and check-ups.References[1]Hilger J., Friedel A., Herr R.. A systematic review of vitamin D status in populations worldwide. Br J Nutr. 2013;9: 1023.[2]Karczmarewicz E., Czekuć-Kryskiewicz E., Płudowski P. Effect of vitamin D status on pharmacological treatment efficiency-impact on cost- effective management in medicine. Dermatoendocrinology, 2013;5: 299-304.[3]Zhu J., Bing C., Wilding J.P.H. Vitamin d receptor ligands attenuate the inflammatory profile of IL-1β-stimulated human white preadipocytes via modulating the NF-κB and unfolded protein response pathways Biochemical and Biophysical Research Communications 2-18, 503: 1049-1056.[4]Luan W., Hammond L.A. Vuillermot S. Maternal vitamin d prevents abnormal dopaminergic development and function in a mouse model of prenatal immune activation. Scientific Reports 2018;8 (1) article numer 9741.[5]Płudowski P., Karczmarewicz E. i wsp. Witamina D: Rekomendacje dawkowania w populacji osób zdrowych oraz w grupach ryzyka deficytów.Wytyczne dla Europy Środkowej 2013 r. Standardy Medyczne/Pediatria 2013, 10, 573-578 (in Polish).Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Thyroid Eye Disease Following COVID-19 Infection in a Patient with a History of Graves' Disease

Introduction: Autoimmune and inflammatory thyroid diseases have been reported following SARS-CoV-2 infection or vaccination, but thyroid eye disease (TED) post-COVID-19 infection is less common. We describe a case of TED following SAR-CoV-2 infection in a patient with a history of Graves' disease. Case Description: A 59-year-old female with history of Graves' disease status post radioiodine ablation therapy in 2002. She developed post-ablative hypothyroidism which has been stable on levothyroxine 88 mcg daily. In January 2021, the patient's husband and daughter were diagnosed with COVID-19 infection. A few days later, the patient developed an upper respiratory tract infection associated with loss of sense of smell and taste consistent with COVID-19 infection. Three days later, she developed bilateral watery eyes which progressed to eye redness, eyelid fullness, retraction, and pain with eye movement over 1-month duration. Her eye examination was significant for severe periocular soft tissue swelling, lagophthalmos and bilateral exophthalmos. The laboratory workup was consistent with normal TSH 0.388 mIU/L (0.358-3.740 mIU/L) and positive TSI 1.01 (0.0-0.55). The patient was referred to an Ophthalmologist for evaluation of TED. He noted bilateral exophthalmos, no restrictive ocular dysmotility or compressive optic neuropathy (clinical activity score 4/7 points). CT scan of orbit showed findings compatible with thyroid orbitopathy. Based on clinical activity score of 4, treatment with Teprotumumab was recommended pending insurance approval. Discussion(s): Many cases of new-onset Graves' hyperthyroidism have been reported after COVID-19, with only a few associated with TED. Our patient has been in remission for 20 years before she developed COVID-19 infection with occurence of TED.This suggests that COVID-19 infection may have played a role. SARS-CoV-2 may act through several mechanisms, including breakdown of central and peripheral tolerance, molecular mimicry between viral and self-antigens, stimulation of inflammasome with release of type I interferon. In our patient, treatment with Teprotumumab was indicated due to Graves' orbitopathy clinical activity score greater than or equal to 3. In conclusion, it is very uncommon for TED to present after COVID-19 infection. Our case reinforces the speculative hypothesis that SARS-CoV-2 virus could have triggered an autoimmune response against eye antigens. There is a need for increased awareness about the link between COVID-19 and autoimmunity to help better define the management of patients.Copyright © 2023

Unusual Myositis of the Temporalis Muscle Occurring with Acute Covid-19

Background. SARS-CoV-2 infection can be accompanied by neuromuscular disorders. Rhabdomyolysis and Guillain-Barre syndrome have been described repeatedly. There are case reports of inflammatory myopathies manifesting during COVID-19, presenting as dermatomyositis, polymyositis or immune-mediated necrotizing myopathy, with dermatomyositis-like presentations most commonly reported. Larger cases series are from postmortem examinations of COVID-19 patients, where variable inflammatory pathology of the skeletal muscle has been found frequently but without local detection of the actual virus. Thus, autoimmune mechanisms or the systemic interferon response are discussed as causes. We report a case of focal inflammatory myopathy with perimysial pathology of the temporalis muscle occurring with acute, but mild COVID-19. Methods. Case report of clinical observations, cranial MRI, histopathological, and laboratory findings. 3T cranial MRI was performed with gadolinium contrast. Open temporalis muscle biopsy was performed. The sample underwent standard cryohistological studies as well as immunohistochemistry with antibodies against MHC-I and II, CD3, CD4, CD19, CD68, anti-MAC, p62 and MxA. Testing for auto-antibodies was based on immunoblots or ELISA. RT-PCR for SARS-CoV-2 was run with RNA extracted from cryopreserved muscle. Results. A Caucasian woman in her 60s with no history of autoimmune or muscle complaints developed swelling and pain of the right jaw musculature five days after testing positive for SARS-CoV-2 due to respiratory tract symptoms. In addition, she experienced trismus, but no further neuromuscular complaints. The course of respiratory tract symptoms stayed mild. She had been vaccinated previously with single shot SARS-CoV-2 vector vaccine. Due to persistent swelling and complaints, giant cells arteritis was excluded by unresponsiveness to five days oral steroids and sonography of the temporal artery. Cranial MRI was performed nearly four weeks after the SARS-CoV-2 infection and showed marked swelling and oedema of the temporalis muscle. Its biopsy showed numerous CD68 and acid phosphatase positive cells infiltrating from perimysial perivascular foci towards the endomysium with perimysial damage but little damage of adjacent, perifascicular muscle fibres. Muscle fibres did not react with anti-MHC-II, anti-MAC or -MxA. Capillaries did not react with anti-MAC or -MxA. SARS-CoV-2 RNA was not detected in muscle tissue. Serum creatine kinase was not elevated in the subacute phase. Slightly elevated ANA titre led to detection of autoantibodies against proliferating cell nuclear antigen (PCNA). No pathological results for other autoantibodies, including myositis-specific antibodies and anti-ds-DNA, were found in blood. Neither were antibodies against hepatitis C and B viruses. Retesting 15 weeks after infection, anti-PCNA immunoblot was still positive, but ELISA did not indicate a pathologic titre. The swelling, myalgia and trismus regressed spontaneously a month after onset, yet the latter still persists at the time of reporting. Conclusion. Our case diverges from the majority of COVID-19 associated my-ositis reports in the unusual location of the focal myositis and the histopathological pattern of predominantly perimysial damage and histiocytic infiltration. It concurs with the literature as no SARS-CoV2 RNA could be detected in the muscle. Anti-PCNA is associated very rarely with myositis. Other associated disorder (systemic lupus erythematosus, chronic viral hepatitis B or C) were not found. Increased levels of autoantibodies are reported in COVID-19 and mostly attributed to loss of self-tolerance during the acute disease phase. Interestingly, the structural protein M of SARS-CoV-2 appears to interact notably with PCNA in infected cells. Still, the causal connection between the myositis and COVID-19 in this case is based on the close temporal association in the absence of alternative, competing explanations from the medical history and findings.

Unique opportunity for double protection: vaccination during pregnancy.

Vaccinations are one of the greatest achievements for protecting public health. Vaccines given to pregnant women protect not only the pregnant woman, but also the newborn. Pregnant women are disproportionately strongly affected by infections. The conflicting demands on the maternal immune system during pregnancy geared toward maintaining fetal immune tolerance make a rapid and effective immune response against pathogens more difficult. This dynamic state of immune adaptation predisposes pregnant women to more severe disease progression. Vaccination can prevent infection or a serious course of disease. As a result, the risk of premature birth and other serious pregnancy complications that can have lifelong consequences for both mother and child also decreases. After birth, when the newborn must first develop an adaptive memory for a hitherto unknown, antigen-rich environment, it is particularly vulnerable to infections and resulting complications. The transfer of maternal antibodies across the placenta protects infants who are too young to be vaccinated. When breastfeeding, this continues through antibodies in breast milk. For the vaccinations recommended by the Standing Vaccination Committee (STIKO) during pregnancy (influenza, pertussis, coronavirus disease [COVID]-19), there is clear evidence from various observational and prospective studies that they protect mother and child either from infection or from a severe disease course. The following article gives an overview of the vaccination strategy for pregnancy and summarizes the scientific data on effectiveness of the vaccinations currently recommended during pregnancy.Copyright © 2022, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

Epidemiological and clinical characteristics of SARS-CoV-2 Omicron variant

The COVID-19 pandemic continues to rage worldwide and the SARS-CoV-2 Omicron variant has now replaced the Delta variant as the leading epidemic strain.Omicron, as one of the SARS-COV-2 variants, incorporates the most critical mutations of the Alpha and Delta variants, and is characterized by having multiple mutation sites, high viral load, stronger infectivity and immune escape, which significantly reduced the protective effect of the vaccine.However, compared with the previous SARS-CoV-2 strains, the Omicron variant is less likely to infect lung tissue, it usually causes mild clinical symptom with reduced hospitalization rate, severe disease rate and fatality rate.Three doses of allogeneic vaccine can offer better tolerance and immunogenicity, and improve the protective effect of the vaccines.The application of small-molecule antiviral drugs and neutralizing antibodies can significantly reduce the hospitalization rate and mortality rate.In this paper, the epidemiological and characteristics of the Omicron variant were reviewed in order to provide reference for clinical diagnosis and treatment of the disease.

PROGRESSIVE ASCENDING WEAKNESS AFTER THE PFIZER/BIONTECH COVID-19 VACCINE

SESSION TITLE: Autoimmune Disorders: Both Primary and Secondary SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Myasthenia gravis (MG) occurs sporadically with no known causes. We present a rare case of new onset MG s/p COVID-19 vaccination. CASE PRESENTATION: A healthy 46-year-old female presented with progressing LE weakness for 3 months. Symptoms started 5 days after her initial Pfizer COVID-19 vaccine. Her workup showed negative neuroimaging, bland basic CSF studies from LP, with negative MS profile and AChR Ab. She presented again in 1 month with difficulty rising from a seated position, raising her arms above her head with blurry vision. Exam showed bilateral ptosis that improved with an ice pack test, weakness is worst in proximal muscles, but normal reflexes. Workup was again negative. Pyridostigmine was added after discharge (DC). 2 months after, she was admitted to the ICU for acute progressive fatiguability and dyspnea. EMG/NCS of the ulnar nerve showed 60-70% electrical decrement. She underwent therapeutic PLEX. Prednisone was added at DC followed by mycophenolate. 2 weeks later, she was again admitted with myasthenic crisis. She again underwent PLEX with improvement and intubation was avoided. Biweekly PLEX was started at DC. Testing for AChR, MuSK, and LRP4 Abs were initially negative, but AChR Abs were present 6 months later. She then underwent thymectomy showing hyperplasia. DISCUSSION: MG exacerbations have been attributable to infections (50%) and medications (30%). This has worsened during the COVID-19 pandemic especially when medications such as azithromycin were used to treat acute infections. While vaccine-induced flares or onset of autoimmune diseases have been described in literatures, new onset MG following vaccines is rare, limited to 1 to 3 case reports. No case, to our knowledge, correlated to the 1st dose like our patient. The temporal relationship between the COVID-19 vaccination and onset of MG symptoms in our patient could represent a correlation, but does not prove causality. Perhaps a more plausible theory is that the vaccine may have unmasked a previously unrecognized disease in high-risk patient. We ask if the COVID vaccine induces a similar cytokine storm, which hyperstimulates the immune system to a point that breaks immunologic self-tolerance. Interestingly, our patient was initially seronegative, but the presence of AChR Ab was confirmed after sensitive cell-based assays testing. Our patient may have had pre-existing self-antigens to the AChR that were released after receiving the Pfizer COVID-19 vaccine. CONCLUSIONS: The rate of COVID-19 vaccinations will soon surpass that of infections placing vulnerable individuals at risk for MG onset. Recognizing this risk will open discussions about vaccine safety. In doing so, we can begin to formulate new parameters for post-vaccination monitoring. The risks of and complications from acute COVID-19 still outweigh the rare adverse events from vaccines;thus, eligible patients should be offered the COVID-19 vaccine. Reference #1: Guidon AC, Amato AA. COVID-19 and neuromuscular disorders. Neurology. 2020 Jun 2;94(22):959-969. doi: 10.1212/WNL.0000000000009566. Epub 2020 Apr 13. PMID: 32284362. Reference #2: Tagliaferri AR, Narvaneni S, Azzam MH, Grist W. A Case of COVID-19 Vaccine Causing a Myasthenia Gravis Crisis. Cureus. 2021;13(6):e15581. Published 2021 Jun 10. doi:10.7759/cureus.15581 Reference #3: Chavez A, Pougnier C. A Case of COVID-19 Vaccine Associated New Diagnosis Myasthenia Gravis. Journal of Primary Care & Community Health. January 2021. doi:10.1177/21501327211051933 DISCLOSURES: No relevant relationships by andrew bui No relevant relationships by Sharonya Shrivastava

COVID-19 INFECTION MAY BE TRIGGER for DEVELOPMENT of IMMUNE-MEDIATED DISEASES (IMDS)

Background: As considerable evidence indicates viruses play an important role in the pathogenesis of infammatory rheumatic diseases as environmental factors. The most prominent pathogenic viruses which have been proposed in the triggering and initiation of autoimmune diseases include Parvovirus B19, Epstein-Barr-virus (EBV), Cytomegalovirus (CMV), Herpes virus-6, HTLV-1, Hepatitis A and C virus, and Rubella virus1. It is possible that COVID-19 infection is also a trigger. Because SARS-CoV-2 infection can break immune tolerance and trigger autoimmune responses, it is also likely to induce clinical autoimmunity2. Objectives: Find out a possible association between Covid-19 infection and development of IMDs. Methods: We analyzed data of 21 patients (Male 4/19 %/, female 17/81%/, mean age 45.5 ± 13,9 years), who were admitted to Rheumatology department of 'Mikayelyan' University Hospital after Covid-19 infection with newly diagnosed IMDs from June till December 2021. All of included had never had such kind of disorder before. EULAR/ACR criteria were used for diagnosis and assessment of disease activity. Results: After SARS-CoV-2 infection some patients presented with preserved fever, high levels of CRP and ESR, had rash and arthritis. Particularly, 3 (14.3%) developed systemic lupus erythematosus, 3(14.3%)-antiphospholipid syndrome, 4 (19%)-rheumatoid arthritis, 2(9.5%)-spondyloarthritis, 3 (14.3%)-sarcoidosis, 4 (19%)-erythema nodosum, 1 (4.8%)-small-vessel vasculitis, 1 (4.8%)-undifferentiated arthritis, and 1(4.8%)-Tietze syndrome. 11 (52.4%) experienced severe course of Covid-19 with pneumonia and respiratory failure, in 10 (47.6%) patients the course of disease was mild. We've found a signifcant association between severe course of Covid-19 and development of erythema nodosum. (p< 0.05). Also an association between female gender and severe course of Covid-19 was determined (p<0,05). Conclusion: In acute progression of the COVID-19 along with development of antiviral immunity, a dysregulated response of immune system may occur, represented by the marked cytokine release syndrome, macrophage activation, and systemic hyperinfammation.3 We analyzed the data of patients who didn't have any typical symptom of rheumatic diseases before coronavirus infection, therefor, on our opinion, virus played an important role to induce clinical autoimmun-ity and autoinfammation and subsequently-IMDs. Possibly, Covid-19 infection may be included in the group of trigger viruses for.

Redirection of anti-virus immunity towards anti-tumor immunity using nanoparticle-induced immune tolerance for oncolytic adenovirus therapy

Recent clinical observations that some coronavirus infections induced complete remissions in lymphoma patients emphasized again the potential of cancer virotherapy. Infection of cancer cells with oncolytic viruses reshapes the tumor microenvironment by activating anti-viral and anti-tumor immunity. A phase 1 clinical trial using oncolytic adenovirus Delta-24-RGD (DNX-2401) to treat recurrent malignant gliomas demonstrated activation of CD8+ T-cells and significant clinical benefits for a subset of patients. However, both anti-virus and anti-tumor immune responses are contingent on the activation of respective clones of CD8+ T-cells, which compete for clonal expansion. Thus, overexpansion of T-cells against viral antigens reduces the frequency of subdominant clones against tumor antigens. We hypothesized that inducing immune tolerance for viral antigens will decrease anti-viral immunity and in turn derepress anti-tumor immunity, resulting in enhanced efficacy of cancer virotherapy. In this work, we used nanoparticles encapsulating adenoviral antigens E1A, E1B and hexon that distributed to liver resident macrophages (P<0.0001) and induced peripheral immune tolerance. Functional experiments to restimulate immune cells with viral or tumor antigens showed that injection of nanoparticles induced virus-specific immune tolerance and redirected the focus of the immune response towards tumor peptides as measured by interferon-gamma secretion (P<0.0001). Co-culture experiments also showed increased activation of immune cells against fixed tumor cells after nanoparticle treatment (P<0.0001). Reduction of virus-specific T-cells and concurrent expansion of tumor-specific T-cell clones were further confirmed with E1A or OVA tetramers (P<0.05). Flow cytometry analysis suggested increased anti-tumor responses were due to differences in T-cell clones and not due to other immune populations including natural killer cells or myeloid-derived suppressor cells (P=0.3). Importantly, virotherapy in combination with nanoparticle-induced immune tolerance towards viral antigens in tumor-bearing mice increased the overall survival and doubled the percentage of long-term survivors compared to virus treatment alone. Our data should propel the development of a future clinical trial aiming to maximize the potential of anti-tumor immunity during cancer virotherapies.

My Journeys with Three Microbes in the Reproductive Tract

Problem: The placenta performs various functions of the lung/GI/GU tract for the developing fetus, while also moderating host defenses of the fetus against infections in utero, and likely educates the developing fetal immune system. It thus has long-term impacts on the health of both the woman and the child. Knowledge is limited about the underlying mechanisms that enable the placenta to serve as a protective barrier for the fetus against infection. The long-term goals of my research program are to, 1) elucidate the normal barriers to infection in the placenta and show how dysfunction in barrier function can lead to adverse maternal-fetal outcomes, 2) define how viral infections impact placental biology, and 3) characterize possible functional roles for the newly described microbiota at the maternal-fetal interface. Method of Study: To address the above questions, our research includes the use human placentas, primary human trophoblasts and immune cells derived from term placentas, cultured placental cells, trophoblast organoids, and mousemodels. Results: We found that placentas from women who gave birth prematurely exhibit reduced autophagy activity. Prematurity and reduced autophagy levels were also strongly associated with maternal infection. In a mouse model of pregnancy, we showed that placentas from mice deficient for Atg16L1 were significantly less able to withstand infection, and the deficient mice gave birth prematurely upon an inflammatory stimulus. We have also shown that the autophagy pathway plays a key role in ZIKV vertical transmission from mother to fetus. We demonstrated that hydroxychloroquine (HCQ), an autophagy inhibitor approved for use in pregnant women, can attenuate placental and fetal ZIKV infection and ameliorate adverse placental and fetal outcomes. More recently, we have identified a small molecule inhibitor that targets the NS2B-NS3 protease of ZIKV and inhibits viral replication. It has recently become evident that SARS-CoV-2 infection is also associated with adverse outcomes for pregnant women, including preterm birth, preeclampsia, and fetal growth restriction. We localized SARS-CoV-2 to the placenta and showed that infection alters the Renin Angiotensin System (RAS) that regulates blood pressure, thereby increasing risk for preeclampsia. In new work, we are showing that SARS-CoV-2 non-structural proteins affect autophagy in different ways than in Zika virus. Finally, we have discovered that the maternal fetal interface of the placenta harbors intracellular resident microbes, and functionally demonstrated that they do not induce any inflammatory response or cell death but may promote immune tolerance and support normal pregnancy outcomes. Conclusions: For the past 10 years of my career, I have been working on host microbial interactions at the maternal fetal interface. Our work has led to new insights into viral infections, showing how they co-opt host defenses, and that tolerance may have microbial drivers. We have shown how cellular pathways in the placenta such as autophagy and RAS mechanistically regulate host defenses against pathogens, including ZIKV and SARS-CoV-2. Additionally, our studies provide a foundation for understanding possible 'commensal' microbial- placental interactions and hint at the functional importance of microbes at the fetal maternal interface in maintaining placental health and supporting fetal development.

Could autoimmune hemolytic anaemia be triggered by SARS-COV- 2 vaccine?-case report

Background: Autoimmnue hemolytic anaemia (AIHA) is characterized by the production of autoantibodies against red cells antigens, leading to hemolysis. AIHA can be primary or secondary to rheumatologic and lymphoproliferative diseases, infections, drugs and vaccines. Several immune phenomena were reported after massive SARS-CoV-2 vaccination, including myocarditis, neurological syndormes, immune thrombocytopenia, among others. Aims: We hereby describe an AIHA case possibly related to SARSCoV- 2 vaccination. Methods: Assessment of the clinical evaluation along with the laboratory and immunohematological tests in a symptomatic patient fwe days after receiving the vaccine. Results: A 72-year-old womwn, previously healthy, rceived her first dose of Coronavac (Sinovac, inactivated virus), in January 2021. After 7 days, she was admitted with fatigue and myalgia. Laboratory results revealed haemoglobin 4.9 g/dl, reticulocyte count 31.7%, total bilirubin 9.15 mg/dl, indirect bilirubin 7.88 mg/dl, haptoglobin<6 mg/dl and lactate dehydrogenase 953 U/L. The peripheral blood smear showed spherocytes and polychromasia. The nasopharyngeal PCR test for Covid-19 was negative. Regarding the immunohematological tests, the patient was group O R1K-k+, polyspecific direct antiglobulin test (DAT) was reactive for IgG and C3d, but the monospecific DAT showed only IgG. The eluate was reactive against all test cells. After all adsorptions performed, no alloantibody was detected and the eluate confirmed only the presence of an autoantibody, with no specificity. The patient was successfully managed with steroids, cyclophosphamide and transfusion support (OR1r, K-, antigens S and JKa negative, according with genotyping). No other causes of AIHA were found in the patient's screening and the patient did not have covid prior to vaccination. Summary/Conclusions: In this case, the temporal relationship between the vaccination and the symptoms of AIHA suggests a possible and rare haematological side effect of the vaccine which are able to activate both cellular and humoral immune systems with an important role in the interactions between dendritic cells, B and T cells, and the self-tolerance system. Since there is the increase of the global number of vaccinated people and few of this reports of this phenomenon have described in the literature, we considered it important to disclose this case in our service.

LOSS of TOLERANCE and ANERGY in HUMAN PERIPHERAL B CELLS during SARS-CoV-2 INFECTION

Background: Severe infection with SARS-CoV-2 induces systemic autoreactive antibodies with specificity to Type I IFN, phospholipids, nuclear or tissue specific targets. The wide breadth of targets suggests a system-wide defect in B cell tolerance during viral infection and that the source of autoreactive antibodies is likely a heterogenous subset of B cells. BND cells are mature naïve B cells that do not express IgM but do express IgD and are enriched in autoreactive specificities. BND cells are held in an anergic state in healthy humans as a mechanism of peripheral tolerance, although in vitro evidence suggests anergy can be broken with strong inflammation. We hypothesized that robust inflammation associated with viral infection from SARS-CoV2 may relax peripheral tolerance and promote breakage of BND cell anergy. Methods: Plasma and PBMCs were collected from healthy controls (N=10), subjects immunized with Pfizer BNT162b2-mRNA/Moderna mRNA-1273 (N=10), subjects with mild (N=11) or severe SARS-CoV-2 infection (N=14). BND cells were examined ex vivo for markers of activation by flow cytometry. Phosphorylation of signaling proteins downstream of the BCR were measured in vitro with or without BCR crosslinking. Inflammatory cytokines were measured in plasma by multiplex. For statistical analysis, unpaired t test between populations or paired t test between unstimulated and BCR stimulated conditions were performed. Results: BND cells from severe SARS-CoV-2 infection have lower expression of CD21, associated with loss of anergy, higher expression of activation markers CD68 and CD86 with lower expression of inhibitory receptors CD22 and CD72 when compared to BND cells from other subjects, suggesting a phenotypical breach of anergy. Upon BCR crosslinking, BND cells have higher levels of downstream signaling components of the BCR (pPLCγ2, pBlnk, and pSyk) when compared to healthy controls and immunized subjects, suggesting a functional breach in anergy with infection. Examination of plasma from severe SARS-CoV-2 infection showed higher levels of inflammatory cytokines (IFNγ, TNFα, IL-6 and CRP) where TNFα and CRP correlated with enhanced BCR signaling in BND cells. Conclusion: We demonstrate that SARS-CoV-2 viral infection relaxes peripheral tolerance of BND cells, likely through strong systemic inflammation produced during infection. These autoreactive cells overcome anergy and become activated with increased BCR signaling. Thus BND cells could be a source of autoreactive antibodies during viral infection.

The Presence of Opportunistic Premise Plumbing Pathogens in Residential Buildings: A Literature Review

Opportunistic premise plumbing pathogens (OPPP) are microorganisms that are native to the plumbing environment and that present an emerging infectious disease problem. They share characteristics, such as disinfectant resistance, thermal tolerance, and biofilm formation. The colonisation of domestic water systems presents an elevated health risk for immune-compromised individuals who receive healthcare at home. The literature that has identified the previously described OPPPs (Aeromonas spp., Acinetobacter spp., Helicobacter spp., Legionella spp., Methylobacterium spp., Mycobacteria spp., Pseudomonas spp., and Stenotrophomonas spp.) in residential drinking water systems were systematically reviewed. By applying the Preferred reporting items for systematic reviews and meta-analyses guidelines, 214 studies were identified from the Scopus and Web of Science databases, which included 30 clinical case investigations. Tap components and showerheads were the most frequently identified sources of OPPPs. Sixty-four of these studies detected additional clinically relevant pathogens that are not classified as OPPPs in these reservoirs. There was considerable variation in the detection methods, which included traditional culturing and molecular approaches. These identified studies demonstrate that the current drinking water treatment methods are ineffective against many waterborne pathogens. It is critical that, as at-home healthcare services continue to be promoted, we understand the emergent risks that are posed by OPPPs in residential drinking water. Future research is needed in order to provide consistent data on the prevalence of OPPPs in residential water, and on the incidence of waterborne homecare-associated infections. This will enable the identification of the contributing risk factors, and the development of effective controls.

wHY DOES IT ALWAYS HAVE to BE HEMOPHILIA FAULT?

Introduction: Hemophilia A is an X-linked bleeding disease caused by coagulation factor VIII (FVIII) deficiency. Clinical presentation include bleeding and their sequalae. Hemarthrosis are the most frequent bleeding manifestation and can lead to disabling hemophilic arthropathy. However, bleeding diathesis could also be unrelated to FVIII deficiency and other causes must be taken into consideration. Methods: Case presentation: A 54-year-old man affected by severe hemophilia A, with previous inhibitors eradicated with immune tolerance induction (ITI) and suffering from a disabling hemophilic arthropathy has been followed at our center since March 1988. After on demand treatment, he started regular prophylaxis in 2003. At 25 and 27 years-old he suffered pathological fractures to both femurs, presenting with pain and functional limitation in both cases. While the first fracture was caused by osteoporosis in abuse of steroids, the second one was related to bone localization of non-Hodgkin large cell malignant lymphoma, treated with chemo and radiotherapy plus autologous stem cells transplantation and currently in clinical remission. In April 2021, 20 days after second inoculation of COVID-19 vaccination (Pfizer®), the patient developed important mucosal and cutaneous bleeding, lasting more than a week despite recombinant FVIII infusion and for which he sought medical consult. Results: Blood count analyses revealed severe immune thrombocytopenia (Platelets 3000/mmc), requiring two lines of therapy (steroid plus intravenous immunoglobulin, followed by Rituximab), always under active FVIII prophylaxis. Further investigation for thrombocytopenia revealed that the cause is a chronic lymphatic leukemia clone in the bone marrow, currently not requiring active treatment. Discussion/Conclusion: The previous case highlights how alternative bleeding cause should be considered also in hemophilia patients and how crucial is physical examination: articular or bone pain can be related to typical hemarthrosis but also to bone damage of different nature. When a bleeding episode is refractory to usual therapy, particularly in patients with severe hemophilia and a previous history, inhibitors should always be suspected. However, especially if clinical presentation is unusual (as mucosal and cutaneous diathesis) a different source should be promptly investigated for lifesaving care.

The New Variants of Corona-Virus Mutations: An Understanding to Their Infectivity, Immunological Tolerance and Vaccine Efficacy

The new COVID-19 variants are triggering a fresh panic all around. Scientists still have not found any closely related identification of these variants in the context of their evolution. The scrupulous deletion/mutations recognized inside the spike protein of the variants are emerging with an amplified pace and are observed to be associated with the alterations in the receptor-binding region (RBD) of the spike protein. This paper highlights the reported mechanistic studies conducted on SARS-CoV-2 mutant variants;the mutant virus's ability in response to the antibody recognition to evade the immune system in humans. The role of cellular immunity in response to its interaction with SARS-CoV-2 variants and importantly the discussion on the antibody-dependent enhancement (ADE) of SARS-CoV-2 disease with therapeutic antibodies and vaccines has been highlighted. It is expected that this may likely be interesting and helpful for readers in clearing all their presumptions related to the spreading severity of the mutant virus strains and more importantly the effectiveness of current and upcoming vaccines for its possible control.

(Auto)immune manifestations in COVID-19

Introduction: It is well established that many types of infections can lead to autoimmunity or autoimmune disease. Since the emergence of coronavirus disease 2019 (COVID-19), a number of confirmed cases reported autoimmune manifestations. Objectives: To evaluate occurence of (auto)immune manifestations in pediatric patients with evidence of recent infection with severe acute respiratory syndrome (SARS) associated coronavirus 2 (SARSCoV- 2). Methods: A single small center study was performed. Included were patients with (auto)immune manifestations and evidence of concomitant or recent SARS-CoV-2 infection seen at our pediatric clinic from December 2020 till April 2021. Infections with other microorganisms were excluded. Data was collected from patients' medical records. Results: A total of 12 patients were enrolled. The results are presented in Table 1. The mean age of all patients was 9.5 years (range 4-18 years). Interestingly, there was a slight male predominance (7 patients, 58%). Among immune diseases related to COVID-19, MIS-C/PIMS-TS was the most common (7 patients, 58%). It has been suggested that the syndrome results from an abnormal immune response to the virus and it is not considered an autoimmune disease. 2 boys with MIS-C/ PIMS-TS, aged 4 and 5 years, also fulfilled diagnostic criteria for Kawasaki disease. Autoantibodies were detected in 2 patients, in a 15 years old boy with Miller Fisher syndrome (anti GQ1b antiganglioside antibodies) and in a 13 years old girl with Henoch- Schonlein purpura (antinuclear antibodies, ANA). Most of our patients had positive COVID-19 serology (10 patients, 83.3%), negative PCR swab for COVID-19 (9 patients, 75%) and had a family history of COVID-19 (9 patients, 75%). Conclusion: So far, some patients have been reported to develop (auto)immune diseases after COVID-19. It is speculated that SARSCoV- 2 can disturb self- tolerance and trigger autoimmune responses through cross- reactivity with host cells. Overall, more data are needed to further understand the relationship between COVID-19 and autoimmunity.

Venom immunotherapy during COVID-19 pandemic: Experience from a university allergy center in northern Italy

Background: During the ongoing pandemic of Coronavirus Disease 2019 (COVID-19) allergic patients need to continue their constant and proper treatment, including allergen-specific immunotherapy. These patients are expected to be at a higher risk for exacerbation of lung inflammation during viral infection. We investigated the putative interplay existing between allergen-specific immunotherapy and COVID-19 infection in Hymenoptera venom-allergic population. Method: We evaluated the frequency and severity of COVID-19 infection in a cohort of 211 Hymenoptera venom-allergic patients referring to our Center from the end of February till May 20th 2020 for the regular administration of venom immunotherapy (VIT). Each patient completed a form with information regarding symptoms (fever, cough, dyspnoea, sore throat, anosmia and/or ageusia) and eventual close COVID-19 contacts in the previous 14 days. Results: Our result showed that the median age of our cohort is similar to the one that in our region has been associated with a high incidence of COVID-19 infection, increased hospitalization and mortality rates. We reported only an isolated positivity of COVID-19 in the overall group, whereas none suffered from upper airway symptoms associated with COVID-19 (fever, cough, dyspnoea, sore throat, anosmia and/or ageusia). In our cohort 24 patients were in monotherapy with ACE-i, but none of these patients developed COVID-19 disease. In our cohort the median serum tryptase level at baseline was 8.13 ± 11.49: no correlations were found between tryptase levels and COVID-19 infection. Conclusion: Even though the demographic characteristics pose a substantial risk for such a population, we suggest that a regular administration of VIT may help to the development of an immunological milieu able to down modulate the Th1/Th17 environment that has been linked to inflammatory manifestations of COVID-19. To the best of our knowledge, this is the first description of the incidence of COVID-19 infection in Hymenoptera venom allergic patients treated with VIT, suggesting indirectly that venom immune tolerance-inducing treatment may be capable of reducing the aberrant inflammatory response induced by the virus in this specific population. (Table Presented).