Acute autoimmune-like hepatitis with atypical anti-mitochondrial antibody after mRNA COVID-19 vaccination: A novel clinical entity?

Autoimmune phenomena and clinically apparent autoimmune diseases, including autoimmune hepatitis, are increasingly been reported not only after natural infection with the SARS-CoV-2 virus, but also after vaccination against it. We report the case of a 63-year old man without a history of autoimmunity or SARS-CoV-2 natural infection who experienced acute severe autoimmune-like hepatitis seven days after the first dose of the mRNA-1273 SARS-CoV-2 vaccine. Liver histology showed inflammatory portal infiltrate with interface hepatitis, lobular and centrilobular inflammation with centrilobular necrosis, in absence of fibrosis and steatosis. Serum immunoglobulin G was slightly elevated. Autoimmune liver serology showed an indirect immunofluorescence pattern on triple rodent tissue compatible with anti-mitochondrial antibody (AMA), but, unexpectedly, this pattern was not mirrored by positivity for primary biliary cholangitis (PBC)-specific molecular tests, indicating that this antibody is different from classical AMA. Anti-nuclear antibody (ANA) was also positive with a rim-like indirect immunofluorescence pattern on liver and HEp2 cell substrates, similar to PBC-specific ANA; however, anti-gp210 and a large panel of molecular-based assays for nuclear antigens were negative, suggesting a unique ANA in our patient. He carries the HLA DRB1*11:01 allele, which is protective against PBC. Response to prednisone treatment was satisfactory. The clinical significance of these novel specificities needs to be further evaluated in this emerging condition.

Impact of disease activity on health-related quality of life in systemic lupus erythematosus - a cross-sectional analysis of the Swiss Systemic Lupus Erythematosus Cohort Study (SSCS).

BACKGROUND: To assess the impact of disease activity on health-related quality of life (HRQoL) in systemic lupus erythematosus (SLE). METHODS: Cross-sectional study of patients included in the Swiss SLE Cohort Study between April 2007 and June 2014. HRQoL outcomes were based on the Medical Outcome Study Short Form 36 (SF-36). Disease activity was assessed by the SLE Disease Activity Index score with the Safety of Estrogens in SLE National Assessment modification (SELENA-SLEDAI) and by the physican's global assessment (PGA). RESULTS: Of the 252 patients included, 207 (82%) were women. Median [interquartile range (IQR)] age was 43 [32-57] years. SLE was active in 125 patients (49.6%). Median [IQR] mental component summary (MCS) in active vs inactive SLE was 40.0 [30.2-51.0] compared to 47.3 [39.2-52.8] (p < 0.01) and median [IQR] physical component summary (PCS) 43.7 [37.0-52.8] compared to 49.1 [38.4-55.6], respectively (p < 0.05). Increase in SELENA-SLEDAI or increase in PGA were negatively correlated with PCS and/or MCS. After adjusting for gender, age and disease duration, disease activity impacted on both PCS and MCS and all subscales except general health. Active lupus nephritis and musculoskeletal involvement were associated with physical limitations and emotional problems, increased bodily pain and poor social functioning. Low complement and/or presence of anti-dsDNA antibodies were associated with increased fatigue and reduced mental health. CONCLUSIONS: In patients with SLE, HRQoL is reduced in those with active disease. Impact of disease activity on HRQoL dimensions depends on SELENA-SLEDAI system components.

Hereditary haemorrhagic telangiectasia: to transplant or not to transplant - is there a right time for liver transplantation?

BACKGROUND & AIMS: Hereditary haemorrhagic telangiectasia is characterized by arterio-venous malformations (AVM). It frequently involves the liver without clinical symptoms, but may lead to biliary ischaemia, portal hypertension, or fatal high-output heart failure. The indication of liver transplantation is controversial. METHODS: Herein, we report the case of a 65-year-old female patient with a 'double Osler syndrome' consisting of hereditary haemorrhagic telangiectasia (HHT) and type I hereditary angioedema diagnosed at the age of 25 and 22 years respectively. RESULTS: Hereditary angioedema was treated with danazol for several decades until multiple hypoechogenic liver masses were detected. Albeit danazol treatment was replaced by C1 esterase inhibitor infusions, hepatocellular carcinoma was diagnosed at the age of 64 and the patient was listed for liver transplantation. HHT was marked by recurrent epistaxis until the age of 63 when severe intestinal bleeding occurred. At the age of 65, severe dyspnoea (NYHA class IV) developed and rapidly progressive high-output cardiac failure was diagnosed. Despite argon plasma coagulation to control bleeding from intestinal angiodysplasia, and treatment with bevacizumab to inhibit angiogenesis, the patient died from severe gastrointestinal bleeding associated with cardiogenic shock at the age of 66 before being transplanted. CONCLUSION: The indication to list this patient for liver transplantation was debated several times before the diagnosis of hepatocellular carcinoma because of good general condition and low MELD score. Precise guidelines for screening and management of patients with hepatic HHT need to be better defined.

The Swiss Systemic lupus erythematosus Cohort Study (SSCS) - cross-sectional analysis of clinical characteristics and treatments across different medical disciplines in Switzerland.

OBJECTIVES: To describe disease characteristics and treatment modalities in a multidisciplinary cohort of systemic lupus erythematosus (SLE) patients in Switzerland. METHODS: Cross-sectional analysis of 255 patients included in the Swiss SLE Cohort and coming from centres specialised in Clinical Immunology, Internal Medicine, Nephrology and Rheumatology. Clinical data were collected with a standardised form. Disease activity was assessed using the Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI), an integer physician's global assessment score (PGA) ranging from 0 (inactive) to 3 (very active disease) and the erythrocyte sedimentation rate (ESR). The relationship between SLE treatment and activity was assessed by propensity score methods using a mixed-effect logistic regression with a random effect on the contributing centre. RESULTS: Of the 255 patients, 82% were women and 82% were of European ancestry. The mean age at enrolment was 44.8 years and the median SLE duration was 5.2 years. Patients from Rheumatology had a significantly later disease onset. Renal disease was reported in 44% of patients. PGA showed active disease in 49% of patients, median SLEDAI was 4 and median ESR was 14 millimetre/first hour. Prescription rates of anti-malarial drugs ranged from 3% by nephrologists to 76% by rheumatologists. Patients regularly using anti-malarial drugs had significantly lower SELENA-SLEDAI scores and ESR values. CONCLUSION: In our cohort, patients in Rheumatology had a significantly later SLE onset than those in Nephrology. Anti-malarial drugs were mostly prescribed by rheumatologists and internists and less frequently by nephrologists, and appeared to be associated with less active SLE.

[The antisynthetase syndrome: a cause of rapidly progressive interstitial lung disease]. / Syndrome des antisynthétases: une cause de pneumopathie interstitielle rapidement progressive.

The anti-synthetase syndrome is associated with inflammatory myopathy, interstitial lung disease, polyarthritis, Raynaud's phenomenon and typical skin lesions known as "mechanic's hands". Anti-Jo1 antibodies are frequently present. Interstitial lung disease is the most important feature, as it determines survival and the therapeutic attitude. We report here two cases of anti-synthetase syndrome with acute respiratory failure. Immunosuppressive treatment combining corticosteroids and cyclosporine lead to clinical improvement, regression of radiological lesions and improvement in pulmonary functions.

Primer: the practical use of biological markers of rheumatic and systemic inflammatory diseases.

The assessment of systemic inflammation by means of laboratory tests often complements the results of medical examination. Traditionally, the erythrocyte sedimentation rate and leukocytosis with left shift are diagnostic markers for inflammatory and infectious diseases. The levels of acute-phase proteins--especially C-reactive protein--are used to assess both the presence of inflammation and any response to treatment. The determination of C-reactive protein levels may be advised in three types of pathological situation: infection, acute or chronic inflammation, and evaluation of metabolic risk. Procalcitonin is useful as a marker of sepsis and severe infection. The concentration of serum amyloid A predicts the chances of survival of patients with secondary (AA) amyloidosis. Ferritin and its glycosylated form are of interest in the study of specific diseases such as adult-onset Still's disease. Markers of cartilage and bone turnover are complementary to these markers of inflammation. Although cytokine serum levels are transiently crucial to the generation of inflammation, their usefulness in the clinic is still under investigation. Serum concentrations of cytokine inhibitors or soluble cytokine receptors, as well as the clinical response of patients to treatment with cytokine antagonists, might generate important information for monitoring autoinflammatory diseases.

[Infections and TNFalpha antagonist treatment]. / Infections et traitement par antagonistes du TNFalpha.

The TNFalpha antagonists have become a standard treatment for many severe chronic inflammatory diseases. After a few years of practical use in individual patient's setting adverse effects, especially infectious have been recorded and a practical attitude can be proposed for prevention and follow-up. TNFalpha antagonists increase the risk of infection by intracellular pathogens. A latent tuberculosis infection must be looked for prior to the initiation of the treatment. A prophylaxis is started in case of positive result. The global infectious risk can also be minimized by an optimal vaccination coverage and a regular screening for leucopenia.

OspA heterogeneity of Borrelia valaisiana confirmed by phenotypic and genotypic analyses.

BACKGROUND: Although European Borrelia burgdorferi sensu lato isolates have been divided into five genospecies, specific tools for the serotype characterization of only three genospecies are available. Monoclonals antibodies (mAbs) H3TS, D6 and I17.3 identify B. burgdorferi sensu stricto (ss.), B. garinii and B. afzelii respectively, but no mAbs are available to identify B. valaisiana. In the same way, specific primers exist to amplify the OspA gene of B. burgdorferi ss., B. garinii and B. afzelii. The aim of the study was to develop species-specific mAb and PCR primers for the phenotypic and genetic identification of B. valaisiana. RESULTS: This study describes a mAb that targets OspA of B. valaisiana and primers targeting the OspA gene of this species. As the monoclonal antibody A116k did not react with strains NE231, M7, M53 and Frank and no amplification was observed with strains NE231, M7 and M53, the existence of two subgroups among European B. valaisiana species was confirmed. CONCLUSIONS: The association of both monoclonal antibody A116k and primers Bval 1F and Bval 1R allows to specific identification of the B. valaisiana isolates belonging to subgroup 1.

Early T cell activation correlates with expression of apoptosis markers in patients with end-stage renal disease.

ABSTRACT. End-stage renal failure (ESRF) and chronic hemodialysis (HD) induce a state of immunodeficiency that involves T cell-mediated responses. A decreased T cell number combined with a reduced T cell lifespan and an increased T cell activation might play a role in the immune impairment associated with ESRF and chronic HD. Increased T cell activation associated with immunodeficiency suggests that activated T cells may be driven to apoptosis. To test this hypothesis, CD3+ T cell activation (CD69) and apoptosis (annexin V, CD95 (Fas), and DNA fragmentation) were analyzed in a case control study after blood draw sampling (ex vivo), in culture conditions, and after phytohemagglutinin or anti-CD3 stimulation. Ex vivo evaluation of T cells showed an increased number of activated CD69+ T cells in chronic HD patients (142 +/- 5 cells/mm3) compared with patients with ESRF (115 +/- 2 cells/mm3, P = 0.04) and controls (74 +/- 2 cells/mm3, P = 0.0006). These data were confirmed in culture conditions and after stimulation. Similarly, annexin V and CD95 (Fas)-positive T cells were more numerous in both patient groups than in controls, irrespective of the experimental conditions (P < or = 0.005 for both markers), and their percentage was always significantly higher in chronic HD patients than in patients with ESRF. The amount of DNA fragmentation was also significantly higher in the cultured resting T cells of chronic HD patients (37 +/- 3%) than in those of patients with ESRF (25 +/- 3%) and controls (20 +/- 2%) (P = 0.01). Percentage of cultured resting T cells expressing both CD69 and annexin V markers was higher in chronic HD patients (17 +/- 4%) than in patients with ESRF (10 +/- 4%) and controls (6 +/- 2%), (P = 0.005). After stimulation (phytohemagglutinin or anti-CD3), CD69+ T cell apoptosis increased by 2.4-fold in chronic HD patients compared with 1.8-fold in patients with ESRF and only 1.2-fold in controls (P = 0.001). T cells from chronic HD patients and patients with ESRF thus showed an aberrant state of early activation that contrasted with an increased proportion of annexin V and CD95 (Fas)-positive T cells engaged in apoptosis, as confirmed by DNA fragmentation. Increased susceptibility to early activated T cell apoptosis is not only associated with uremia, but is also enhanced by HD procedure. This may account for the T lymphopenia, progressive immunodeficiency, and increased infection risk seen in these patients.

Interpretation of immunoblots for Lyme borreliosis using a semiquantitative approach.

OBJECTIVE: To test the performances of new Borrelia garinii immunoblots specific for Borrelia burgdorferi sensu lato with a selected panel of sera from patients with various clinical presentations of Lyme borreliosis. METHODS: In order to establish the sensitivity and the specificity of these immunoblots, we tested serum samples obtained from patients with early- and late-stage Lyme disease (erythema migrans n=35, neuroborreliosis n=61, acrodermatitis chronica atrophicans (ACA) n=27 and arthritis n=41), from patients with diagnoses and laboratory findings associated with serologic cross-reactivity to Lyme disease (syphilis n=12, Epstein-Barr infection n=9, autoimmune markers n=29) and from blood donors residing in regions of low and medium endemicity (n=80, n=100). RESULTS: The combined sensitivity (IgG and IgM) of the tests was 90% for patients with erythema migrans, 92% for neuroborreliosis, 96% for ACA and 100% for Lyme arthritis. The specificity of the IgG immunoblot was 94%, and that of the IgM immunoblot was 97%, taking into account the prevalence of borrelia antibodies in the overall population. Interpretation of these immunoblots is based on scores allocated to different specific borrelia antigens. CONCLUSIONS: The Western blot technology is extremely useful in dissecting the immune response to borrelia infections, which develops gradually over a period of weeks to years and which involves the appearance of IgM and IgG antibodies directed against a number of borrelia-associated proteins.

Association of distinct species of Borrelia burgdorferi sensu lato with neuroborreliosis in Switzerland.

OBJECTIVE: To evaluate by species-specific immunoblots the association of Borrelia burgdorferi sensu stricto, B. garinii and B. afzelii with neuroborreliosis in Switzerland. METHODS: Borrelia strains isolated from the cerebrospinal fluid (CSF) of three children with neuroborreliosis were typed by phenotypic and genotypic analysis. The serologic reactions (IgG) of these three patients as well as those of 28 patients, including one of these three children, with confirmed neuroborreliosis were characterized and scored by immunoblots on the three individual Borrelia species antigens. Twenty patients with typical erythema migrans served as a control group. RESULTS: Phenotypic and genotypic analysis confirmed that all three CSF isolates were B. garinii. In the 28 patients with neuroborreliosis, the comparatively strongest reactions were as follows: 18 to B. garinii, three to B. burgdorferi sensu stricto and two to B. afzelii; five were inconclusive. In the control group (erythema migrans), the comparatively strongest reactions were as follows: six B. garinii, one to B. burgdorferi sensu stricto and five to B. afzelii; eight were indeterminate. CONCLUSIONS: Typing of these three CSF isolates and characterization by immunoblots of the antibody reactions of patients with neuroborreliosis give additional evidence of the association of B. garinii and neuroborreliosis. Our serologic results suggest that B. burgdorferi sensu stricto and B. afzelii are also responsible for some neuroborreliosis cases in Switzerland. Our immunoblots and the scoring system proved particularly useful for the serologic typing of patients with late Lyme borreliosis.