Acquired hypophosphatemic osteomalacia is easily misdiagnosed or neglected by rheumatologists: A report of 9 cases.

The aim of the present study was to assist rheumatologists in differentiating hypophosphatemic osteomalacia (HO) from mimic rheumatology diseases. Clinical data was obtained from 9 patients with acquired HO, initially misdiagnosed as mimic rheumatologic diseases. The data were retrospectively analyzed and a literature review was performed. The etiology of the cases was as follows: Adefovir dipivoxil-induced Fanconi syndrome was present in 6 of the cases, 2 were tumors and 1 case was chronic nephropathy. The chief complaint was thoracic or back pain and arthralgia, followed by progressive muscle weakness and dramatic movement limitation. All patients were transferred to 3-6 hospitals for extended periods due to misdiagnosis with conditions such as ankylosing spondylitis, chronic arthritis, lumbar disc disease, osteoporosis and somatoform disorder. Hypophosphatemia was observed in the patients and bone scans revealed diffusely decreased tracer uptake, with multiple hot spots of fractured sites and involved joints. Furthermore, patients' bone density was markedly low compared with the normal range for their age and sex. In the present study, 6 of the patients recovered when adefovir dipivoxil was stopped. In 1 case, hypophosphatemia was ameliorated following tumor resection. The remaining patients, 1 with sub-skull tumor and 1 with chronic kidney disease, had poor prognoses due to incurable diseases. In conclusion, diagnosing HO is challenging for rheumatologists and physicians. Basic examinations of electrolyte balance and bone mineral density should be performed, as should tumor screening and a careful collection of patient medical history and drugs in young patients with unexplained thoracic or back pain and muscle weakness. Removing any secondary etiology, such as drugs may dramatically improve the patients clinical manifestations and result in an improved prognosis.

Association of Serum CXCL13 with Intrarenal Ectopic Lymphoid Tissue Formation in Lupus Nephritis.

Aims. To assess the concentrations of serum CXCL13 and intrarenal ectopic lymphoid tissue (ELT) profiles and their correlation in the patients with lupus nephritis (LN). Methods. Serum CXCL13 levels were measured using enzyme-linked immunosorbent assays (ELISA). The expression of CD3, CD20, and CD21 in renal biopsy specimens was tested using immunohistochemical methods. Results. Serum CXCL13 levels were significantly higher in the LN group than those in the SLE group without LN and also in the type III and IV LN patients than in type V LN patients. LN patients with positive CD20 expression (CD20+ LN) had a longer disease course and poorer response to combination therapy and higher serum CXCL13 levels than CD20- LN patients. Moreover, the serum CXCL13 level was positively correlated with the number of B cells/HP in the renal tissue of LN patients. The coexpression patterns of CD3, CD20, and CD21 in the renal tissue of LN patients with different WHO pathological types were significantly different. Serum CXCL13 levels were significantly higher in ELT-2 type LN patients than in 0 or 1 type LN patients. Conclusions. This study suggested that increased serum levels of CXCL13 might be involved in renal ELT formation and renal impairment process in LN.

Effect of Leflunomide on the Abnormal Expression of Lipid Rafts and F-Actin in B Lymphocytes from Patients with Systemic Lupus Erythematosus.

PURPOSES: To investigate the possible changes in B cell subsets and in B cell expression patterns of lipid rafts (LRs) and F-actin in patients with SLE and whether leflunomide treatment may have effect on these changes. METHODS: The B cell subsets and LRs expression were determined by flow cytometry and confocal microscopy, and F-actin expression was examined by confocal microscopy. RESULTS: CD27(+)IgD(+) B cell subsets were significantly decreased while CD38(+)CD95(+) B cell subsets increased in SLE patients. The LRs levels of B cells were remarkably increased and positively correlated with SLEDAI and anti-dsDNA titer in SLE patients. The expression level of LRs was significantly higher in CD38(+) B cells than CD38(-) B cells and negatively correlated with C3 levels. The increased expression of LRs was associated with reduced expression of F-actin in the B cells from active SLE patients. Furthermore, in vitro treatment of the cells with A771726 reduced the expression level of LRs, attenuated the overaggregation of LRs, and normalized the distribution of F-actin. CONCLUSIONS: There were abnormalities in B cell subsets and LRs and F-actin expression of B cell from SLE patients. Modulation of B cell expression of LRs and F-actin by LEF could be a potential therapeutic target for SLE.

[Adefovir dipivoxil-induced Fanconi syndrome and hypophosphatemic osteomalacia associated with muscular weakness in a patient with chronic hepatitis B].

Adefovir dipivoxil is commonly used for treatment of chronic hepatitis B. The renal toxicity of adefovir dipivoxil is dose- and time-related, occurring often in patients with a daily dose over 30 mg and those with impaired renal function. We report a case of chronic hepatitis B with a history of taking adefovir dipivoxil at 10 mg/day for 4 years. The patient complained of lumbosacral and joint pain and had the diagnosis of ankylosing spondylitis (AS) or spondyloarthropathy in several hospitals before admission in our hospital. A diagnosis of acquired Fanconi syndrome and hypophosphatemia osteomalacia associated with progressive muscular weakness was made eventually. We reviewed the literature and found reports of only fewer than 10 similar cases. Clinical attention should be given to kidney damage induced by adefovir dipivoxil.

[Neonatal lupus erythematosus: a report of 7 cases and review of 87 cases of China].

OBJECTIVE: To acquire more knowledge about neonatal lupus erythematosus (NLE). METHOD: Seven cases with neonatal lupus erythematosus who were seen in this hospital from 1990 to 2009 are reported in this paper and 87 cases reported previously from 1980 to now in China were reviewed. The clinical manifestations, serum autoantibodies, treatment and results of long-term follow-up are analyzed and summarized. RESULT: Totally 94 cases were summarized. Male/female ratio was 48/46; 73 cases had skin rash; 23 had heart abnormality, among whom 13 had cardiac conductive problems including 8 cases of atrioventricular blockage (AVB) (3 degree I, 3 degree II and 2 degree III) and 5 cases of right bundle branch block cases (RBBB). Nine cases had anatomical abnormality including 5 cases of atrial septal defect (ASD), 2 cases of ventricular septal defect (VSD) and 2 cases of atrial enlargements. Forty-four cases had hematological problems including 28 with thrombocytopenia, 11 with leukocytopenia and 34 with anemia. Thirty cases had hepatic abnormality, including 24 liver dysfunction, 22 hepatomegaly, 6 splenomegaly and 3 cholestasis. Three cases had nephropathy; 3 had elevated creatine kinase; 2 had nervous disorder. Among the 94 cases, 86 (91.5%) were positive for anti-SSA, 51 (54.3%) anti-SSB, 16 anti-ds-DNA, 14 anti-U1-RNP, 13 anti-Sm (+), 6 anti-RNP and 4 anti-rRNP(+). Among the corresponding mothers, 39 cases (44.8%) were asymptomatic before pregnancy, 35 had SLE, 5 had SCLE, 3 had Sjogren syndrome, 2 had chilblain, photosensitivity and arthralgia, respectively, 1 had rheumatoid arthritis and 1 had psoriasis. During pregnancy, 8 mothers developed SLE. Totally 48 mothers (51.1%) suffered from LE. Together with 15 mothers who had transient skin rash during the pregnancy, there were 23 mothers (59%) who had new clinical manifestation among the 39 asymptomatic mothers. Twenty NLE cases accepted glucocorticoid treatment, 4 of them were treated with intravenous immunoglobulin. Sixty-eight cases were followed up for up to 12 years, 58 cases were healthy, 5 cases improved and 3 died. Two cases still had grade III AVB without pacemaker. CONCLUSION: NLE is a rare acquired autoimmune disease. Although nearly half of the mothers were asymptomatic before pregnancy, more than half of them developed LE or other symptoms. The clinical presentations in Chinese cases include a transient rash, cardiac lesion while grade III AVB was rare, hematological changes and liver impairments which were common but not serious. Anti-SSA and/or anti-SSB were the most related autoantibody. Most patients with NLE have relatively good prognosis.

[Effect of recombinant human tumor necrosis factor receptor type II-Fc fusion protein antibody on cytokines and bone metabolism in patients with juvenile idiopathic arthritis].

OBJECTIVE: To evaluate the influence of the recombinant human type II tumor necrosis factor receptor-antibody Fc fusion protein (rhTNFR:Fc) on cytokines and bone metabolism in patients with juvenile idiopathic arthritis (JIA). METHODS: This was a prospective, non-randomized, controlled and open-label study. Thirty-one patients with JIA in active state were enrolled at our hospital from December 2006 to June 2009. The mean age was 12.7 ± 2.3 years. Exclusive criteria included infection with tuberculosis and hepatitis B etc., abnormal renal or hepatic function. Study consists of two phases. During the first phase (0-3 months), according to the economic status, all JIA patients were divided into treatment and control groups. The treatment group consisted of 18 patients (enthesitis-related arthritis, n = 15; polyarticular-onset arthritis, n = 2; systemic-onset type, n = 1) on a regimen of rhTNFR:Fc 0.4 mg/kg, subcutaneously injected twice weekly. The control group contained 13 patients (enthesitis-related arthritis, n = 9; polyarticular-onset arthritis, n = 2; systemic-onset type, n = 2) on a regimen of MTX 10 mg × m(-2) × w(-1). Two intolerance patients were given sulfasalazine (SASP) 30-50 mg × kg(-1) × d(-1). During the second phase (3-6 months), the responding patients continued the original therapy. The rhTNFR:Fc group received a reduced dosage of 0.4 mg × kg(-1) × w(-1). All patients of both groups who became complicated with peripheral arthritis or were non-responding had the addition of SASP. Follow-up was conducted at baseline, 1 month, 3 months and 6 months. And TNF-α, MMP-3, IL-1ß, osteocalcin (BGP), ß-collagen fragment (ß-CTx), alkaline phosphatase, erythrocyte sedimentation rate (ESR), c-reactive protein (CRP) and bone mineral density dynamic changes were examined respectively in the treatment process. RESULTS: Alkaline phosphatase and lumbar spine bone mineral density increased while TNF-α, IL-1ß, ESR and CRP decreased significantly in two groups (P < 0.05). ESR were 16 ± 8.0 mm/h vs 60 ± 38 mm/h, CRP 10 ± 7 mg/L vs 47 ± 37 mg/L and ß-CTx 2.1 ± 0.8 vs 1.1 ± 0.9 µg/L at 1 month in two groups respectively with statistic difference (P < 0.05). BGP increased and MMP-3 decreased in both groups with no statistic difference. Femur Ward's triangular area and forearm bone mineral density had no statistic difference between two groups. Interestingly, one case with bone fracture for two years has healed after a 6-month therapy of rhTNFR:Fc as proved by X-ray. CONCLUSION: Both rhTNFR:Fc and traditional DMARDs both can reduce the levels of TNF-α, IL-1ß, ESR and CRP and increase lumbar spine bone mineral density and ALP significantly. RhTNFR: Fc improves the acute phase index and bone metabolism index earlier than the traditional therapy. Thus disease and bone destruction are controlled more earlier.

[Efficacy comparison between transplanting microenvironmental induced and non-induced bone marrow mesenchymal stem cells in ischemic rat hearts].

OBJECTIVE: To compare the efficacy of transplanting bone marrow mesenchymal stem cell (BMSC) or microenvironmental induced BMSC (iBMSC) into the ischemic myocardium of rats with myocardial infarction. METHODS: iBMSC was defined as BMSC co-cultured with myocardial cells for 2 weeks. The stem cells or equal volume PBS were injected into ischemic border zone 1 wk after experimental infarction. Cardiac performance was evaluated at 1, 2, and 4 wk after cell transplantation by echocardiography and analyzed histologically at 4 wk after cell transplantations. RESULTS: Compared with PBS group, both BMSC and iBMSC transplantations reduced infarct size. iBMSC enhanced the beneficial effects of BMSC on improving cardiac function (FS: 28.5% +/- 4.3% in PBS, 29.0% +/- 2.0% in BMSC and 45.1% +/- 3.1% in iBMSC group at 4 weeks post transplantation, iBMSC group vs. PBS group P < 0.05, iBMSC group vs. BMSC group P < 0.05). Immunofluorescence microscopy results revealed co-localization of SPIO-labeled transplanted cells with cardiac markers for cardiomyocytes, indicating regeneration of damaged myocardium. CONCLUSION: Our data suggest that iBMSC implantation is more effective on improving cardiac function than BMSC implantation in this model. iBMSC might serve as a new promising therapeutic cell source for regenerating ischemic myocardium in patients with post-infarction heart failure.

[Clinical analysis of 79 pulmonary arterial hypertension cases from 1892 connective tissue disease patients].

OBJECTIVE: To understand the prevalence, investigate the correlation of clinical features, explore the early-stage diagnosis and treatment of pulmonary arterial hypertension (PAH) in patients with connective tissue disease (CTD). METHODS: All cases with pulmonary arterial hypertension in 1892 CTD patients were analyzed retrospectively. The risk factor of PAH was evaluated and the prognostic influence of different treatments and primary diseases analyzed. RESULTS: The prevalence of PAH in patients with connective tissue disease was about 4.2%(79/1892). In these patients, systemic sclerosis (SSc) and mixed connective tissue disease (MCTD) had the highest incidence of PAH (18.18% and 12.00%) (P < 0.01). It was obviously higher than polymyositis/dermatomyositis (6.2%), systemic lupus erythematosus (4.4%), Sjogren syndrome (3.8%), rheumatoid arthritis (0.8%) and anti-phospholipid syndrome (0.5%), etc. (P < 0.01). Raynaud's phenomenon was related to a higher pulmonary arterial pressure (P < 0.01). There was a positive correlation (P < 0.01) between the presence of Raynaud's phenomenon and pulmonary arterial pressure. Abnormal lung function was a common finding. There were associations (P < 0.05) between the degree of pulmonary hypertension and IgG, anti-U1RNP antibody positive, antiphospholipid antibody positive, pericardial effusion and interstitial pneumonia. CONCLUSION: PAH is common in connective tissue disease. SSc and MCTD have the highest prevalence of PAH. The presence of Raynaud's phenomenon anti-U1RNP antibody is positively correlated with pulmonary arterial pressure. It can predict the development of PAH. It is useful to perform ultraechocardiogrphy for an early-stage diagnosis and prognostic analysis.

[Combined mesenchymal stem cells and allogenic bone marrow transplantation in treatment of MRL/lpr mice].

OBJECTIVE: In order to study the role of the bone marrow-derived mesenchymal stem cells (MSCs) transplanted with or without bone marrow (BM) in the treatment of lupus mice and the effect of MSCs in the onset of systemic lupus erythematosus (SLE). METHOD: Twenty 12-week-old female MRL/lpr mice were randomly divided into four groups, including simple bone marrow transplantation group (SG, BM 1 x 10(7)), united group-1 (UG1, BM 1 x 10(7) + MSCs 1 x 10(4)), united group-2 (UG2, BM 1 x 10(7) + MSCs 1 x 10()6), the positive control group (PG, no transplantation). BALB/c mice were used as the negative control group (NG, no transplantation). MSCs which were amplified from the bone marrow of male BALB/c mice in vitro were transplanted into the female MRL/lpr mice with or without BM. One month later Y chromosome was detected to confirm if the transplantation was successful or not. The change of weight, white blood cells, urine protein, anti-dsDNA antibody, the pathology and immunofluorescence of renal were observed to evaluate the therapeutic efficacy. RESULTS: Y chromosome was detected in all transplanted female mice. Compared with PG, urine protein concentration in SG, UG1 and UG2 significantly decreased 30 days after transplantation (P < 0.05). 40 days after transplantation, the tite of anti-dsDNA antibodies in SG (0.91 +/- 0.27) was still higher than NG, which OD value was 0.47 +/- 0.10 (P < 0.05), but there was no statistical difference among UG1 (0.76 +/- 0.28), UG2 (0.73 +/- 0.10) and NG (P > 0.05). However, 50 days after transplantation, there was no marked difference of the tite of anti-dsDNA antibodies in SG (0.55 +/- 0.15), UG1 (0.57 +/- 0.14) and UG2 (0.58 +/- 0.05) compared with NG (P > 0.05). After transplantation there was no vasculitis, no inflammatory cell infiltration in matrix and no obvious intercapillary cells proliferation in the kidney. The immunofluorescence became negative or weakly positive. CONCLUSION: MSCs transplantation with or without BM can both improve the pathogenetic condition of MRL/lpr mice. MSCs can accelerate the clearance of anti-dsDNA antibody and promote the restoration of injured organs. We presume that MSCs are important immunological regulation cells in SLE.

[An exploratory study on in vitro effects and mechanism of leflunomide on dendritic cells of systemic lupus erythematosus].

OBJECTIVE: To detect the effects of leflunomide to phenotype and function of dendritic cells (DCs) in systemic lupus erythematosus (SLE) patients, reveal the effective mechanism inducing remission of SLE and lay a research foundation for using 'inhibit' DCs to treat SLE in future. METHODS: The monocytes were isolated from peripheral blood of SLE patients and cultivated into DCs with cytokines such as GM-CSF and IL-4. A771726 (active metabolite) was added in with cytokines in leflunomide group, but not in control. DCs were harvested after 9 days culture. CD(80), CD(83), CD(86) and HLA-DR surface markers on DCs were detected by flow cytometry (FACS). The ability of DCs stimulating lymphocytes proliferation was detected by MTT assay. IL-10 and IFNgamma level in the supernatant of MLR were detected by ELISA and T cell subtype after MLR was detected by FACS. RESULTS: The DCs treated with A771726 showed a lower percentage expression of CD(83), CD(86) and HLA-DR phenotype (CD(83): 72.70 +/- 1.77 vs. 79.36 +/- 4.80, CD(86): 63.50 +/- 14.06 vs. 83.91 +/- 9.81, HLA-DR: 80.44 +/- 12.56 vs. 90.51 +/- 8.63, all P < 0.01), a weaker ability to stimulating T lymphocytes proliferation (at DC:TC = 1:10, 0.285 +/- 0.079 vs. 0.458 +/- 0.100; at DC:TC = 1:50, 0.194 +/- 0.054 vs. 0.382 +/- 0.023, all P < 0.01) and a lower secretive level of IL-10 in the MLR supernatant [(195.0 +/- 36.9) microg/L vs. (423.6 +/- 93.2) microg/L, P < 0.01], exclude those it could still increase amount of a new T cell subtype--CD(4)(+)CD(25)(+)CTLA(4)(+) T cell (12.00% & 6.23%). CONCLUSIONS: A771726 can inhibit DCs maturation, the immature DCs can inhibit T cells proliferation and refrain T cells from dividing into Th(2) subtype, and also the immature DCs can induce a sort of regulate T cell (CD(4)(+)CD(25)(+)CTLA(4)(+) T cell) production. Through that LEF may correct part over humor immune dysfunction and get a new immune balance in SLE.