Association of the Spectrum of Cutaneous Lupus Erythematosus with Disease Activity and Systemic Manifestations in Patients with Systemic Lupus Erythematosus.

Background: Cutaneous involvement is common in systemic lupus erythematosus (SLE) patients and may be essential to the disease activity. This study aimed to describe cutaneous manifestations spectrum and determine the association of cutaneous lesions with the disease activity and systemic involvement among SLE patients in Malang, Indonesia. Methods: A cross-sectional study was conducted using 54 SLE patients from rheumatology outpatient clinic at Saiful Anwar General Hospital Malang, Indonesia. Cutaneous features were classified according to Gilliam and Sontheimer classification of cutaneous lupus. Disease activity and clinical manifestations were documented according to Mexican-SLE disease activity index (Mex-SLEDAI). Results: Among 54 subjects, 50% of the patients had cutaneous manifestations. Subacute cutaneous lupus erythematosus (SCLE) was observed in 11.1% of patients, and malar rash in 20.4%. Subjects with cutaneous lesions had significantly higher Mex-SLEDAI scores, especially those who had SCLE (p<0.001), malar rash (p=0.002), alopecia (p=0.002), and photosensitivity (p=0.032). Six patients (11.1%) had skin infections with higher disease activity (9[8-11]vs.2[0-4];p<0.001). SCLE was significantly associated with malar rash (OR 11.7[1.8-76.5]), vasculitis (OR 43.0[4.1-445.6]), and fatigue (OR 15.0[2.1-108.8]). Malar rash was associated with photosensitivity (OR 8.4[1.6-44.0]), while oral or nasal ulcer was associated with fatigue (OR 8.6 [1.4-54.6]). Vasculitis (OR 5.9[1.0-35.1]) and nephritis (OR 11.7 [1.8-76.5]) were associated with the presence of skin infection. Conclusion: SCLE and malar rash are the most common cutaneous lesions among subjects. Subjects with cutaneous lesions have relatively higher disease activity. Several skin lesions are also associated with SLE patients' systemic manifestations.

Randomised Clinical Trial Study: The Combination of Vitamin D and Curcumin Piperine Attenuates Disease Activity and Pro-inflammatory Cytokines Levels Insystemic Lupus Erythematosus Patients.

BACKGROUND: Curcumin-piperine might synergise with vitamin D to induce clinical remission in patients with systemic lupus erythematosus (SLE). OBJECTIVE: To observe the improvement of patients with SLE clinically and the levels of inflammatory cytokines after receiving supplements of curcumin-piperine and cholecalciferol (Vitamin D3). METHODS: Forty-five female SLE patients were included in a three-month double-blind, randomized controlled trial. Participants were classified into: Group I (400 IU cholecalciferol + placebo three times daily, n = 15), Group II (600 mg curcumin + 15,800 m piperine once daily and three times daily placebo, n = 15), and Group III (cholecalciferol 400 IU three times and 600 mg curcumin + 15,800 mg piperine once a day, n = 15). Mexican SLE disease activity score (Mex- SLEDAI), fatigue severity scale (FSS), TGF-ß, and IL-6 levels were measured from all patients before and after the treatments. RESULTS: Mex-SLEDAI, FSS, and IL-6 were reduced significantly, while TGF-ß serum levels were increased in all groups after the treatments (p <0.05). Changes in Mex-SLEDAI score (p = 0.003 and p = 0.008), FSS (p = 0.001 and p <0.001), and TGF-ß (p = 0.003 and p = 0.004) serum levels were significantly higher in group III compared to the group I or group II. On the other hand, changes in Mex-SLEDAI, FSS, IL-6, and TGF-ß serum levels were similar between groups I and II. CONCLUSION: Although vitamin D or curcumin-piperine alone could improve the clinical outcome and cytokines levels in SLE, curcumin-piperine combined with vitamin D had the best outcome in improving the disease activity and cytokines levels among patients with SLE. (ClinicalTrials.gov number, NCT05430087).

Factors Associated with Vaccine Breakthrough Incidence among Health Care Workers Vaccinated with Inactivated SARS-CoV2 Vaccine (CoronaVac).

BACKGROUND: Healthcare workers (HCWs) run a high risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The HCWs are prone to the SARS-CoV-2 infection in the hospital despite being fully vaccinated. The present study aimed to address the factors associated with the coronavirus disease 2019 (COVID-19) vaccine breakthrough among HCWs. STUDY DESIGN: A prospective cohort study. METHODS: Participants were 184 HCWs receiving two doses of inactivated SARS-CoV-2 vaccine (CoronaVac, Sinovac Life Science). All participants were followed for six months. Confirmed COVID-19 was defined as positive SARS-CoV-2 by reverse transcription-polymerase chain reaction (RT-PCR). Before undergoing RT-PCR, questionnaires were used to obtain information on demographic characteristics, profession, contact with COVID-19 cases, personal protective equipment (PPE), health protocols adherence, exercise, and nutritional habits. RESULTS: A number of 57 (31%) participants were COVID-19 positive. Close contact with COVID-19 cases (adjusted RR 6.82, 95% CI: 1.97, 47.98, P = 0.044), being a resident doctor (adjusted RR 4.72, 95% CI: 1.11, 20.11, P = 0.036), improper mask-wearing (adjusted RR 2.36, 95% CI: 1.15, 4.85, P = 0.019), and lower frequency of eating fruit and vegetables (adjusted RR 2.73, 95% CI: 1.34, 5.57, P = 0.006) increased the risk of vaccine breakthrough. Compared to single surgical masks, KN95 and N95 significantly reduced the risk of COVID-19 (adjusted RR 0.27, 95% CI: 0.07, 0.97, P = 0.045 and adjusted RR 0.25, 95% CI: 0.07, 0.87, P = 0.029), respectively. CONCLUSION: As evidenced by the obtained results, being a resident doctor, close contact with confirmed COVID-19 cases, health protocol incompliance, as well as the lower frequency of fruit and vegetable consumption were associated with the risk of vaccine breakthrough among HCWs. Appropriate strategies are needed to prevent the risk of SARS-CoV-2 infection among HCWs.

The Role of Vitamin D for Modulating the T Helper 1 Immune Response After the Coronavac Vaccination.

The purpose of this study was to observe the role of vitamin D levels with T helper 1 (Th1)-type cytokines, such as interferon γ (IFN-γ) and interleukin-12 (IL-12) efficacy, in those who had already received 2 injections of inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) vaccines (CoronaVac). We also observed if these cytokines played any significance in the CoronaVac effectiveness for preventing coronavirus disease 2019 (Covid-19) infection. One hundred ninety-four volunteers were monitored for 8 months upon receiving 2 inactivated SARS-CoV2 vaccination injections (CoronaVac, Sinovac Life Sciences). The rate of confirmed Covid-19 infections was the primary outcome. Six to 7 weeks after the second vaccine injection, and blood samples were obtained to measure the serum vitamin D, IFN-γ, and IL-12 levels. Low vitamin D level was defined if vitamin D level <30 ng/mL. Subjects with low vitamin D had lower IFN-γ and IL-12 levels (P = 0.04 and P = 0.04, respectively). The receiver operating characteristics curve analysis revealed that the area under curve for IFN-γ was 0.59, whereas IL-12 was 0.59 for predicting the low vitamin D levels. During follow-up, a higher incidence of Covid-19 infections was observed in subjects with low IFN-γ levels (P = 0.03). Kaplan-Meier survival analysis revealed that the cumulative hazard of confirmed Covid-19 cases was increased in subjects with low IFN-γ levels (log-rank test, P = 0.03). We concluded that lower vitamin D level was correlated with a lower Th1 immune response, whereas the adequate IFN-γ level was required to obtain better CoronaVac effectiveness.

Association Between the Effectiveness and Immunogenicity of Inactivated SARS-CoV2 Vaccine (CoronaVac) with the Presence of Hypertension among Health Care Workers.

OBJECTIVE: This study aimed to observe the association between the presence of hypertension with Covid-19 vaccine effectiveness among healthcare workers who received CoronaVac vaccination. METHODS: We conducted a prospective cohort study in Saiful Anwar General Hospital, Malang, Indonesia on 155 healthcare workers aged 18-59 years old who already received twice of the CoronaVac (Sinovac Life Science, Beijing, China) injection with 14-day intervals. Hypertension was diagnosed according to the 2020 International Society of Hypertension. Subjects were monitored for six months. The primary outcome was the rate of Covid-19 diagnosed by the pharyngeal swab for the real-time reverse transcription-polymerase chain reaction (RT-PCR) examination. The secondary endpoints were: (1) severity of Covid-19 among infected participants; (2) rate of hospitalizations; and (3) anti-SRBD antibody levels measured by ECLIA. RESULTS: Among 155 participants, 18.7% of them were diagnosed with hypertension, and 31.0% had the desirable BP target according to the current guidelines. Subjects with hypertension, especially those with uncontrolled blood pressure, had a higher incidence of Covid-19 infection than subjects without hypertension. Subjects with symptomatic Covid-19 and hospitalized because of Covid-19 were higher in participants with hypertension. The anti-SRBD antibody levels were lower in the second month after CoronaVac vaccination in hypertensive subjects. In contrast, comparable anti-SRBD levels were seen from both groups at sixth months after vaccination. CONCLUSION: Hypertension was associated with lower vaccine effectiveness in healthcare workers. Subjects with hypertension had a higher risk of being infected with Covid-19 despite getting a complete dose of vaccination and lower antibody production.

Association of the premature immunosenescence with the presence and severity of anemia among patients with systemic lupus erythematosus.

INTRODUCTION: One of the possible mechanisms that contribute to the development of anemia in systemic lupus erythematosus (SLE) is the presence of premature immunosenescence in SLE. This study aimed to observe the correlation between immunosenescence with anemia in SLE. METHODS: This research was a cross-sectional study with the subject was 60 women with SLE aged 16-45 years old. Subjects were recorded for the demographic and clinical data, complete blood counts, iron status (iron serum, total iron-binding capacity, and transferrin saturation), ferritin, inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]), and anti-dsDNA levels. Immunosenescence was observed by measuring the senescent T cells from peripheral blood mononuclear cells (PBMC) by flow cytometry, counted as CD4+CD57+ and CD8+CD57+ T cells. Serum IL-2 and IFNγ as the cytokines associated with immunosenescence were also measured from all subjects. Subjects were divided into anemic and non-anemic groups according to the classification of anemia from WHO (Hb < 12 gr/dl). RESULTS: Anemic SLE patients had higher CD4+CD57+, CD8+CD57+, and IFNγ, while IL-2 was lower in SLE patients with anemia. Multivariate linear regression revealed that the decreasing levels of Hb were associated with the increase of CD8+CD57+ percentages and IFNγ levels. Anti-dsDNA, ESR, CRP, ferritin, iron serum, and transferrin saturation were correlated with CD8+CD57+. IFNγ level also correlated with the anti-dsDNA, iron serum, and ferritin levels. No correlation was found between the iron status and inflammatory markers with CD4+CD57+ percentages and IL-2 levels. Multivariate regression analysis showed that IFNγ was positively associated with anti-dsDNA and negatively associated with iron serum and transferrin saturation, while CD8+CD57+ percentages were positively associated with the ferritin levels. CONCLUSION: Immunosenescence is associated with anemia by modulating the inflammatory response and causing iron dysregulation in SLE.

Diagnostic Challenge in a Patient Presenting with Ascites and Hypergammaglobulinemia.

Ascites is defined as the accumulation of intra-peritoneal fluid that can be caused by several diseases. We described a 47-year-old female presenting with low serum-ascites albumin gradient (SAAG) and a markedly high level of serum globulin. Serum protein electrophoresis revealed an M spike in the gamma region. Other laboratory results showed a marked increase in aspartate aminotransferase and alanine aminotransferase and predominantly conjugated hyperbilirubinemia without a sign of dilatation of bile ducts from abdominal ultrasonography examination. Furthermore, the follow-up showed a positive result for the anti-nuclear antibody test. The patient was assessed with autoimmune hepatitis, and the cause of ascites was suggested from portal hypertension although the level of SAAG was low. The ascites condition got improved after salt restriction, diuretics treatment, and abdominal paracentesis. However, the patient passed away because of the intracranial hemorrhage as a result of prolonged INR and APTT due to liver failure.

Low levels of vitamin D were associated with coagulopathy among hospitalized coronavirus disease-19 (COVID-19) patients: A single-centered study in Indonesia.

BACKGROUND: This study was aimed to explore the association of vitamin D in the risk of coagulopathy in coronavirus disease-19 (COVID-19). METHODS: Clinical and laboratory findings were obtained from 50 confirmed COVID-19 patients hospitalized in Saiful Anwar General Hospital, Malang, Indonesia, from September to November 2020. Thrombotic events during hospitalization were recorded, and the ISTH disseminated intravascular coagulation (DIC) score was used to classify overt DIC. Hypovitaminosis D was defined by serum vitamin D level <49.92 nmol/L. RESULTS: Among 50 patients, 42 (84%) had hypovitaminosis D, and 6 (12%) developed thrombotic events. Vitamin D levels were lower in patients with thrombotic events (p=0.015), D-dimer >2 mg/L (p=0.006), ISTH DIC score 5 (p=0.020), admitted on ICU (p=0.002), and non-survivor groups (p=0.007). Multivariate analysis for the risk in increased D-dimer levels showed low vitamin D as the only significant risk factor with OR 1.8 (1.2-4.4), p=0.034. Low vitamin D also increased the risk for developing overt DIC with OR. 5.4 (1.0-30.2), p=0.039. Vitamin D level had negative correlations with ferritin (R=-0.316, p=0.044) and CRP (R=-0.530, p=0.000). CONCLUSIONS: In conclusion, a low level of vitamin D was found in most hospitalized COVID-19 patients and might be associated with the development of coagulopathy.

Association between senescence of T cells and disease activity in patients with systemic lupus erythematosus.

OBJECTIVES: Systemic lupus erythematosus (SLE) patients are predisposed to chronic immune activation, leading to accelerated immunosenescence. The aging of the immune system causes the T cells to express several senescence markers such as CD57 and KLRG1, which produce pro-inflammatory cytokine interferon γ (IFN-γ). Immunosenescence was associated with high morbidity and mortality in other diseases. This research was conducted to prove the association between senescent T cells and SLE disease activity. MATERIAL AND METHODS: This research was an observational cross-sectional study on 53 women aged 16-45 years diagnosed with SLE based on SLICC 2012 criteria. All subjects were recorded for demographic and clinical data, and their SLE disease activity index (SLEDAI) score was measured to evaluate disease activity. Active disease was defined as SLEDAI score ≥ 3. The CD57 antigen and KLRG1 expression on CD4+ and CD8+ T cells were calculated from peripheral blood mononuclear cells (PBMC) by flow cytometry. Interferon γ was measured from serum using ELISA. The comparison was done using the Mann-Whitney U test, and correlation was tested using the Spearman test. Associations between variables were calculated using linear regression models. RESULTS: Systemic lupus erythematosus patients with active disease had markedly higher CD4+KLRG1+ (3.1 [1.3-5.5]% vs. 0.3 [0.1-0.5]%), CD8+CD57+ (11.6 ±7.1% vs. 2.4 ±2.0%, p = 0.000), and CD8+KLRG1+ T cell percentages (13.7 ±7.5% vs. 0.3 ±0.1%, p = 0.000), and IFN- γ levels (208.9 [148.3-233.8] vs. 146.7 [130.2-210.8] pg/ml, p = 0.048), compared to the inactive patients. Positive correlation and association was found between the CD8+CD57+ and CD8+KLRG1+ percentages with the SLEDAI score (p = 0.007 and p = 0.007, for the linear regression analysis, respectively). CONCLUSIONS: Systemic lupus erythematosus patients showed significantly higher senescence T cell markers compared to controls, and the increase of T cell senescence, especially in the CD8 compartment, has some association with increased disease activity in patients with SLE.

Accelerated immune aging was correlated with lupus-associated brain fog in reproductive-age systemic lupus erythematosus patients.

AIMS: Cognitive impairment is common in systemic lupus erythematosus (SLE) patients with substantial adverse effects on function and quality of life. One hypothesis to understand the mechanisms of cognitive impairment in SLE is accelerated immunosenescence. The aim of this study is to observe the correlation between immunosenescence with cognitive impairment in patients with SLE. METHODS: Sixty-one female SLE patient were measured for CD4 and CD8 T cell-associated senescence markers, including percentage of end-stage differentiated T cells (CD4 and CD8 T cells expressing CD57+ or loss of CD28 expression), of naïve T cells (CD4+ CD45RA+ and CD8+ CD45RA+ ), memory T cells (CD4+ CD45RO+ and CD8+ CD45RO+ ), and antigen-experienced T cells (CD4+ KLRG1+ and CD8+ KLRG1+ ) which were measured using flow cytometry. One hallmark of immunosenescence called immune risk profile (IRP) was defined by an inverted ratio of CD4 and CD8. Cognitive functions were measured by Mini-Mental State Examination (MMSE) and Montréal Cognitive Assessment (MOCA) questionnaire. RESULTS: Thirty-six (59.1%) SLE patients who had IRP develop significantly lower attention and recall from both MMSE (P = .005 and P = .000) and MOCA (P = .017 and P = .000) examinations. Decreased visuospatial ability was also found in patients with IRP measured by MOCA (P = .046). There was a negative correlation between memory CD4+ CD45RO+ T cells with recall and visuospatial domain (R = -0.204, P = .039 and R = -0.250, P = .033; respectively), and negative correlation between CD8+ CD28- T cells with recall and attention domain (R = -0.249, P = .027 and R = -0.145, P = .048, respectively). CONCLUSION: Systemic lupus erythematosus patients develop an accelerated immunosenescence which contributes to cognitive dysfunction, especially in attention, recall, and visuospatial domains.

Effect of active immunization with IL-17A on B cell function and infection risk in pristane-induced lupus model.

PURPOSE: The aim of this study was to determine the effect of active immunization of interleukin (IL)-17A to inhibit B cell functions and monitor the risk of infection in a pristane-induced lupus mice model. METHODS: Female Balb/c mice were given a single intraperitoneal injection of 0.5 mL pristane. IL-17A was coupled to keyhole limpet hemocyanin (KLH) and given to mice in three different doses: D0 (0 µg/mL), D1 (1 µg/mL), and D2 (10 µg/mL). The vaccine was given three times with 3-week intervals. At day 42, mice were injected intraperitoneally with methicillin-resistant Staphylococcus aureus (MRSA) and monitored for 3 weeks. Plasma cells proliferation, Th17 and plasma cell percentages were measured by flow cytometry; anti-IL-17A antibody titers, IL-17A, and anti-double-stranded DNA (anti-dsDNA) levels were measured by enzyme-linked immunosorbent assay; and MRSA colonization was measured by bacterial counter. RESULTS: Anti-IL-17A antibody titers were significantly higher in D2 compared to D0 (P = 0.012). Serum IL-17A levels were also significantly lower in D2 compared to D0 (P = 0.000) while Th17 percentages were not significantly different between groups. D2 was also had significantly lower anti-dsDNA (P = 0.021), lower plasma cell percentages (P = 0.000) and lower B cell proliferation rate (P = 0.001) compared to D0. Analysis for the risk of infection also revealed that D2 did not increase the risk of infection compared to D0 (P = 0.504). CONCLUSION: Active immunization with IL-17A coupled to KLH was able to induce a high titer of neutralizing antibodies against IL-17A and inhibit B cell functions without increasing the risk of infection in a pristane-induced lupus mice model.

Regulatory T Cells Compensation Failure Cause the Dysregulation of Immune Response in Pristane Induced Lupus Mice Model.

INTRODUCTION: Regulatory T cells' (Tregs') role remains unclear in the pathogenesis of systemic lupus erythematosus (SLE). This study was aimed at monitoring the percentage of Tregs within 32 weeks and monitoring its relationship with the percentage of other T helper (Th) cell subsets and the levels of autoantibodies and pro-inflammatory cytokines in a murine SLE model induced by pristane. METHODS: Forty-eight female BALB/c mice were divided into a healthy control (HC) and a pristine-induced (PI) group. SLE was induced by a single 0.5 cc pristane intraperitoneal injection. Six from each group were sacrificed every eight weeks until 32 weeks post-pristane injection. Treg, Th1, Th2 and Th17 percentages from the spleen were measured using flowcytometry. ANA, IL-6 and IFN-α levels were measured from serum using ELISA. RESULTS: The Treg percentage from the PI group increased significantly at 16 weeks compared to the HC group, while Th1, Th2 and Th17 percentages decreased. Tregs in the PI group began to reduce from the 24th to 32nd weeks, followed by an elevation of the Th1, Th2 and Th17 percentages. Tregs were negatively correlated with Th1 and Th2. Tregs in the PI group had a negative correlation with ANA and IFN-α levels from serum, whereas Tregs had a positive correlation with IL-6 levels. CONCLUSION: The compensation of Tregs observed at 16 weeks after pristane injection failed, marked by a decreasing number of Tregs, followed by an increase of Th subsets, pro-inflammatory cytokines and autoantibodies. This compensatory failure of Tregs could be affected by pro-inflammatory cytokines, such as IFN-α and IL-6.

Vitamin A improve Th17 and Treg regulation in systemic lupus erythematosus.

The aim of this study was to determine the role of vitamin A in modulating T helper 17 (Th17) and regulatory T cell (Treg) balance in systemic lupus erythematosus (SLE) patients. Sixty-two female SLE patients and sixty-two female controls were measured for vitamin A levels from serum by enzyme-linked immunosorbent assay (ELISA) and percentages of Th17 and Treg from peripheral blood mononuclear cells (PBMC) by flow cytometry. We also performed an in vitro study to evaluate the effects of retinoic acid treatment (0, 0.1, 0.2, and 0.3 µg/ml) in modulating Th17/Treg balance in CD4(+) T cell culture from hypovitaminosis A SLE patients. Th17 and Treg percentages from cell cultures were measured by flow cytometry. Vitamin A levels in the SLE patients were lower compared to those in the healthy control (46.9 ± 43.4 vs. 75.6 ± 73.1 ng/ml, p = 0.015). Vitamin A levels also had a negative correlation to Th17 percentages in the SLE patients (p = 0.000, R = -0.642). Th17 percentages in the hypovitaminosis A SLE patients were higher compared to those SLE patients with normal vitamin A levels (10.9 ± 5.3 vs. 2.9 ± 2.2 %, p = 0.000). Treatment of 0.3 µg/ml of retinoic acid could increase Treg differentiation (33.9 ± 1.6 vs. 21.8 ± 1.1 %, p = 0.000) and decrease Th17 differentiation (27.2 ± 2.5 vs. 37.4 ± 1.3 %, p = 0.000). In conclusion, vitamin A has important roles in modulating Th17/Treg balance in the SLE patients shown by the significant decrease of vitamin A levels in the SLE patients which negatively correlate with Th17 population, and treatment of retinoic acid could decrease Th17 and increase Treg percentages in CD4(+) T cells cultures.

Treatment of low doses curcumin could modulate Th17/Treg balance specifically on CD4+ T cell cultures of systemic lupus erythematosus patients.

INTRODUCTION: The balance between T helper 17 (Th17) and regulatory T cells (Treg) is a new paradigm in the pathogenesis of systemic lupus erythematosus (SLE). Currently, there are no drugs that able to modulate Th17/Treg balance specifically in SLE. Curcumin is a bioactive agent that has a specific action against hyperproliferative cells. However, its role in modulating Th17/Treg balance in SLE is still unknown. This research aimed to investigate the role of curcumin in modulating Th17/Treg balance on CD4+ T cell cultures of SLE patients. MATERIAL AND METHODS: CD4+ T cells from SLE 6 untreated patients and 6 healthy subjects were collected, stimulated with Th17 differentiating factors, and curcumin 0.1 and 1 µg/ml was added on cultures. After 72 hours incubation, cells were harvested and measured for Th17 and Treg percentages using flow cytometry and interleukin-17A (IL-17A) and transforming growth factor-ß1 (TGF-ß1) levels using ELISA. RESULTS: Administration of low doses of curcumin (0.1 and 1 µg/ml) could decrease Th17 percentages (p = 0.000 and p = 0.000 compared to control), reduce IL-17A productions (p = 0.000 and p = 0.000 compared to control), increase Treg percentages (p = 0.001 and p = 0.000 compared to control), and increase TGF-ß1 productions (p = 0.001 and p = 0.000 compared to control) on CD4+ T cells of SLE patients. Interestingly, these effects were not reproduced on CD4+ T cells cultures of healthy subjects. CONCLUSIONS: These data suggest that curcumin can modulate Th17/Treg balance specifically on CD4+ T cells of SLE patients without affecting healthy subjects.