Association between autoimmune diseases and COVID-19 as assessed in both a test-negative case-control and population case-control design.

BACKGROUND: COVID-19 epidemic has paralleled with the so called infodemic, where countless pieces of information have been disseminated on putative risk factors for COVID-19. Among those, emerged the notion that people suffering from autoimmune diseases (AIDs) have a higher risk of SARS-CoV-2 infection. METHODS: The cohort included all COVID-19 cases residents in the Agency for Health Protection (AHP) of Milan that, from the beginning of the outbreak, developed a web-based platform that traced positive and negative cases as well as related contacts. AIDs subjects were defined ad having one the following autoimmune disease: rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, Sjogren disease, ankylosing spondylitis, myasthenia gravis, Hashimoto's disease, acquired autoimmune hemolytic anemia, and psoriatic arthritis. To investigate whether AID subjects are at increased risk of SARS-CoV-2 infection, and whether they have worse prognosis than AIDs-free subjects once infected, we performed a combined analysis of a test-negative design case-control study, a case-control with test-positive as cases, and one with test-negative as cases (CC-NEG). RESULTS: During the outbreak, the Milan AHP endured, up to April 27th 2020, 20,364 test-positive and 34,697 test-negative subjects. We found no association between AIDs and being positive to COVID-19, but a statistically significant association between AIDs and being negative to COVID-19 in the CC-NEG. If, as likely, test-negative subjects underwent testing because of respiratory infection symptoms, these results imply that autoimmune diseases may be a risk factor for respiratory infections in general (including COVID-19), but they are not a specific risk factor for COVID-19. Furthermore, when infected by SARS-CoV-2, AIDs subjects did not have a worse prognosis compared to non-AIDs subjects. Results highlighted a potential unbalance in the testing campaign, which may be correlated to the characteristics of the tested person, leading specific frail population to be particularly tested. CONCLUSIONS: Lack of availability of sound scientific knowledge inevitably lead unreliable news to spread over the population, preventing people to disentangle them form reliable information. Even if additional studies are needed to replicate and strengthen our results, these findings represent initial evidence to derive recommendations based on actual data for subjects with autoimmune diseases.

[Developing an algorithm based on health and social sources to stratify general population in different levels of health, socio-sanitary frailty and disability]. / Definizione di un algoritmo basato sulle fonti informative sanitarie e sociosanitarie per classificare la popolazione generale in relazione allo stato di salute e alla condizione di fragilità sociosanitaria e disabilità.

OBJECTIVES: to describe an innovative algorithm to classify the general population, in homogeneous groups of severity and complexity of disease and real needs, by using three dimensions: health, frailty, and disability. DESIGN: retrospective cohort study. SETTING AND PARTICIPANTS: the study includes the population covered by the Agency for health protection of Metropolitan Area of Milan (3,4 million of habitants). We identified two cohorts of residents: the first at 01.01.2015 and the second at 01.01.2016, classified in four different and mutually exclusive groups based on health and social data of the previous year. MAIN OUTCOME MEASURES: we estimated prevalence by age of the four main groups and we studied the transition, observed among groups, from 2015 to 2016. The algorithm validation was performed using non-conditional logistic regression+R14 models to estimate the association with total mortality with increasing levels of severity through the odds ratio (OR) and corresponding 95% confidence intervals (95%CI). The model performance, i.e., its predictive power and calibration, was evaluated by means of C-index and Hosmer-Lemeshow test, respectively. RESULTS: a total of 19% of subjects is healthy (group A); 41.6% has non-specific access to the health regional system (group B); 17% is a vulnerable (group C); and 22% has a chronic condition (group D). Combining chronic conditions with the frailty level, we classified population into subgroups. The risk of death within a year increases linearly in relation with increasing complexity of the health category and frailty level, with a grow of estimates from 0.83 to 135.6, using the healthy subjects as reference. The evaluation of the overall predictive power of the model, calculated by the C-index, shows a value of 0.94. The calibration of the model evaluated using the Hosmer-Lemeshow test returns a value of 327.2 (χ2 8 df, p-value <0.0001), underestimating the expected in the first three deciles and overestimating in the last deciles. CONCLUSIONS: the algorithm classify general population in homogeneous groups allowing to develop taking care models allocating health resources based on the real needs of patients.

Beyond hemostasis: the challenge of treating plasminogen deficiency. A report of three cases.

Congenital plasminogen deficiency is a rare autosomal recessive disorder, characterized by chronic mucosal membranous lesions. Although the most common clinical manifestation is eye involvement as ligneous conjunctivitis, extra-ocular lesions affecting other mucosal surfaces indicates a systemic disease. In this report we describe two cases with atypical extra-ocular involvement that includes pericarditis and recurrent hematocolpos, and one with paradoxical correlation between ocular lesions and plasminogen levels. In ligneous conjunctivitis, although different treatment strategies have been tried with mild success, the only effective therapy is topical or systemic plasminogen concentrates that are not commercially available. Unfortunately there is not either effective management for cases with multisystemic disease. Hence, treatment for plasminogen deficiency is still a challenge and the variability of the clinical spectrum in this pathology makes necessary a multidisciplinary approach.

[Analysis of psychological distress between the paediatric population immigrant and resident in a Local Health Unit of Milan Province (Northern Italy)]. / Analisi del disagio psichico nella popolazione pediatrica immigrata e residente in una ASL della Provincia di Milano.

OBJECTIVES: to figure out if there are differences in access to psychiatric services between Italian and immigrant paediatric populations. DESIGN: we analysed the data of the year 2012 from the Banca dati del disagio psichico, a database on psychological distress created by the Epidemiological Unit of the Local Health Unit Milan 1 (Lombardy, Northern Italy). The database is based on a data warehouse system that integrates health and social data, and gives the opportunity to calculate the prevalence rates of the main clusters of psychiatric diseases according to ICD-10 categories. SETTING AND PARTICIPANTS: the sample includes 162,197 residents younger than 18 years (minors), divided into 4 subgroups depending on the place of birth (Italy or abroad) and citizenship (Italian or foreign). MAIN OUTCOME MEASURES: we calculated the standardised treated prevalence of the 11 clusters of mental diseases in the 4 subgroups and evaluated the Standardised Prevalence Ratio (SPR) and their confidence intervals using as reference the Italian paediatric population with Italian citizenship. RESULTS: in 2012, 7.2%minors were diagnosed a mental illness or accessed mental health services or were prescribed psychotropic medicines. We found the lowest SPRs of psychiatric illnesses in immigrants (0.91 born in Italy; 0.74 born abroad) and the higher in Italians born in foreign Countries (1.34). In particular, migrant minors born in Italy have lower SPR of developmental disorders (0.84) and behaviour and emotional disorders (0.68), but higher SPR of mental retardation (1.52) and anxiety disorders (1.36). Migrant minors born abroad have lower SPR of developmental disorders (0.52), but higher rates of mental retardation (1.30). Italians born in foreign Countries show a SPR for personality disorders and mental retardation of 4.86 and 2.02, respectively. CONCLUSIONS: immigrant minors have a lower prevalence of psychiatric diseases than Italian minors; however, Italians born in foreign Countries show a higher prevalence of psychiatric disorders.

5q- syndrome and multiple myeloma diagnosed simultaneously and successful treated with lenalidomide.

A 72-year-old woman was diagnosed with 5q- myelodysplastic syndrome in the course of an indolent multiple myeloma (MM). Bone marrow (BM) cytogenetics disclosed two unrelated clones: 46,XX,del(5)(q13q33), and [47,X,-X,der(1;21)(q10;q10),-4,-4,+5,del(5)(q13q31),+7,der(7)t(1;7)(p34.2;p22),add(8)(p23),-13,+15,der(16) t(1;16)(q23;q12.2),+19,-21,+mar1,+mar2]. The last complex karyotype belonged to malignant plasma cells. FISH and SKY techniques demonstrated different 5q deletions. EGR1 gene (on 5q31) lost in 5q- syndrome remained in 5q- plasma cells. Biclonal evolution was noted: myeloid 5q- cells added a deletion 13q and plasma cells showed monosomy 13. Patient achieved complete cytogenetic response of 5q- syndrome with low-dose of lenalidomide, and a partial remission of MM with high-dose of lenalidomide/dexamethasone combination.

Neurofilament ELISA validation.

BACKGROUND: Neurofilament proteins (Nf) are highly specific biomarkers for neuronal death and axonal degeneration. As these markers become more widely used, an inter-laboratory validation study is required to identify assay criteria for high quality performance. METHODS: The UmanDiagnostics NF-light (R)enzyme-linked immunoabsorbent assays (ELISA) for the neurofilament light chain (NfL, 68kDa) was used to test the intra-assay and inter-laboratory coefficient of variation (CV) between 35 laboratories worldwide on 15 cerebrospinal fluid (CSF) samples. Critical factors, such as sample transport and storage, analytical delays, reaction temperature and time, the laboratories' accuracy and preparation of standards were documented and used for the statistical analyses. RESULTS: The intra-laboratory CV averaged 3.3% and the inter-laboratory CV 59%. The results from the test laboratories correlated with those from the reference laboratory (R=0.60, p<0.0001). Correcting for critical factors improved the strength of the correlation. Differences in the accuracy of standard preparation were identified as the most critical factor. Correcting for the error introduced by variation in the protein standards improved the correlation to R=0.98, p<0.0001 with an averaged inter-laboratory CV of 14%. The corrected overall inter-rater agreement was subtantial (0.6) according to Fleiss' multi-rater kappa and Gwet's AC1 statistics. CONCLUSION: This multi-center validation study identified the lack of preparation of accurate and consistent protein standards as the main reason for a poor inter-laboratory CV. This issue is also relevant to other protein biomarkers based on this type of assay and will need to be solved in order to achieve an acceptable level of analytical accuracy. The raw data of this study is available online.

Oligoclonal IgG band patterns in inflammatory demyelinating human and mouse diseases.

We evaluated oligoclonal IgG band (OCB) patterns obtained by analyzing paired cerebrospinal fluid (CSF) and serum samples of 77 patients with acute demyelinating encephalomyelitis (ADEM) and 411 patients with multiple sclerosis (MS). OCBs were searched with isoelectric focusing and capillary immunoblotting. CSF-restricted OCBs were found in 89% of MS patients and 10% of ADEM patients (p<0.0001). Identical serum and CSF OCBs ('mirror pattern'), or no OCBs, were detected in 10% of MS patients and 84% of ADEM patients (p<0.0001). OCBs were also analyzed in 27 mice with proteolipid protein-induced experimental autoimmune encephalomyelitis (EAE). In this animal model, the 'mirror pattern' was the most frequently detected pattern (74%), with the immunizing antigen being the main OCB target. These results indicate that CSF analysis can help differentiate between MS and ADEM and that, similarly to EAE, the 'mirror pattern' observed in ADEM accounts for a predominantly systemic immune activation.

Dysregulated Epstein-Barr virus infection in the multiple sclerosis brain.

Epstein-Barr virus (EBV), a ubiquitous B-lymphotropic herpesvirus, has been associated with multiple sclerosis (MS), an inflammatory disease of the central nervous system (CNS), but direct proof of its involvement in the disease is still missing. To test the idea that MS might result from perturbed EBV infection in the CNS, we investigated expression of EBV markers in postmortem brain tissue from MS cases with different clinical courses. Contrary to previous studies, we found evidence of EBV infection in a substantial proportion of brain-infiltrating B cells and plasma cells in nearly 100% of the MS cases examined (21 of 22), but not in other inflammatory neurological diseases. Ectopic B cell follicles forming in the cerebral meninges of some cases with secondary progressive MS were identified as major sites of EBV persistence. Expression of viral latent proteins was regularly observed in MS brains, whereas viral reactivation appeared restricted to ectopic B cell follicles and acute lesions. Activation of CD8+ T cells with signs of cytotoxicity toward plasma cells was also noted at sites of major accumulations of EBV-infected cells. Whether homing of EBV-infected B cells to the CNS is a primary event in MS development or the consequence of a still unknown disease-related process, we interpret these findings as evidence that EBV persistence and reactivation in the CNS play an important role in MS immunopathology.

Cytokines and chemokines in cerebrospinal fluid and serum of adult patients with acute disseminated encephalomyelitis.

Cytokines and chemokines contribute to the pathogenesis of acute disseminated encephalomyelitis (ADEM). Using a multiplex immunochemiluminescence ELISA, we measured 8 Th1/Th2 cytokines and 18 chemokines in the cerebrospinal fluid (CSF) and serum of 17 ADEM patients, 14 multiple sclerosis (MS) patients, and 7 healthy controls (HCs). Relative to HCs, ADEM patients had significantly high mean CSF concentrations of chemokines with attractant/activating properties towards neutrophils (CXCL1 and CXCL7), monocytes/T cells (CCL3 and CCL5), Th1 cells (CXCL10), and Th2 cells (CCL1, CCL22, and CCL17). Mean CSF concentrations of CXCL7, CCL1, CCL22, and CCL17 were higher in ADEM than in MS, whereas those of CCL11 were lower in MS than in ADEM and HCs. CSF pleocytosis correlated with CSF concentrations of CXCL1, CXCL10, CCL1, CCL17, and CCL22. Most of the functionally homologous chemokines correlated with each other. CSF Th1/Th2 cytokines were not detectable in most samples. Their mean concentrations did not differ in the three groups, and the same held for serum cytokines and chemokines. Our data suggest that the upregulation of chemokines active on neutrophils and Th2 cells differentiates ADEM from MS inflammation, and that both Th1 and Th2 chemokines might be produced in ADEM. Chemokines upregulated in ADEM could become CSF biomarkers after a posteriori evaluations in unselected case series.

Interferon-gamma- and interleukin-4-producing T cells in Down's syndrome.

Down's syndrome (DS) associates with genetic-dependent dysregulation of the interferon (IFN) system. We used intracellular cytokine staining to analyse the percentages of IFN-gamma- and interleukin (IL)-4-producing T cells in the peripheral blood of patients with DS, individuals with mental retardation (MR), and healthy controls (HCs). The percentages of IFN-gamma-producing CD4(+) and CD8(+) T cells (IFGCs), namely Th1 (mean, 21.4+/-S.D. 1.3) and Tc1 (12.6+/-1.1), and the Th1/Th2 ratio (6.1+/-0.2) in DS were significantly higher than in MR (15.9+/-1.3, 7.9+/-0.6, 4.8+/-0.3) and in HCs (15.6+/-1.9, 7.2+/-1.1, 4.6+/-0.6). Most of the DS patients with high IFGC percentages were seropositive for anti-transglutaminase IgA. We found no correlation between sex, age, APOE genotypes, coexisting autoimmune diseases, susceptibility to infections, or degree of cognitive impairment and high IFGC percentages. This abnormality might thus contribute to immune dysfunction in DS without manifest clinical correlates.