Effectiveness of subcutaneous tocilizumab in refractory adult Still's disease: report of three cases and a review of the literature.

Adult Still's disease (ASD) is a systemic inflammatory disorder characterised by spiking fever, skin rash, arthritis, hepatosplenomegaly, and elevated inflammatory markers. Several proinflammatory cytokines, including interleukin (IL)-6, contribute to its pathogenesis. There have been some recent reports on the efficacy of tocilizumab (TCZ), a humanised anti-IL-6 receptor antibody, in the treatment of ASD refractory to conventional therapy. However, most of the evidence is for intravenous administration of TCZ, whereas subcutaneous injection is often preferred in terms of efficiency in cost and labour. We have experienced three patients whose ASD was refractory to corticosteroid and immunosuppressant therapy but showed a marked response to off-label use of subcutaneous TCZ (TCZ-SC). Patient 1 received TCZ-SC 162 mg on days 0 and 14 and every week thereafter. Patients 2 and 3 received TCZ-SC every 2 weeks. At the time of initiation of TCZ-SC, all three patients had elevated inflammatory markers and two had fever despite previous therapy. After the first TCZ-SC injection, the patients became afebrile within one day and inflammatory parameters (i.e. C-reactive protein and erythrocyte sedimentation rate) returned to normal within 2 weeks. None of the patients developed severe infection or other serious side effects during 104 weeks of follow-up. There have been only a limited number of case reports showing that TCZ-SC significantly improves refractory ASD during its active phase. Our experience with these patients suggests that TCZ-SC could, as well as offering cost efficiency in clinical practice, be a potent treatment option for refractory ASD.

Large-vessel involvement in granulomatosis with polyangiitis successfully treated with rituximab: A case report and literature review.

Granulomatosis with polyangiitis (GPA) is primary necrotizing vasculitis, which predominantly affects small to medium vessels. Herein, we describe a case of a 60-year-old female with GPA who developed inflammatory wall thickening localized in the aortic arch, upper abdominal aorta, and pulmonary artery. The wall thickening in the large vessels and other GPA lesions such as lung nodules and orbital mass had failed to respond to high-dose glucocorticoids combined with cyclophosphamide; however, all were successfully treated with rituximab. Our literature review identified 24 cases of large-vessel involvement associated with GPA. Luminal stenosis, occlusion, or wall thickening were observed in 8, periaortitis in 11, and aneurysms in 5 cases. The most commonly affected vessel was the abdominal aorta (12 cases), followed by the thoracic aorta (6 cases), subclavian artery (4 cases), and internal carotid artery (4 cases). Glucocorticoids were used in 23 cases, 20 of which received combination therapy with cyclophosphamide. Surgical or endovascular therapies were performed in 10 cases with aneurysmal dilatation. This is the first case showing the potential efficacy of rituximab for refractory large-vessel involvement associated with GPA.

Steroid-sparing effects of etanercept in a patient with steroid-dependent adult-onset Still's disease.

We herein report the case of an 84-year-old man with steroid-dependent adult-onset Still's disease (AOSD) whose daily steroid dose was successfully tapered after etanercept treatment. The corticosteroids worked well initially, and the patient went into remission promptly; however, he suffered a relapse due to steroid tapering. Because treatment with cyclosporine and methotrexate was ineffective, reducing the steroid dose was difficult, and the corticosteroids induced myopathy and diabetes. However, steroid tapering was accomplished in combination with etanercept therapy, and the patient's steroid-induced side effects disappeared. Etanercept should therefore be considered as a steroid-sparing treatment option in patients with steroid-responsive, steroid-dependent AOSD.

Promotive effect of macrophage colony-stimulating factor on long-term engraftment of murine hematopoietic stem cells.

Large ex vivo expansion of hematopoietic stem cells (HSCs) sufficient for use in clinical applications has not been achieved, although the influence of some cytokines including SCF, IL-11, Flt3-L, and TPO for this purpose has been reported. We present evidence for an indirect effect of macrophage colony-stimulating factor (M-CSF) on expansion of murine HSCs. Fresh Lin(-/low) cells were isolated from Ly5.1 mouse bone marrow and cultured with or without M-CSF in the presence of SCF + IL-11 + Flt3-L or SCF + IL-11 + TPO for 6 days. The expanded cells were harvested and transplanted into lethally irradiated Ly5.2 recipients with competitor cells. Culture of Lin(-/low) cells with M-CSF significantly enhanced long-term engraftment. When the more enriched HSC populations of Lin(-/low) c-Kit(+) Sca-1(+) cells were used as a source of HSCs, such a promotive effect was not observed, in agreement with negative expression of the M-CSF receptor (c-Fms). However, co-culture with Lin(-/low) c-Fms(+) resulted in a significant increase of long-term engraftment. These results suggested that M-CSF is an indirect stimulator for ex vivo expansion of HSCs in the presence of SCF, IL-11, Flt3-L, and TPO. These observations provide new directions for ex vivo expansion and insight into new engraftment regulation through M-CSF signaling.

Expression change of Flk-2/Flt-3 on murine hematopoietic stem cells in an activating state.

OBJECTIVE: The receptor tyrosine kinase Flk-2/Flt-3 (Flt-3) represents an important molecule involved in early hematopoiesis. Murine hematopoietic stem cells (HSCs) have been shown to be negative for the expression of Flt-3. We now present clear evidence for the expression change of Flt-3(-) HSCs in an activating state, and the reversibility of Flt-3 expression by HSCs in vivo. MATERIALS AND METHODS: Bone marrow cells isolated from Ly5.1 mice were sorted on the basis of Flt-3 expression and transplanted into lethally irradiated Ly5.2 recipients. After 24 weeks, peripheral blood was analyzed for donor contribution by flow cytometry. RESULTS: Although long-term engraftment was predominantly detected in Flt-3(-) populations as previously described, a 6-day cultivation of Lin(-/low)c-kit(+)Sca-1(+) Flt-3(-) bone marrow cells with stem cell factor and interleukin-11 resulted in the generation of Flt-3(+) HSCs with long-term engraftment capabilities. However, the Flt-3 ligand had no significant effect on self-renewal of the Flt-3(+) HSCs. Next, to examine reversible expression of this receptor molecule, Flt-3(+) cells converted in vitro from Ly5.1 Lin(-/low)c-kit(+)Sca-1(+) Flt-3(-) bone marrow cells were isolated and transplanted into Ly5.2 primary recipients. After 24 weeks, Ly5.1 Lin(-/low) bone marrow cells were again separated into Flt-3(-) and Flt-3(+) cells and retransplanted into Ly5.2 secondary recipients. The majority of donor HSCs with long-term engraftment capabilities were detected in the Flt-3(-) populations, indicating the reversion of Flt-3(+) to Flt-3(-) HSCs. CONCLUSIONS: These observations suggest that Flt-3 is a useful cell-surface marker of HSC activation and that this phenotypic change is reversible.