Macrophage activation syndrome as an initial presentation of systemic lupus erythematosus

In a recent article on World J Clin Cases 2019;7:3859-3865,Sun et al reported a case of 36-year-old female with macrophage activity syndrome as an onset of systemic lupus erythematosus.Although this is a very interesting case,some concerns still need to be addressed.First,the patient had an extremely elevated serum ferritin but a normal C-reactive protein level,which was unparallel with the inflammatory condition before she received any treatments.Second,the diagnosis of systemic lupus erythematosus seemed to be insufficient according to the patient’s medical information presented,most of which were not specific to lupus but could be explained by macrophage activity syndrome.Hence,more medical information on the patient should be provided,and a profound discussion needs to be addressed.

Clinical deep remission and related factors in a large cohort of patients with rheumatoid arthritis

Background:Clinical remission is the treatment target in rheumatoid arthritis (RA).This study aimed to investigate clinical remission and related factors in a large cohort of patients with RA.Methods:This study composed of 342 patients with RA.Data were collected by face-to-face interview of 1049 patients with RA who visited the Department of Rheumatology of three teaching hospitals from September 2015 to May 2016.The patients with RA were clinically assessed by rheumatologists and a four-page questionnaire was completed on site.Subsequently,patients fulfilled remission criteria were further analyzed.The practicability of different definitions of remission of RA was rated by a panel of rheumatologists.Sustained intensive disease modifying anti-rheumatic drug (DMARD) treatment was defined as a combination treatment with two or more DMARDs for at least 6 months.Results:In this cohort of 342 patients with RA,the proportions of patients achieving remission were 38.0%,29.5%,24.9%,21.1%,19.0%,18.1%,and 17.0%,based on criteria of disease activity score in 28 joints (DAS28) using CRP (DAS28-CRP),DAS28 using ESR (DAS28-ESR),routine assessment of patient index data 3 (RAPID-3),Boolean,simplified disease activity index (SDAI),clinical disease activity index,and the newly described clinical deep remission (CliDR),respectively.Boolean and CliDR are the best in practicability scored by rheumatologists (7.5 and 8.0,respectively).Compared with the non-sustained intensive group,sustained intensive treatment with DMARDs yielded higher remission rates of 25.6%,23.8%,and 21.3% in patients with RA based on Boolean (χ^2=3.937,P=0.047),SDAI (χ^2=4.666,P=0.031),and CliDR criteria (χ^2=4.297,P=0.038).The most commonly prescribed conventional synthesized DMARDs (csDMARDs) in patients with RA was leflunomide,followed by methotrexate,and hydroxychloroquine.Compared with the non-remission group,patients achieving remission had a longer median duration of DMARDs (45.0 [22.8–72.3] months,Z=-2.295,P=0.022).Conclusions:The findings in this study indicated that clinical deep remission is achievable in patients with RA.Sustained intensive DMARD treatment is needed to achieve a better outcome in RA.

Elevated Levels of Soluble ST2 were Associated with Rheumatoid Arthritis Disease Activity and Ameliorated Inflammation in Synovial Fibroblasts

Background：Much evidence has demonstrated that interleukin （IL）-33 plays an important role in rheumatoid arthritis （RA）.However,there have been limited studies about soluble ST2,a receptor for 1L-33,in RA.The aims of this study were to detect the levels of ST2 in the serum and synovial fluid of RA patients and to reveal the association of these levels with disease activity and the function of ST2 in RA.Methods：A total of 56 RA patients and 38 age-matched healthy controls were enrolled in this study.Synovial fluid samples were collected from another 30 RA patients and 20 osteoartbritis patients.Serum and synovial fluid levels of ST2 were measured by ELISA.In addition,the levels of ST2 in the serum of RA patients before and after therapy were detected.The function of ST2 in RA was revealed by the results of an in vitro cell assay,where recombinant ST2 proteins were used to treat peripheral blood mononuclear cells （PBMCs） and RA synovial fibroblasts （RASFs）.Results：Serum-soluble ST2 levels were significantly higher in RA patients （127.14 ± 61.43 pg/ml） than those in healthy controls （78.37 ± 41.93 pg/ml,P 〈 0.01）.Synovial fluid-soluble ST2 levels （41.90 ± 33.58 pg/ml） were much higher in RA patients than those in osteoarthritis patients （19.71 ± 16.72 pg/ml,P 〈 0.05）.RA patients who received effective therapy for 6 months showed decreased serum-soluble ST2 levels （113.01 ± 53.90 pg/ml） compared to baseline （139.59 ± 68.36 pg/ml） （P =0.01）.RA patients with high disease activity had higher serum-soluble ST2 levels （162.02 ± 56.78 pg/ml） than those with low disease activity （94.67 ± 40.27 pg/ml,P =0.001）.Soluble ST2 did not affect IL-1β,IL-6,IL-8,or tumor necrosis factor-α （TNF-o） expression in PBMCs from RA patients.However,soluble ST2 ameliorated the expressions of IL-33 and IL-1 β but not that of IL-6,IL-8,or TNF-α in resting RASFs.Interestingly,in the RASFs stimulated by TNF-α plus IL-1 β,soluble ST2 showed extensive suppressive effects on the expression of IL-6,IL-8,and TNF-α.Conclusion：Elevated levels of ST2 in the serum and synovial fluid were associated with disease activity and ameliorated IL-33 expression and IL-33-induced inflammation in RASFs,suggesting that soluble ST2 might be a potential therapeutic candidate for RA.

Effect of sustained intensive therapy with disease modifying anti-rheumatic drugs in rheumatoid arthritis:a 5-year real-world consecutive study

Background:Intensive therapy with disease modifying anti-rheumatic drugs(DMARDs)has been reported to improve the outcomes of rheumatoid arthritis(RA).However,real-world study on the effect of intensive therapy on RA sustained remission is still lacking.This study aimed to investigate the outcome of sustained intensive DMARD therapy(SUIT)for RA in a real-world 5-year consecutive cohort.Methods:Based on a consecutive cohort of 610 out-patients with RA,remission of RA was assessed in 541 patients from 2012 to 2017,by dividing into SUIT,non-SUIT,and intermittent SUIT(Int-SUIT)groups.Changes in the disease activity scores were evaluated by 28-joint disease activity score based on erythrocyte sedimentation rate(DAS28-ESR),28-joint disease activity score based on C-reactive protein(DAS28-CRP),and clinical deep remission criteria(CliDR).Cumulative remission rates between different groups were compared using Kaplan-Meier curves and predictive factors of sustained remission were identified by univariate and multivariate logistic regression analysis.Results:The remission rates of the SUIT group decreased from 12.0%(65/541)to 5.6%(20/359)based on DAS28-ESR,from 14.0%(76/541)to 7.2%(26/359)based on DAS28-CRP,and from 8.5%(46/541)to 3.1%(11/359)based on CliDR,respectively,with a gradually decreasing trend during the 5 years.The SUIT regimen led to a significantly higher cumulative remission rate than non-SUIT regimen based on DAS28-ESR(39.7%vs.19.5%,P=0.001),DAS28-CRP(42.0%vs.19.6%,P=0.001),and CliDR(24.5%vs.8.7%,P=0.001).The cumulative remission rates of patients treated with SUIT regimen were significantly higher than those treated with Int-SUIT regimen based on DAS28-ESR(39.7%vs.25.7%,P=0.043)and CliDR(24.5%vs.14.2%,P=0.047),but there was no significant difference between the two groups based on DAS28-CRP(42.0%vs.27.4%,P=0.066).Multivariate logistic regression analysis showed that the use of SUIT regimen was an independent favorable predictor according to different remission definitions(for DAS28-ESR:odds ratio[OR],2.215,95%confidence interval[CI]:1.271–3.861,P=0.005;for DAS28-CRP:OR,1.520,95%CI:1.345–1.783,P=0.002;for CliDR:OR,1.525,95%CI:1.314–1.875,P=0.013).Conclusion:Sustained intensive treatment of RA is an optimal strategy in daily practice and will lead to an increased remission rate.