Showing papers by "Norimitsu Kadowaki published in 2017"

Hepatocyte growth factor produced in lung fibroblasts enhances non-small cell lung cancer cell survival and tumor progression

Abstract: The influence of lung fibroblasts on lung cancer progression is not fully understood. Lung fibroblasts (HFL1, MRC5, and IMR90 cells) and non-small cell lung cancer (NSCLC)-derived cell lines (A549, EBC1, and HI1017) were cultured under serum-free conditions, and the resulting culture media were designated “cell-conditioned media”. Cell survival (viability) was assessed by WST-1 assay. Concentrations of hepatocyte growth factor (HGF) were measured by ELISA. The BALB/c-nu mouse strain was used for the xenograft model. Lung fibroblast-conditioned media enhanced the survival of the three NSCLC cell lines tested. HGF was produced to a greater extent by lung fibroblasts than NSCLC cells. Exogenous HGF enhanced the survival of NSCLC cells. Either an anti-HGF neutralizing antibody or the Met inhibitor PHA-665752 inhibited the fibroblast-conditioned media-enhanced survival of NSCLC cells. The co-inoculation of mice with NSCLC cells and fibroblasts enhanced tumorigenicity and tumor progression in a mouse xenograft model. PHA-665752 significantly inhibited tumor progression that occurred after the co-inoculation of NSCLC cells and fibroblasts. In addition, HGF production by fibroblasts was stimulated by NSCLC cells. The current study provides evidence for an interaction between fibroblasts and NSCLC cells via the HGF/Met signaling pathway, which affects NSCLC cell survival and tumor progression. These findings may contribute to the development of anti-cancer-associated fibroblast therapeutic strategies. No trial registration is required because this study is not a clinical trial. This study does not include any participants or patients.

Principal component analysis uncovers cytomegalovirus-associated NK cell activation in Ph+ leukemia patients treated with dasatinib.

Abstract: Dasatinib treatment markedly increases the number of large granular lymphocytes (LGLs) in a proportion of Ph+ leukemia patients, which associates with a better prognosis. The lymphocytosis is predominantly observed in cytomegalovirus (CMV)-seropositive patients, yet detectable CMV reactivation exists only in a small fraction of patients. Thus, etiology of the lymphocytosis still remains unclear. Here, we identified NK cells as the dominant LGLs expanding in dasatinib-treated patients, and applied principal component analysis (PCA) to an extensive panel of NK cell markers to explore underlying factors in NK cell activation. PCA displayed phenotypic divergence of NK cells that reflects CMV-associated differentiation and genetic differences, and the divergence was markedly augmented in CMV-seropositive dasatinib-treated patients. Notably, the CMV-associated highly differentiated status of NK cells was already observed at leukemia diagnosis, and was further enhanced after starting dasatinib in virtually all CMV-seropositive patients. Thus, the extensive characterization of NK cells by PCA strongly suggests that CMV is an essential factor in the NK cell activation, which progresses stepwise during leukemia and subsequent dasatinib treatment most likely by subclinical CMV reactivation. This study provides a rationale for the exploitation of CMV-associated NK cell activation for treatment of leukemias.

Strain-specific transmission in an outbreak of ESBL-producing Enterobacteriaceae in the hemato-oncology care unit: a cohort study

Abstract: Extended-spectrum β-lactamase (ESBL)-producing bacteria are resistant to several types of antibiotics excluding carbapenems. A transmissibility of ESBL-producing Enterobacteriaceae would be depending on each bacterial property, however, that has not been elucidated in clinical setting. In this study, we attempted to identify the source of an outbreak of ESBL-producing bacteria in a medical oncology and immunology care unit. An ESBL-producing Enterobacteriaceae (ESBL-E) outbreak observed between July 2012 and August 2012 in Kagawa University Hospital was surveyed using various molecular microbiology techniques. We used Pulsed-field gel electrophoresis (PFGE), PCR-based ESBL gene typing, and direct sequence of ESBL gene as molecular microbiology typing method to distinguish each strain. The typical prevalence of ESBL-E isolation in the unit was 7.0 per month (1.7 per week). The prevalence of ESBL-E isolation during the target research period was 20.0 per month (5.0 per week). In total, 19 isolates (11 K. pneumoniae and 8 E. coli) were obtained from clinical samples, including four control strains (two each of both bacteria), that were physically different from those obtained from other inpatient units in our hospital. Pulsed-field gel electrophoresis (PFGE) for K. pneumoniae (digested by XbaI) produced similar patterns excluding one control strain. PCR classification of the ESBL gene for K. pneumoniae revealed that all strains other than the control strain carried SHV and CTX-M-9. This result was reconfirmed by direct DNA sequencing. Although the outbreak of K. pneumoniae was considered to be “clonal,” PFGE and PCR classification of the ESBL genes for E. coli uncovered at least six different “non-clonal” strains possessing individual ESBL gene patterns. According to the result of an antibiogram, the pattern of antimicrobial susceptibility was more variable for K. pneumoniae than for E. coli. Typing by PFGE and ESBL gene PCR analysis is practical for discriminating various organisms. In our cohort, two outbreaks were concomitantly spread with different transmission strategies, namely clonal and non-clonal, in the same unit. This might represent clinical evidence that transmissibility differs according to the type of strain. We speculated that patient-to-patient transmission of ESBL-E occurred according to the properties of each individual strain.

Complete mimicry: a case of alveolar rhabdomyosarcoma masquerading as acute leukemia.

Abstract: A small number of rhabdomyosarcoma (RMS) cases involve the bone marrow. A leukemic presentation of RMS has been reported in a few case series, although almost all cases of leukemic RMS are not completely mimicking leukemia. We encountered a case with RMS cell infiltration of the bone marrow that resembled floating hematological cells. We encountered a rare case of a 15-year-old boy with a 2-week history of left femoral pain. Upon admission, he was afebrile with no other symptoms. No apparent cause of femoral pain was detected on an initial examination. Laboratory findings revealed normal white blood cell (WBC) count and hemoglobin concentration, with a platelet count of 10.3 × 104/μL. WBCs included 2.0% metamyelocytes, 4.5% myelocytes, and 0.5% blasts. Lactate dehydrogenase concentration was 1299 U/L, creatine kinase was 437 U/L, and C-reactive protein was 1.25 mg/dL. Bone marrow aspiration demonstrated hypercellular marrow (nucleated cell count 1.84 × 104/μL) and 89.0% of blast-like cells of all nucleated cells. The proliferating cells were negative for myeloperoxidase and esterase, and strongly positive for CD56. Positron emission tomography exhibited extensive accumulation of 18F–fludeoxyglucose with a SUVmax of 7.09. Magnetic resonance imaging revealed T1-low intensity, gadolinium-enhanced, diffuse, and irregular lesions on his pelvis and bilateral femurs. These laboratory and imaging findings suggested hematological malignancy with diffuse bone involvement, suggestive of acute leukemia. However, the pathological diagnosis of bone marrow and basal penile muscle biopsy was alveolar RMS. Karyotype analysis of bone marrow cells revealed the characteristic translocation of t(2;13)(q35;q14). The final diagnosis was alveolar RMS with massive involvement of the bone marrow and the primary site in the perineal muscles. The tumor cells both of the primary site and bone marrow were positive for myogenin. A literature review found a misdiagnosed case of completely mimicking leukemic RMS as natural-killer (NK)-cell leukemia. Such a misdiagnosis can have critical consequences. We experienced a rare case of alveolar RMS with symmetrical diffuse bone marrow involvement completely masquerading as acute leukemia. The results of a surface marker study showing that the tumor cells had a near NK-cell phenotype were misleading.

Infective endocarditis and infected aneurysm caused by Streptococcus dysgalactiae subsp. equisimilis: a case report.

Abstract: Endocarditis caused by Streptococcus dysgalactiae subsp. equisimilis (SDSE) is rare. Infected aneurysm is one of the most serious complications of infective endocarditis. However, no reports have described SDSE-related infected aneurysm. We herein report a successfully treated case of SDSE-associated infective endocarditis with an infected aneurysm.

Fibronectin and Hepatocyte Growth Factor Produced by Lung Fibroblasts Augment Migration and Invasion of Malignant Pleural Mesothelioma Cells.

Abstract: Background The interaction between fibroblasts and malignant pleural mesothelioma (MPM) cells is not well understood. Materials and methods Lung fibroblasts (HFL1, MRC5 and IMR90) and MPM cells (H28, H226 and H2052) were cultured under serum-free conditions and the resulting culture media were collected. Migration and invasion of MPM cells were assessed by chemotaxis and Matrigel assays, respectively. Results Lung fibroblast-derived media enhanced the migration and invasion of the three tested MPM cell lines. Fibronectin and hepatocyte growth factor (HGF) were produced by lung fibroblasts. Exogenous fibronectin and HGF also enhanced the migration and invasion of the three MPM cells, respectively. Neutralizing anti-HGF antibody inhibited the invasion of H28 cells enhanced by fibroblast-derived media. In addition, the production of fibronectin and HGF was stimulated by MPM cell-derived media. Conclusion The current study provides additional evidence that might contribute to the development of antitumor-associated fibroblast therapeutic strategies.

An autopsy case of bronchiolitis obliterans as a previously unrecognized adverse event of afatinib treatment.

Abstract: Interstitial lung disease is a well-known pulmonary adverse event that occurs during epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy and results in restrictive ventilatory dysfunction However, obstructive changes such as those associated with bronchiolitis obliterans (BO) have never been reported as adverse events resulting from the use of any approved EGFR-TKI This report documents an autopsy case of BO that developed during afatinib treatment for adenocarcinoma of the lung Knowledge of the possibility of this fatal adverse event is important for adequate follow-up of patients with lung cancer undergoing afatinib treatment

Phanerochaete sordida as a cause of pulmonary nodule in an immunocompromised patient: a case report.

Abstract: Phanerochaete sordida is a species of wood rotting fungus, which can degrade lignin, cellulose and hemicellulose contained in wood and other hard-to-biodegrade organic substances. However, to date, there have been no other reports demonstrating that P. sordida can infect humans. A 66-year-old Japanese man presented for a mass increasing in size on his left thigh. He had been suffering from rheumatoid arthritis for 18 years and chronic obstructive pulmonary disease for 20 years, for which he was being treated with 5 mg/day prednisolone and 8 mg/week methotrexate. The mass resection was performed two months later, and was diagnosed as malignant fibrous histiocytosis. However, a computed tomography examination for tumor recurrence after surgery showed a newly emergent pulmonary nodule. We therefore decided to resect the nodule by thoracoscopic procedure. Histopathological examination of the excised specimen showed that the lesion was a granuloma, with necrotic tissue and clumping of Aspergillus-like hyphae. Therefore, the nodule was diagnosed as a fungal infection and tissue specimens were cultured microbiologically. However, fungal growth was not observed. We consequently performed genetic analysis using a broad-range polymerase chain reaction. The 28S rRNA sequence demonstrated 100% homology with P. sordida using the NCBI BLAST program against the GenBank DNA databases. Using broad-range polymerase chain reaction, we identified P. sordida as the causative agent of a pulmonary nodule. These findings indicate that P. sordida may be an additional opportunistic causative organism of pulmonary infection in immunocompromised patients.

Cytomegalovirus pulls strings behind NK cells.

Abstract: Tyrosine kinase inhibitors (TKIs) targeting the BCRABL1 kinase have revolutionized the treatment strategy for Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia (CML) and acute lymphoblastic leukemia (ALL). Among the TKIs, dasatinib is distinctive in that it inhibits a broad spectrum of tyrosine kinases, including key regulators of immune responses [1]. In agreement with this profile, dasatinib suppresses activity of various immune cells, such as T cells, NK cells, and plasmacytoid dendritic cells in vitro. Meanwhile, a unique immunological phenomenon, expansion of large granular lymphocytes (LGLs), has been frequently observed in Ph+ leukemia patients treated with dasatinib. Such expansion does not occur with other TKIs, imatinib or nilotinib. Importantly, LGL expansion during dasatinib treatment is associated with superior therapeutic responses [2]. Thus, elucidating the mechanisms underlying the LGL expansion is instrumental in improving the treatment outcome for Ph+ leukemia. Here is an enigma; dasatinib is immunosuppressive in vitro, whereas it is immunostimulatory in vivo. How can we reconcile these apparently opposite phenomena? A previous study implicated cytomegalovirus (CMV) in the LGL expansion, since it is predominantly observed in CMV-seropositive (CMV+) patients [3]. However, CMV reactivation is observed only in a small fraction of patients, and therefore, underlying factors in the lymphocytosis were uncertain. Thus, we aimed to identify them. LGLs are composed of CD8+ T cells, γδT cells, and NK cells, collectively cytotoxic lymphocytes. We first identified NK cells as the dominant LGLs expanding in dasatinib-treated patients. All the patients with NK cell expansion were CMV+. NK cells express a complex mosaic of inhibitory and activating receptors with large variation among individuals. In order to assess the accurate status of such variegated cells, we performed multiparametric phenotyping of NK cells from healthy donors and Ph+ leukemia patients treated with imatinib, nilotinib or dasatinib. We then analyzed the data using principal component analysis (PCA), a mathematical algorithm that reduces dimensionality of multiparametric data by defining a novel parameter (principal component) as a combination of the parameters to preserve the most essential characteristics of the dataset. PCA revealed that NK cells from CMV+ dasatinib-treated patients underwent phenotypic progression that reflects CMVassociated differentiation (such as NKG2Chigh CD57high LIR-1high NKp30low NKp46low). NK cells from CMV+ imatinibor nilotinib-treated patients and CMV+ healthy donors had an intermediate phenotype, and those from CMV-seronegative individuals did not have the CMVassociated phenotype. Seven of 30 CMV+ dasatinibtreated patients developed CMV reactivation as defined by an elevation of CMV-IgM or a positive result of PCR. Notably, the CMV-associated highly differentiated status of NK cells was already observed at leukemia diagnosis in the majority of CMV+ patients, and was further enhanced after starting dasatinib in virtually all CMV+ patients. CMV reactivation was detected in 8 of 20 CMV+ patients at leukemia diagnosis. Importantly, the patients with a higher degree of NK cell differentiation at diagnosis underwent significantly greater NK cell expansion and faster decreases in BCR-ABL1 mRNA after starting dasatinib. Thus, pretreatment differentiated status of NK cells predicts robust expansion of NK cells and an earlier clinical response after starting dasatinib in CMV+ patients. In this study, the PCA revealed that virtually all the CMV+ patients exhibited enhancement of CMV-associated NK cell differentiation during dasatinib treatment, regardless of the presence or absence of documented CMV reactivation. We assume that a low level of continuous Editorial

Methionine PET Might Be Reliable for the Detection of Low M-Protein-Producing Myelomas.

Abstract: C-methionine (MET) positron emission tomography (PET) is more sensitive than F-fluorodeoxyglucose (FDG)-PET for detecting myeloma lesion. Many clinical studies support this evidence mainly for multiple myeloma cases of IgG or IgA subtypes. However, this is not confirmed for low monoclonal protein-producing myelomas, such as IgD, IgE, and nonsecretory type. We encountered a 71-year-old man with IgD λ-type myeloma. In this patient, FDG-PET did not reveal any abnormal uptake lesions, whereas MET-PET revealed diffuse bone marrow uptake that relieved after initial chemotherapy. We speculate that the determinants for high serological activity of protein metabolism are transporter system activity or proliferation index.

FRI0704 Analysis of risk factor for pregnancy outcomes in 142 pregnancies complicated with connective tissue disease

Abstract: Background Recently, many connective tissue disease (CTD) patients wish to become a mother because immunosuppressants and biologics enable to improve the outcome of underlying CTD and quality of life respectively. However, Pregnancies in CTD patients often have problems including underlying disease exacerbation, some complications during pregnancy especially in preterm birth, light for date (LFD) and premature rapture of membrane (PROM). Previous study identified that high clinical activities with hypocomplementemia and positive anti-dsDNA antibody were at highest risk for pregnancy loss and preterm delivery in SLE1). It is unclear whether these problems are associated with the activity of underlying CTD or immunosuppressant treatment. Objectives We examine the issue of pregnancy and delivery complicated with CTD by the analysis of the cases in our institution. Methods We investigated the risk factors of preterm birth, LFD (light for dates) and perinatal complication from exacerbation of underlying disease, anti SS-A antibody, antiphospholipid antibody, doses of corticosteroid, immunosuppressants or biologics before pregnancy in 142 cases which were delivered in our institution. Results In 23 among all cases underlying diseases were exacerbated, and these occurred more often in PM/DM (60%), MCTD (33.3%), RA (15.3%) and SLE (13.3%). In SLE, SS, MCTD and PM/DM, preterm births and LFD were closely related to disease exacerbation and dose of corticosteroid, pulse therapy, and these were extracted as risk factors for these perinatal complications. Preterm birth was also associated with low complement (CH50) and high titer of anti-dsDNA antibody, and LFD was associated with high titer of anti-dsDNA antibody before pregnancy. However, there was no significant association with these factors in threatened premature delivery and PROM. In RA, perinatal complications were not influenced by methotrexate and biologics before pregnancy. However, only LFD was related with doses of corticosteroid during pregnancy. Conclusions We extracted disease exacerbation and dose of corticosteroid, pulse therapy during pregnancy and also low complement, high titer of anti-double stranded DNA antibody before pregnancy as risk factors of pregnancy outcomes. In pregnancy complicated with CTD, we need to control the disease activity strictly, however, we should consider the increase or pulse therapy of corticosteroid carefully. References Clowse ME, Maqder LS, et al. The clinical utility of measuring complement and anti-dsDNA antibodies during pregnancy in patients with systemic lupus erythematosus. J Rheumatol. 2011 Jun; 38(6):1012–6. Disclosure of Interest None declared

SAT0360 Myositis-specific and myositis-associated autoantibodies in patient with dermatomyositis / polymyositis; comparison between line blot and enzyme-immunoassay assays

Abstract: Background MESACUPTM test (enzyme-immunoassay assays; TIF1γ, MDA5, Jo-1, EJ, PL-7, PL-12, and KS; MBL) (MESA) is used for a diagnosis of idiopathic inflammatory myopathies (IIMs) in Japan. On the other hand, EUROLINE myositis Profile 3 (line blot; EUROIMMUN) (EURO) can analyze plural Myositis-specific autoantibodies (MSA: Mi-2, Jo-1, SRP, PL-7, PL-12, EJ, OJ) and Myositis-associated autoantibodies (MAA; Ku, PM-Scl) at the same time, which is used commercially in Western countries. However, the difference between utility of MESA and that of EURO haven9t be disclosed. Objectives To clarify difference between utility of EURO and MESA, and extract the problem of respective examination. Methods We enrolled 58 patients diagnosed DM/PM in our facility. Polymyositis (PM) and dermatomyositis (DM) were diagnosed according to Bohan and Peter9s criteria.1) The MAA and MSA were analyzed using MESA and EURO. In case of MESA (+), MSA (anti-Jo1, anti-PL7, anti-PL12, anti-KS) were identified by specific ELISA. When those results were different, we analyzed by immunoprecipitation. And we analyzed the association between each autoantibody and clinical features. Results MSA and MAA were detected in 43/58 (74%) (anti-PL7: 12, anti-Jo1: 7, anti-EJ: 3, anti-PL12: 1, anti-OJ: 0, anti-Ro52: 27, anti-PM-Scl75: 7, anti-Ku: 6, anti-PM-Scl100: 1) by EURO. On the other hand, MSA and MAA were detected in 30/58 (52%) (anti-PL7: 9, anti-Jo1: 7, anti-EJ: 4, TIF1γ: 4, MDA5: 3, U1RNP: 3) by MESA. Five patients were MESA (-) and EURO (-). In the case of ARS positive patient, Two of EURO (-) patients was positive in MESA, respectively Jo1 and EJ. Three of MESA (-) patients was positive in EURO. Although MESA(-) and EURO(+) patients had plural MSA and MAA (PL7+Jo1, PL7+PL12, PL7+Ku), MSA and MAA weren9t detected by immunoprecipitation in MESA(-) and EURO(+) patients. Two of patients that detected plural MSA or MAA had rapid progressive ILD. (Association between clinical manifestations and MSA, MAA) All patients with anti-ARS (anti-Jo-1, anti-PL-7, anti-PL-12 and anti-EJ) had ILD. In addition, anti-ARS were associated with arthritis and mechanic9s hands. Anti-Mi-2 positive patients didn9t have ILD. Patients detected anti-PM-Scl75, anti-PM-Scl100, anti-Ku were almost overlap syndrome. All of Anti-SRP positive patients was PM. Conclusions EURO is a convenient and reliable method useful for detection of MSA and MAA. It was suggested the patients whom plural antibodies were detected by EURO have unique clinical course in others. References Bohan, A., Peter, J.B., 1975. Polymyositis and dermatomyositis (second of two parts). N. Engl. J. Med. 292, 403–407. Disclosure of Interest None declared

THU0209 Lymphocyte subsets in biopsy specimen are associated with spontaneous regression of lymphoproliferative disorders in rheumatoid arthritis patients treated with methotrexate

Abstract: Background Patients with rheumatoid arthritis (RA) have a high risk for lymphoproliferative disorders (LPDs). An LPD in a patient treated with methotrexate (MTX) is known as MTX-associated LPD (MTX-LPD), which is classified among immunodeficiency-associated lymphoproliferative disorders (ID-LPD) as “other iatrogenic ID-LPD” in the 2008 World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues (1). We previously reported that MTX is an independent risk factor for LPD onset in Japanese patients with RA (2). In MTX-LPD, MTX withdrawal can result in spontaneous regression of LPD. In addition, limited evidence indicates that Epstein–Barr virus infection is related to spontaneous regression of MTX-LPD. No biomarker has been identified that predicts spontaneous regression of MTX-LPD. Objectives To identify a biomarker that predicts spontaneous regression of MTX-LPD in RA patients. Methods We enrolled RA patients from Kagawa Prefecture, Japan, who developed MTX-LPD during the period from June 2010 through December 2016. RA was diagnosed in accordance with the American College of Rheumatology 1987 classification criteria and was treated with disease-modifying antirheumatic drugs, including MTX. The patients were divided into two groups: those followed-up after discontinuation of MTX alone (MTX withdrawal group) and those who received chemotherapy at 1 month or later after MTX discontinuation (chemotherapy group). The following variables were compared between groups: change in peripheral lymphocyte subsets after MTX discontinuation, serum soluble interleukin-2 receptor, and lymphocyte subsets and Epstein–Barr virus–encoded RNAs in a biopsy specimen from a lesion. Results We enrolled 43 MTX-LPD patients (29 in the withdrawal group and 14 in the chemotherapy group). From among these groups, we selected 32 patients for analysis of changes in peripheral lymphocyte subsets (23 in the withdrawal group and 9 in the chemotherapy group) and 22 for analysis of lymphocyte subsets in a lesion specimen (11 each in the withdrawal group and chemotherapy group). Peripheral lymphocyte counts were significantly higher after MTX discontinuation in the withdrawal group. Analysis of lymphocyte subsets from lesion specimens revealed significantly higher CD8-positive lymphocyte counts in the chemotherapy group than in the withdrawal group. Conclusions Lymphocyte count differed before and after MTX discontinuation, and a higher CD8-positive lymphocyte count in a lesion specimen was associated with spontaneous regression of MTX-LPD. These findings may help identify a predictive marker for MTX-LPD treatment and management. References Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. IARC Press, Lyon, 2008. Association of higher methotrexate dose with lymphoproliferative disorders onset in rheumatoid arthritis patients. Kameda T, Dobashi H, Miyatake N, Inoo M, Onishi I, Kurata N, Mitsunaka H, Kawakami K, Fukumoto T, Susaki K, Izumikawa M, Nakashima S, Shimada H, Takeuchi Y, Haba R, Mano S, Onishi H, Imataki O, Matsunaga T. Arthritis Care Res (Hoboken). 2014 Sep;66(9):1302–9. Disclosure of Interest None declared

Paradoxical thrombosis in idiopathic thrombocytopenic purpura

Abstract: a platelet count of 17.0 × 10/μL and rhabdomyolysis, showing creatinine kinase elevation to 6798 U/L (normal range 40–200 U/L). After recovery of the platelet count, he underwent catheter intervention that restored the blood flow (day 83) (Fig. 1c). Thromboembolism in the setting of thrombocytopenia is a hematological conundrum. The treatment of thromboembolism in thrombocytopenic patients is problematic due to its paradoxical pathophysiology. In ITP patients, both venous thromboembolism and arterial thrombus are more prevalent in patients with more comorbidities [1]. This risk is similar both before and after treatment. These apparently contradictory conditions can be understood based on the classical rule for thrombus formation, as hypothesized by Virchow’s triad: (1) hypercoagulopathy occurs with low platelet numbers and excessive platelet turnover; (2) endothelial cell injury occurs when platelet numbers are decreased; and (3) disturbed blood flow is caused by a precedent condition, for instance arteriosclerosis, as was seen in the present case. Our patient did not have glucose intolerance and hyperlipidemia, but had a smoking history (40 cigarettes/day × 48 years) as a risk factor for thromboembolism. The determinant risk posed by co-existing vascular conditions can be evaluated before the treatment, for A 77-year-old male patient was referred to our hospital with frailty, accompanied with muscle weakness and gait disturbance, and bilateral lower leg resting pain. Blood tests showed severe thrombocytopenia without remarkable coagulopathy, and cranial CT revealed multiple focal hemorrhages (Fig. 1a), which suggested a potential cause for the gait disturbance. At the onset of intracranial hemorrhage, the patient’s platelet count was 0.3 × 10/μL. Diagnostic testing for thrombocytopenia was performed by examining bone marrow aspirate. We diagnosed idiopathic thrombocytopenic purpura (ITP) based on the unrepressed proliferation of megakaryocytes in the hyperplastic bone marrow (day 0). His presentation was not consistent with any other possible differential diagnosis. We did not observe any immunological abnormalities in the blood tests, including anti-cardiolipin antibody and lupus anticoagulant (antiCL–β2GP1 complex). Soon after the diagnosis of ITP, the patient was treated with prednisolone at 1.0 mg/kg/day. His platelet count immediately recovered from 0.2 × 10 to 13.8 × 10/μL 10 days after corticosteroid treatment. Seventeen days after prednisolone treatment for ITP, the pain in the patient’s right leg was exacerbated, and ischemia and cyanosis were observed (day 17). CT angiography revealed arterial sclerosis obliterans in the right leg (Fig. 1b), with

AB0465 Association between safety, efficacy and hydroxychloroquine dosage in the treatment of cutaneous lupus erythematosus and systemic lupus erythematosus

Abstract: Background Hydroxychloroquine (HCQ) are considered to be effective against cutaneous lupus erythematosus (CLE) and symptoms associated with systemic lupus erythematosus (SLE) such as rashes, joint pain, and fatigue. In a randomized controlled trial in stable active patients with SLE on HCQ treatment, those who achieved blood HCQ levels greater than or equal to 1000ng/ml had a tendency for reduced SLE flares during a 7 month period [1]. To prevent ocular toxicity, HCQ should be maintained at a dose of 6.5mg/kg or less for ideal body weight [2], however, optimal HCQ dosage is unclear. Objectives To extract the problem of the dosage based on ideal body weight and identify safer and more effective HCQ dosage. Methods We enrolled patients who took HCQ for SLE or CLE more than 3 months in our institute and 2 related facilities from September 2015. We used Cutaneous Lupus Erythematous Disease Area and Severity Index (CLASI) to evaluate cutaneous symptoms and evaluated effect at start of administration and 3 months of that. The attending doctors assessed the adverse events (AEs). We investigated the change of serum biomarker, such as the value of serum complement and anti-ds-DNA body, the number of white blood cells, lymphocytes and platelets. Results We enrolled the 30 patients with administration of HCQ more than 3 months and in CLE were 2 cases, in SLE were 28 cases. In 21 cases HCQ dosage were based on ideal weight. The AEs were in 13/30 cases (43.3%). The AEs were the new cutaneous symptoms in 5 cases, eye manifestation in 3 cases (abnormal visual field in 2 cases, color anomaly in 1 case), diarrhea in 2 cases, fever in 2 cases, feeling of fatigue in 2 cases, renal dysfunction in 1 case, muscular pain in 1 case, and pericarditis in 1 case. The eye manifestation in the 3 cases disappeared for a few days by stopping or reducing HCQ dosage. Although we needed glucocorticoid treatment for pericarditis, the other AEs improved by reducing HCQ dosage or stopping. The AEs of taking HCQ 200mg/day were in 6 cases, 200mg and 400mg alternatively on every other day in 6 cases, and 400mg/day in 1 case. The AEs of taking HCQ dosage based on ideal body weight were in 10/21 cases (47.6%) and by minimal dosage in 3/9 cases (33.3%). 22/28 cases (78.6%) significant improved cutaneous symptoms (amount of mean change of CLASI -4.57, p=0.024). There is no difference in the efficacy of cutaneous symptoms between group received HCQ based on ideal body weight (80.0%) and the others (92.3%). 5/21 cases of HCQ based on ideal body weight were made to reduce HCQ dosage due to AEs, but all 5 cases improved cutaneous symptoms. 53.3% (16/30) cases increased complement, but other biomarkers didn9t change. Conclusions HCQ was effective for the treatment of CLE even when HCQ dosage was reduced due to AEs. These findings suggest that low-dose HCQ is also effective and safe, and HCQ initial dosage wasn9t the need to adjust for ideal body weight. References Costedoat-Chalumeau N, et al. Hydroxychloroquine in systemic lupus erythematosus: results of a French multicentre controlled trial (PLUS Study). Ann Rheum Dis. 2013;72(11):1786–92. Ronald B. Melles, Michael F.Marmor. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol. 2014;132(12):1453–60. Disclosure of Interest None declared