Estudo da prevalência da infecção pelo Papiloma Vírus Humano (HPV) em mulheres portadoras de Lúpus Eritematoso Sistêmico (LES) em um hospital de referência de Belém

Introdução: O câncer de colo uterino representa o terceiro câncer mais comum no mundo e o Papiloma Vírus Humano (HPV) está diretamente implicado, porém doenças auto-imunes, como o Lúpus Eritematoso Sistêmico (LES), podem comportar-se como fator facilitador para esta infecção e o desenvolvimento do câncer. Objetivo: Analisar a prevalência da infecção pelo HPV e fatores de risco associados em pacientes lúpicas atendidas em um centro de referência em Belém-Pará. Método: Estudadas 70 mulheres lúpicas que realizaram exame Preventivo do Câncer de Colo Uterino (PCCU) e foram divididas em dois grupos, mulheres infectadas pelo HPV (n= 16) e não infectadas pelo vírus (n= 54). A detecção e subtipagem viral foram realizadas por Reação em Cadeia de Polimerase (PCR). Aplicados os testes do Qui-quadrado, binominal, Fisher e t de Studentcomnível alfa = 0,05 para rejeição da hipótese nula. Resultados: A prevalência encontrada do HPV nessas pacientes foi de 22,8% e a faixa etária entre 18 a 25 anos foi relacionada com o aumento do risco para infecção pelo HPV (p < 0,001*). Alterações no PCCU e sintomas músculo-esqueléticos obtiveram, também, significância estatística para o aumento desse risco (p = 0,0360*, p = 0,0463* respectivamente). O uso de imunossupressores, não teve associação com a infecção pelo vírus. Os subtipos mais prevalentes nessa população foram o HPV tipo 58 (37,5%) e o 31 (31,3%). Duas pacientes apresentaram infecção múltipla. Conclusão: Nas pacientes lúpicas estudadas o fator idade foi implicado em um maior risco de infecção, a maioria dessas pacientes apresentava de 1 a 5 anos de diagnóstico e todas as pacientes com HPV positivo apresentavam alterações no exame do PCCU.

Análise da adesão ao tratamento em mulheres com lúpus eritematoso sistêmico

O lúpus eritematoso sistêmico (LES) é uma doença inflamatória crônica do tecido conjuntivo, de caráter auto-imune e natureza multissistêmica, podendo afetar diversos órgãos e sistemas. Há predomínio no sexo feminino e apresenta períodos de remissão e exacerbação. Embora de etiologia ainda desconhecida, vários fatores contribuem para o desenvolvimento da doença, dentre eles os fatores hormonais, ambientais, genéticos e imunológicos. Algumas manifestações clínicas têm desafiado os especialistas, como é o caso da associação do LES com estados depressivos. Este estudo teve como objetivo identificar variáveis relacionadas à adesão ao tratamento em mulheres com diagnóstico de LES. Foram feitas correlações entre características sociodemográficas, níveis de depressão, qualidade de vida, estratégias de enfrentamento e comportamentos de adesão ao tratamento. Foram usados os instrumentos: Roteiros de entrevista, Escalas Beck, International Quality of Life Assessment Project (SF-36), Escala Modos de Enfrentamento de Problemas (EMEP) e Inventário de Qualidade de Vida (WHOQOL-Breve). As participantes integravam um grupo de trinta pacientes assistidas no ambulatório de reumatologia de um hospital público. Foram distribuídas em dois grupos, de acordo com o uso ou não de medidas orientadas pelo médico: Adesão (n=17) e Não Adesão (n=13). O grupo Adesão, independentemente da idade e do tempo de diagnóstico, apresentou menores níveis de depressão se comparado com o grupo Não Adesão. Os resultados sugerem que, em ambos os grupos, nos primeiros cinco meses de convivência da paciente com o LES, o aspecto físico, a dor e o estado geral de saúde são percebidos como fatores difíceis de lidar. Entretanto, é possível afirmar que, nesse mesmo período, se o paciente não adere às prescrições médicas, o desconforto em relação aos fatores citados é intensificado. A correlação entre o domínio Vitalidade, o domínio Aspectos sociais (medidos pelo SF-36) e a adesão ao tratamento apresentou-se válida, pois as participantes do grupo Adesão também relataram que se sentiam amparadas, tanto pelo seu grupo social quanto pela equipe de saúde. Os resultados sugerem que o comportamento depressivo pode ocorrer pelo longo tempo de convivência dessas pacientes com a incontrolabilidade dos sintomas da doença, e também por conta das seqüelas do LES, que as atinge severamente, comprometendo órgãos vitais como rins, coração, pulmões, prejudicando a qualidade de vida das mesmas. Discutem-se as vantagens e limitações do uso de instrumentos para identificação de variáveis relevantes no estudo da adesão ao tratamento em doenças crônicas. Sugere-se a realização de estudos longitudinais, com delineamento do sujeito como seu próprio controle para investigar a relação entre estados depressivos, controle de sintomas e adesão ao tratamento.

Fluctuation of Anti-Endothelial Cell Antibody Titers in Mixed Connective Tissue Disease

Background: Antibodies directed against endothelial cell surface antigens have been described in many disorders and have been associated with disease activity. Since the most prominent histopathologic feature in mixed connective tissue disease (MCTD) is the widespread and unique proliferative vascular lesion, our aim was to evaluate the frequency of anti-endothelial cell antibodies (AECA) in this condition. Objectives: To evaluate the frequency of AECA in this disease and assess its clinical and laboratory associations. Methods: Seventy-three sera from 35 patients with MCTD (Kasukawa's criteria), collected during a 7 year period, were tested for immunoglobulins G and M (IgG and IgM) AECA by cellular ELISA, using HUVEC (human umbilical vein endothelial cells). Sera from 37 patients with systemic lupus erythematosus (SLE), 22 with systemic sclerosis (SSc) and 36 sera from normal healthy individuals were used as controls. A cellular ELISA using HeLa cells was also performed as a laboratory control method. Results: IgG-AECA was detected in 77% of MCTD patients, 54% of SLE patients, 36% of SSc patients and 6% of normal controls. In MCTD, IgG-AECA was associated with vasculitic manifestations, disease activity and lymphopenia, and was also a predictor of constant disease activity. Immunosuppressive drugs were shown to reduce IgG-AECA titers. Since antibodies directed to HeLa cell surface were negative, AECA was apparently unrelated to common epitopes present on epithelial cell lines. Conclusions: AECA are present in a large proportion of patients with MCTD and these antibodies decrease after immunosuppressive treatment. IMAJ 2012; 14:84-87

Analyse der Wirkung des Naturstoffes Oxacyclododecindion in einem chronisch-inflammatorischen Krankheitsmodell

Die medikamentöse Standardtherapie entzündlich-rheumatischer Erkrankungen wie der rheumatoider Arthritis (RA) und des systemischen Lupus erythematodes (SLE) sind oft unzureichend und erlauben keine nebenwirkungsarme beziehungsweise -freie Behandlung. Daher ist es von großem Interesse für diese Indikationsgebiete, wirkungsvolle Substanzen zu entwickeln, die für eine Langzeittherapie geeignet sind. Naturstoffe wie Oxacyclododecindion (Oxa) können dabei als mögliche Leitstruktur dienen. Oxa wurde bereits in in-vitro Untersuchungen als ein potenter Inhibitor der Expression von proinflammatorischen und profibrotischen Genen identifiziert. rnZiel dieser Arbeit war es in in-vivo Modellen der RA und des SLEs das therapeutische Potential des Naturstoffes Oxa aufzuklären. Da eine Etablierung der Kollagen-induzierten Arthritis im untersuchten murinen RA-Modell, dem HLA-DR4.AE° Stamm, nicht möglich war, wurden die Untersuchungen ausschließlich im MRL Faslpr Mausstamm, einem anerkannten SLE-Modell durchgeführt. MRL Faslpr Mäuse entwickeln wie SLE-Patienten unter anderem eine schwerwiegende Glomerulonephritis. rnIn den Nieren weiblicher MRL Faslpr Mäuse konnte die Oxa-Behandlung die Expression zahlreicher proinflammatorischer Mediatoren beeinflussen, die in Zusammenhang mit der Pathogenese des humanen SLE gebracht werden. So reduziert der Naturstoff die Expression von Zytokinen wie TNFα, IFNγ und IL6 als auch Chemokinen wie CCL2, CSF-1 und RANTES auf mRNA- und Proteinebene. Dabei war die Wirkung von Oxa in den in-vivo Analysen ähnlich gut wie die des potenten Glukokortikoids Dexamethason. Die Reduktion chemotaktischer Moleküle durch die Oxa-Behandlung führte nachweislich zu einer reduzierten Akkumulation von Immunzellen. Die anti-inflammatorischen und immunmodulatorischen Effekte von Oxa waren so ausgeprägt, dass klinisch-pathologische Marker der Glomerulonephritis, wie die Ablagerung von Immunkomplexen, die vermehrte Bildung von Kollagenfasern und die Ausscheidung von Proteinen im Urin gemildert wurden. Weiterführende Untersuchungen im SLE Modell konnten neue Zielmoleküle von Oxa identifizieren, wie KIM1 und zahlreiche SLE-assoziierte microRNAs (miR 19a, 29c und 369). Diese Befunde legen nahe, dass Oxa eine vielversprechende anti-entzündliche und -fibrotische Verbindung darstellt. rnDie Entschlüsselung des Wirkmechanismus von Oxa steht erst am Anfang. Die Analysen im Rahmen dieser Arbeit zeigten jedoch, dass Oxa einen Einfluss auf die Phosphorylierung und somit Aktivierung der p38 MAPK sowie auf die mRNA-Stabilität von proinflammatorischen Zytokinen wie TNFα zu haben scheint.rn

Different disparities of gender and race among the thrombotic thrombocytopenic purpura and hemolytic-uremic syndromes

Thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) represent multiple disorders with diverse etiologies. We compared the gender and race of 335 patients enrolled in the Oklahoma TTP-HUS Registry across 21 years for their first episode of TTP or HUS to appropriate control groups. The relative frequency of women and white race among patients with TTP-HUS-associated with a bloody diarrhea prodrome and the relative frequency of women with quinine-associated TTP-HUS were significantly greater than their control populations. The relative frequency of women and black race among patients with idiopathic TTP and TTP-associated with severe ADAMTS13 deficiency was significantly greater than their control populations. The relative frequency of black race among patients who had systemic lupus erythematosus (SLE) preceding TTP was significantly greater than among a population of patients with SLE, and the relative frequency of black race among patients with other autoimmune disorders preceding TTP was significantly greater than their control population. No significant gender or race disparities were present among patients with hematopoietic stem cell transplantation-associated thrombotic microangiopathy, TTP associated with pregnancy, or TTP associated with drugs other than quinine. The validity of these observations is supported by the enrollment of all consecutive patients across 21 years from a defined geographic region, without selection or referral bias. These observations of different gender and race disparities among the TTP-HUS syndromes suggest the presence of different risk factors and may serve as starting points for novel investigations of pathogenesis.

Interaction of pregnancy and autoimmune rheumatic disease

During pregnancy, the fetus represents a natural allograft that is not normally rejected. While the maternal immune system retains the ability to respond to foreign antigens, tolerance mechanisms are up-regulated to protect the fetus from immunologic attacks by the mother. The profound immunologic adaptations during and after pregnancy do influence maternal autoimmune rheumatic diseases in several ways. One is triggering the onset of a rheumatic disease in the post partum period, the other influencing disease activity of established rheumatic disease. The review will discuss the mechanisms of increased susceptibility of rheumatoid arthritis (RA) in the first year post partum with a specific emphasis on the role of fetal cells or antigens persisting in the maternal circulation (so called microchimerism). Furthermore, the different influences of pregnancy on established rheumatic diseases will be highlighted. A marked beneficial effect of pregnancy is observed on RA whereas several other rheumatic diseases as ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) show either no particular effect or an aggravation of symptoms during pregnancy. Differences emerging in regard to modulation of disease symptoms during pregnancy seem related to response to hormones, the type of cytokine profile and immune response prevailing as well as further downstream interactions of molecular pathways that are important in disease pathogenesis.

Cytokines and pregnancy in rheumatic disease

Cytokines are important mediators involved in the successful outcome of pregnancy. The concept of pregnancy as biased toward a Th2 immune response states that Th1 type cytokines are associated with pregnancy failure and that Th2 cytokines are protective and counteract pregnancy-related disorders. Studies at the level of the maternal-fetal interface, in the maternal circulation and in cells of peripheral blood have shown that the Th2 concept of pregnancy is an oversimplification. Both Th1 and Th2 type cytokines play a role at different stages of pregnancy and are adapted to the localization and function of cells and tissues. The changes of local and systemic cytokine patterns during pregnancy correspond to neuroendocrine changes with hormones as powerful modulators of cytokine expression. Several autoimmune disorders show a modulation of disease activity during and after pregnancy. In rheumatic diseases with a predominance of a Th1 immune response, a shift to a Th2 type immune response during pregnancy has been regarded as beneficial. Studies of pregnant patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have shown a cytokine expression similar to that found in healthy pregnant women. Significant differences were present only for a few cytokines and seemed related to the activity of the underlying disease. Interestingly, a gestational increase of cytokine inhibitors interleukin 1 receptor antagonist (IL-1ra) and soluble tumor necrosis factor receptor (sTNFR) in the circulation corresponded to low disease activity in RA. The influence of hormones and cytokines on autoimmune disease is an issue for further study.

Multiple major morbidities and increased mortality during long-term follow-up after recovery from thrombotic thrombocytopenic purpura

Recovery from acute episodes of thrombotic thrombocytopenic purpura (TTP) appears complete except for minor cognitive abnormalities and risk for relapse. The Oklahoma TTP-HUS (hemolytic uremic syndrome) Registry enrolled 70 consecutive patients from 1995 to 2011 with ADAMTS13 activity <10% at their initial episode; 57 survived, with follow-up through 2012. The prevalence of body mass index (BMI), glomerular filtration rate (GFR), urine albumin/creatinine ratio (ACR), hypertension, major depression, systemic lupus erythematosus (SLE), and risk of death were compared with expected values based on the US reference population. At initial diagnosis, 57 survivors had a median age of 39 years; 45 (79%) were women; 21 (37%) were black; BMI and prevalence of SLE (7%) were greater (P < .001) than expected; prevalence of hypertension (19%; P = .463) was not different. GFR (P = .397) and ACR (P = .793) were not different from expected values. In 2011-2012, prevalence of hypertension (40% vs 23%; P = .013) and major depression (19% vs 6%; P = .005) was greater than expected values. Eleven patients (19%) have died, a proportion greater than expected compared with US and Oklahoma reference populations (P < .05). TTP survivors may have greater risk for poor health and premature death.

State of the art: Reproduction and pregnancy in rheumatic diseases

Throughout the last decade, increasing awareness has been raised on issues related to reproduction in rheumatic diseases including basic research to clarify the important role of estrogens in the etiology and pathophysiology of immune/inflammatory diseases. Sub- or infertility is a heterogeneous condition that can be related to immunological mechanisms, to pregnancy loss, to disease burden, to therapy, and to choices in regard to family size. Progress in reproductive medicine has made it possible for more patients with rheumatic disease to have children. Active disease in women with rheumatoid arthritis (RA) affects their children's birth weight and may have long-term effects on their future health status. Pregnancy complications as preeclampsia and intrauterine growth restriction are still increased in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), however, biomarkers can monitor adverse events, and several new therapies may improve outcomes. Pregnancies in women with APS remain a challenge, and better therapies for the obstetric APS are needed. New prospective studies indicate improved outcomes for pregnancies in women with rare diseases like systemic sclerosis and vasculitis. TNF inhibitors hold promise for maintaining remission in rheumatological patients and may be continued at least in the first half of pregnancy. Pre-conceptional counseling and interdisciplinary management of pregnancies are essential for ensuring optimal pregnancy outcomes.

17-beta estradiol and progesterone-induced alterations in human type-1/type-2 cytokine balance and the role of costimulatory and apoptotic mechanisms

Evidence suggests that sex-based differences in immune function may predispose women to numerous hypersensitivity conditions such as Systemic lupus erythematosus (SLE), Hashimoto's thyroiditis and asthma. To date, the exact mechanisms of sexual dimorphism in immunity are not fully characterized but sex hormones such as 17-β estradiol (E2) and progesterone (PR) are believed to be involved. Since E2 and PR may modulate the production of critical regulatory cytokines, we sought to characterize their effects on the in vitro human type-1/type-2 cytokine balance. We hypothesized that E2 and/or PR vary cytokine production and influence costimulatory molecule expression and apoptosis. We first described the effect of E2 and/or PR on type-1 (IFN-γ and IL-12) and type-2 (IL-4 and IL-10) cytokine production by human peripheral blood mononuclear cells (PBMC) treated with various T-lymphocyte and monocyte stimuli. E2 and/or PR were each used at concentrations similar to those found at the maternal-fetal interface during pregnancy. At this dose, E2 increased IFN-γ and IL-12 production and PR decreased IFN-γ production and tended to increase IL-4 production. Furthermore, the combination of E2+PR decreased IL-12 production. This suggests that E2 shifts the type-1/type-2 cytokine balance towards a type-1 response and that PR and E2+PR shift the balance towards a type-2 response. Next, we used intracellular cytokine detection to demonstrate that E2 and/or PR are capable of altering cytokine production of CD3+ T-cells and the CD3+CD4+ and CD3+CD8+ subsets. In addition, we used the H9 T-lymphocyte cell line and the THP-1 monocyte cell line to show that E2 and/or PR can induce cytokine effects in both T-cells and monocytes independent of their interaction. Lastly, we determined the effect of E2 and/or PR on costimulatory molecule expression and apoptosis as potential mechanisms for the cytokine-induced alterations. E2 increased and PR decreased CD80 expression on THP-1 cells and PR and E2+PR decreased CD28 expression in PBMC and Jurkat cells. Furthermore, E2, PR and E2+PR increased Fas-mediated apoptosis in Jurkat cells and E2 increased FasL expression on THP-1 cells. Thus, E2 and/or PR may alter the cytokine balance by modulating the CD28/CD80 costimulatory pathway and apoptosis. ^

Microarray analysis of autoimmune diseases by machine learning procedures

—Microarray-based global gene expression profiling, with the use of sophisticated statistical algorithms is providing new insights into the pathogenesis of autoimmune diseases. We have applied a novel statistical technique for gene selection based on machine learning approaches to analyze microarray expression data gathered from patients with systemic lupus erythematosus (SLE) and primary antiphospholipid syndrome (PAPS), two autoimmune diseases of unknown genetic origin that share many common features. The methodology included a combination of three data discretization policies, a consensus gene selection method, and a multivariate correlation measurement. A set of 150 genes was found to discriminate SLE and PAPS patients from healthy individuals. Statistical validations demonstrate the relevance of this gene set from an univariate and multivariate perspective. Moreover, functional characterization of these genes identified an interferon-regulated gene signature, consistent with previous reports. It also revealed the existence of other regulatory pathways, including those regulated by PTEN, TNF, and BCL-2, which are altered in SLE and PAPS. Remarkably, a significant number of these genes carry E2F binding motifs in their promoters, projecting a role for E2F in the regulation of autoimmunity.

Precursor B cells for autoantibody production in genomically Fas-intact autoimmune disease are not subject to Fas-mediated immune elimination

The Fas/Fas ligand (FasL) system participates in regulation of the immune system through the apoptotic process. However, the extent to which abnormalities in this system are involved in the loss of self-tolerance and development of autoimmune disease not associated with Fas/FasL mutations remains unknown. The present study addresses this issue in Fas/FasL-intact, systemic lupus erythematosus (SLE)-prone (NZB × NZW) (NZB/W) F1 mice. While splenic B cells from 2-month-old mice before overt SLE expressed Fas poorly, in vitro stimulation with an agonistic anti-CD40 mAb up-regulated their Fas expression, thus revealing the existence of two populations: one was Fashigh and highly susceptible to anti-Fas mAb-induced apoptosis, and the other was Faslow and apoptosis-resistant. The Faslow cells were included in the CD5+ B cell subpopulation and contained most of the cells that produced IgM anti-DNA antibodies. The isotype of anti-DNA antibodies switches from IgM to IgG in NZB/W F1 mice at ages beginning at about 6 months. These IgG anti-DNA antibodies were produced almost exclusively by a subpopulation of splenic B cells that spontaneously expressed low levels of Fas in vivo and were apoptosis-resistant. The findings indicate that precursor B cells for autoantibody production and presumably autoantibody-secreting cells in these mice are relatively resistant to Fas-mediated apoptosis, a finding supporting the concept that abnormalities of Fas-mediated apoptotic process are involved in the development of autoreactive B cells in Fas/FasL-intact autoimmune disease.

Autoimmune response to U1 small nuclear ribonucleoprotein (U1 snRNP) associated with cytomegalovirus infection

The induction of autoantibodies to U1 small nuclear ribonucleoprotein (U1 snRNP) complexes is not well understood. We present evidence that healthy individuals with cytomegalovirus (CMV) infection have an increased frequency and quantity of antibodies to ribonucleoprotein, directed primarily against the U1-70k protein. A significant association between the presence of antibodies to CMV and antibodies to the total RNP targeted by the immune response to the spliceosome (to both the Sm and RNP; Sm/RNP) was found for patients with systemic lupus erythematosus (SLE) but not those with mixed connective-tissue disease. CMV thus may play a role in inducing autoimmune responses in a subset of patients with systemic lupus erythematosus.

Human autoantibody recognition of DNA.

Combinatorial IgG Fab phage display libraries prepared from a systemic lupus erythematosus (SLE) donor and a healthy donor were affinity selected against human placental DNA. Human monoclonal antibody Fab fragments specific for DNA were isolated from both libraries, although Fabs of the highest affinity were isolated only from the lupus library. Generally, apparent affinities of the Fabs for human placental DNA, purified double-stranded DNA, and denatured DNA were approximately equivalent. Surface plasmon resonance indicated Fab binding constants for a double-stranded oligodeoxynucleotide of 0.2-1.3 x 10(8) M-1. The higher-affinity Fabs, as ranked by binding to human placental DNA or to the oligonucleotide probe, tested positive in the Crithidia luciliae assay commonly used in the diagnosis of SLE, and interestingly the genes encoding the heavy-chain variable regions of these antibodies displayed evidence of only minimal somatic hypermutation. The heavy chains of the SLE Fabs were characterized by a predominance of basic residues toward the N terminus of complementarity-determining region 3 (CDR3). The crucial role of heavy-chain CDR3 (HCDR3) in high-affinity DNA recognition was suggested by the creation of DNA binding in an unrelated antibody by HCDR3 transplantation from SLE antibodies. We propose that high-affinity DNA-binding antibodies can arise in SLE without extensive somatic hypermutation in the variable-region genes because of the expression of inappropriate HCDR3s.

Risco cardiovascular em doentes com lúpus eritematoso sistémico

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014