i n d i a n j o u r n a l o f r h e uma t o l o g y 9 ( 2 0 1 4 ) S 1eS 6 S5

November 30, 2014, Sunday

O13. Assesment of efficacy of local steroid injection for heelenthesitis in patients with seronegative spondyloarthropathy:A serial ultrasound study

Puja Srivastava, Amita Aggarwal; Department of ClinicalImmunology, Sanjay Gandhi Postgraduate Institute of MedicalSciences, Lucknow, India

Introduction: Corticosteroid injection for heel enthesitis in SpA is

controversial. We studied soft tissue changes at symptomatic heel

enthesitis, by ultrasound examination and compared VAS pain

score and USG findings, at baseline and 6 weeks after local corti-

costeroid injection.

Methods: SpA patients with symptomatic heel enthesitis, re-

fractory to 6 weeks of full dose NSAIDs, were offered local corti-

costeroid injection. Heel entheses were examined by USG before

and 6 weeks after injection. Standard OMERACT definitions were

used to define enthesitis, Achilles tendon >5.2 mm and plantar

fascia >4.4 mm thick at 2 cm proximal to insertion, were consid-

ered thickened).

Results: Forty two symptomatic entheses were examined by USG

in 32 patients, which included 22 right and 16 left tendoachilles, 1

right and 3 left plantar fascia. Mean age of patients was 29.2 years,

29 were males. Cohort included 17 patients with Ankylosing SpA,

7 with JIA-ERA and 2 each with IBD associated Arthritis, PsA, ReA

and Undifferentiated SpA.

Sixweek followup (post-injection)wasavailable for 26patients.All

patients reported improvement in Pain on VAS after injection

(p<0.0001), which correlated with USG findings. There was signif-

icant reduction in entheseal thickness (p<0.0001), power Doppler

signal (p<0.0001), peritendinous edema (p¼0.002), bursitis and

bursal vascularity (p¼0.003 and <0.0001 respectively). There was

no change in bone erosions and enthesophytes. None of the pa-

tients had injection related complications at 6 weeks of follow up.

Conclusions: This study confirms the clinical and sonographic

efficacy of local steroid injection for refractory heel enthesitis in

patients with SpA

O14. Comparison between colour doppler Ultrasound and MRIin documenting response to treatment with NSAIDs and inassessing disease activity in non-radiographicspondyloarthropathy

Debanjali Sinha, Sumantro Mondal, Alakendu Ghosh; Departmentof Rheumatology, IPGME&R, Kolkata, West Bengal, India

Introduction: The objective of our study was to assess changes in

ultrasound features of sacroiliitis after NSAID use in patients with

non-radiographic spondyloarthropathy and to compare the

changes with that of MRI after treatment.

Methods: 20 patients diagnosed with non-radiographic spondy-

loarthropathy based on inflammatory low back pain and MRI

proven sacroiliitis, were made to undergo a baseline USG of

sacroiliac (SI) joints. They were then kept on NSAIDs for duration

of 3months. After 3months, USG andMRI of sacroiliac joints were

repeated and the both compared. USG findings at baseline and at

follow up were also correlated with BASDAI.

Results: A Wilcoxon’s signed rank test was done to compare the

number of flow signals on USG of SI joint at baseline and after 3

months of treatment and p value was found to be significant

(p<0.05), which means that vascularity of SI joints significantly

decreases with NSAID. Number of flow signals in SI joint also

correlated well with BASDAI at baseline (Spearman’s rho corre-

lation coefficient ¼0.632) and follow up (Spearman’s rho correla-

tion coefficient ¼0.701). However, MRI at baseline and follow up

were same and could not assess change with NSAID nor could it

predict disease activity.

Conclusion: Ultrasonography of SI joint is a sensitive way of

assessing response to NSAID use in Spondyloarthropathy patients

and may help in monitoring disease activity.

O15. Recombinant Salmonella typhimurium outermembrane protein (OMP) A and D reactive T cells areexpanded in synovial fluid of patients with Reactive arthritis(ReA) and Undifferentiated spondyloarthropathy (uSpA)

Smriti Chaurasiaa, A.K. Shasanyb, Amita Aggarwala,

Ramnath Misraa; aSanjay Gandhi Postgraduate Institute of MedicalSciences, Lucknow, India; bPlant Biotechnology Division, CentralInstitute of Aromatic and Medicinal Plant, Lucknow, India

Introduction: Among the outer membrane proteins of S typhimu-

rium identified by us using proteomics earlier, we studied the

frequency of recombinant OMPA and OMPD reactive T cells in the

synovial fluid (SF) of patients with ReA /uSpA.

Methods: rOMPA and rOMPD were synthesized by using pET

expression vector and His tag for purification of protein. SF

mononuclear cells of 20 patients with ReA/uSpA and 8 patients

with rheumatoid arthritis (RA) were cultured with rOMPA/D and

IFN-g production by T cells was assessed by Flow cytometry,

ELISPOT and ELISA.

Results: Frequency of IFN-g producing CD8 T cells was increased

to crude OMP in 13/20, rOMPA in 9/20 and to rOMPD in 4/20 pa-

tients. Frequency of IFN-g producing CD4 T cells was increased to

crude OMP in 6/15, rOMPA in 4/15 and to rOMPD in 2/15 patients.

By ELISPOT, 13, 7 and 3 patients showed increased g-IFN produc-

ing SF T cells to OMP crude, rOMPA and rOMPD respectively. Mean

spots/well were 75±69.35 to OMP crude, 38.29±33.0 to OMPA and

18.67±11.7 to OMPD in comparison to blank (10±6.29).

IFNg level was found to be higher in culture supernatant of cells

treated with rOMPA (3129.4±536.48, p¼0.03), but not with rOMPD

(1793.2±2842.79) as compared to blank media.

Conclusion: OMPA is a major antigenic target in patients with

Salmonella triggered ReA/uSpA.

O16. Presence of HLA-B27 gene in reactive arthritis patientsand its association with Chlamydia trachomatis infection

Praveen Kumara, Darshan Singh Bhakunib, Sangita Rastogia;aMicrobiology Laboratory, National Institute of Pathology (ICMR),Safdarjung hospital, India; bDepartment of Rheumatology and ClinicalImmunology, Army Hospital (Research & Referral), New Delhi, India

Introduction: The Human Leukocyte Antigen (HLA-B27) is a class I

antigen of the major histocompatibility complex, and is strongly

associated with spondyloarthropathy. The aim of the present

study was to investigate the distribution of HLA-B27 in patients

with reactive arthritis (ReA)/ undifferentiated spondyloar

i n d i a n j o u rn a l o f r h e uma t o l o g y 9 ( 2 0 1 4 ) S 1eS 6S6

thropathy (uSpA) and to find its association with Chlamydia

trachomatis infection.

Methods: Following ethical permission, a prospective case-control

studywas conducted on 60 ReA/ uSpA/ RA patients (ESSG and ACR

criteria) attending a tertiary care hospital in India. Synovial fluid

was aspirated in all patients and DNA isolation was done. These

patients were screened for C. trachomatis plasmid gene by PCR

while HLA-B27 gene was located by commercially available

Sequence Specific Primer (SSP) PCR kit. Clinical data was corre-

lated with the presence of C. trachomatis and HLA-B27 gene.

Results: 40% (12/30) ReA/ uSpA and 3.3% (1/30) RA patients were

found positive for HLA-B27 gene (p value- 0.005 versus RA). 23.3%

(7/30) ReA/uSpA patients were positive for C. trachomatis plasmid

gene (p value- 0.01 versus RA). Among C. trachomatis-positive

patients, 57.1% (4/7) were found positive for HLA-B27 gene. All C.

trachomatis-infected patients found to be positive for HLA-B27

had moderate to severe effusion with multiple joint involvement

and <6 months disease duration.

Conclusions: Results suggest that the presence of HLA-B27 gene

probably causes moderate to severe disease in C. trachomatis-

positive ReA/ uSpA patients, hence, screening for HLA-B27 might

be useful in such patients.

O17. Clinical & Immunological Profile Of Primary Sjogren’sSyndrome In South Indian Tamils: A Single Centre Experience

Vikramraj Jain, Bharat Singh, Sonal Mehra, Jignesh Usdadiya,

M. Christina Mary, C.B. Mithun, Vir Singh Negi; Department ofClinical Immunology , JIPMER, Puducherry, India

Introduction: Primary Sjogren’s syndrome disease spectrum

constitutes glandular, extra glandular and systemic manifesta-

tions. We analyzed 104 primary Sjogren’s syndrome patients with

respect to their clinical and immunological profile.

Methods: One hundred and four patients satisfying American-

European Consensus Group criteria for Primary Sjogren’s syn-

drome were enrolled over a period of 5 years. Demographic, clin-

ical, serological & therapeutic data was analyzed retrospectively.

Results: Themean age at presentation was 42.01(±12.24; range 15-

87) years; 96.2% were females (M:F ¼1:25). Dryness of eyes, mouth

and parotid swelling were noted in 64.4 %, 73.1 % and 29.8 % pa-

tients respectively. Extra glandular manifestations included:

articular (82.7%); renal (26.9%); purpura/cutaneous vasculitis

(22.1%); ILD (5.7%); Raynaud’s phenomenon (4.8%) and peripheral

neuropathy (1. 9%) . Hypokalemic periodic paralysis was seen in

22.2% and autoimmune hypothyroidism was present in 10/

104(9.61%) patients. One patient developed non-Hodgkin’s lym-

phoma during follow up period. Salivary scintigraphy was

abnormal in 78.9%, while 56.9 % had positive Schirmer’s test.

Minor salivary gland biopsy was consistent with Sjogren’s syn-

drome in 46/54 (85.2%) biopsied patients. Antinuclear antibody

was positive in 93.4%. Rheumatoid factor was positive in 75.4%,

anti-SSA in 84.4 % and anti-SSB in 51.1%. Anti-TPO and anti-TG

antibodies were detected in 48.89% and 36.67% patients respec-

tively. Most of the patients were on methotrexate (42%), hydrox-

ychloroquine (87%) & low dose steroids (44.2%). Only 10% patients

had severe extra glandular involvement requiring more aggres-

sive immunosuppression.

Conclusions: Clinical and immunological profile of primary Sjog-

ren’s syndrome at our center was consistent with reported liter-

ature. However, we observed higher articular and renal

involvement.

O18. Randomized controlled trial of low-dose intravenouscyclophosphamide versus oral mycophenolate mofetil intreatment of lupus nephritis

Manish Rathia, Aman Sharmab, Ajay Goyala, Ajay Jaryala,

Pramod K. Guptac, Krishan Lal Guptaa; aDepartments ofNephrology; bInternal Medicine, and cBiostatistics, PostgraduateInstitute of Medical Education and Research, Chandigarh, India

Introduction: There is no study till date comparing oral myco-

phenolate mofetil (MMF) with fixed low-dose intravenous (i.v.)

cyclophosphamide (Euro-Lupus Nephritis Treatment, ELNT)

regimen in the treatment of less severe, proliferative lupus

nephritis (LN).

Methods: This was an open label, prospective, randomized, two-

arm study including cases of class III, IV, & V LN. Those with

crescentic LN, serum creatinine >265.0 mmol/L, and prior immu-

nosuppressive treatment were excluded. The subjects were

randomised to receive either fixed low dose i.v. CYC (ELNT

regimen) or oral MMF (2-3 gm/day). All subjects also received 3

pulses of i.v. methylprednisolone 750 mg each followed by 1mg/

kg/day prednisolone. The primary end point was the treatment

response. The secondary end points were a. complete renal

remission b. systemic Lupus Erythematosus Disease Activity

Index (SLEDAI)] and c. adverse events.

Results: A total of 139 subjects were screened, of which 81 were

randomized to receive either i.v. CYC (n¼39) or oral MMF (n¼42).

There was no difference in the baseline characteristics except for

uPCR which was significantly higher in the CYC group. At the end

of 24 weeks, 81.8% subjects in the CYC group and 80% subjects in

the MMF group achieved primary endpoint (p¼ns). Similarly, the

remission rate was achieved equally in both the groups (51.5% in

CYC vs 60% in MMF, p¼ns). Significantly higher number of sub-

jects in the MMF group as compared to CYC group had gastroin-

testinal symptoms (50% vs 2.7% respectively, p<0.001). There was

no difference in other adverse event between the two groups. The

monthly cost of oral MMF was four fold higher to that of the CYC

therapy.

Conclusion: Both the treatment options achieved similar treat-

ment response and remission rates with significantly higher cost

and greater incidence of gastrointestinal symptoms in the MMF

group.