Pathogenesis of Behcet's disease and Still's disease

白塞病和斯蒂尔病的发病机制

• 批准号: 8746522
• 负责人: Raphaela Goldbach-Mansky
• 金额: $ 43.74万
• 依托单位: NATIONAL INSTITUTE OF ARTHRITIS AND MUSCULOSKELETAL AND SKIN DISEASES
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8746522
• 关键词: Accounting; Adult; Adult-Onset Still' s Disease; Affect; Age; American; Anaerobic Bacteria; Antigens; Arthralgia; Arthritis; Autoantibodies; Autoimmune Diseases; Bacteria; Behcet Syndrome; Biopsy Specimen; Blood; Cells; Childhood; Chronic; Clinical; Clinical Markers; Clinical Research; Cluster Analysis; Colchicine; Communities; Complex; Country; DNA; Data; Databases; Deficiency Diseases; Dendritic Cells; Dermatologic; Development; Disease; Enrollment; Etiology; Eye diseases; Functional disorder; Future; Gastrointestinal Diseases; Gene Mutation; Genes; Genetic; Genital system; Goals; Grouping; Immune response; Immunophenotyping; Inflammation; Inflammatory; Inflammatory Response; Interleukin-1; Interleukin-1 Receptors; Interleukin-10; Interleukin-18; Interleukin-6; Juvenile-Onset Still' s Disease; Laboratories; Lipodystrophy; Measurement; Meleagris gallopavo; Methods; Modeling; Monitor; Mucous Membrane; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Neonatal; Neurologic; New York; Oral; Oral Ulcer; Oral mucous membrane structure; Organ; Organism; Outcome; Pathogenesis; Pathology; Pathway Analysis; Pathway interactions; Patients; Peripheral; Pharmaceutical Preparations; Phase; Phenotype; Pilot Projects; Play; Prednisone; Principal Component Analysis; Production; Protocols documentation; Quality of life; Questionnaires; RNA; RNA Sequences; Randomized; Reading; Recombinant DNA; Relapse; Reporting; Risk Factors; Role; Running; Safety; Sampling; Serum; Site; Specimen; Streptococcus; Syndrome; T-Lymphocyte; Temperature; Testing; Therapeutic Uses; Thrombosis; Tissues; Toxic effect; Transcript; Travel; Trees; Ulcer; United States; United States National Institutes of Health; Universities; Withdrawal; Woman; anakinra; arm; base; cohort; conventional therapy; cytokine; effective therapy; inhibitor/antagonist; insight; interest; microbial colonization; microbial community; microbiome; monocyte; neutrophil; open label; pathogen; receptor; response; sex; skin disorder; therapeutic target; time interval; treatment effect; treatment strategy

RESEARCH ACCOMPLISHMENTS Behcet's Disease CLINICAL Dr. Sibley traveled to Istanbul in December 2010 to collect patient disease questionnaire data, blood, DNA, RNA, and tissue specimens. Organ manifestations and patient questionnaires were compared between patient cohorts followed by Dr. Yusuf Yazici at New York University (NYU), Dr. Hasan Yazici at the University of Istanbul and NIAMS. While the mean age did not differ between sites, more women were seen in the United States (US) than in Turkey (p < 0.0001). Prior organ manifestations were similar for oral ulcers, genital ulcers, skin disease, arthralgia, eye disease and thrombosis. However, percentages differed among NIH, NYU, and University of Istanbul patients with gastrointestinal disease (42.9, 37 and 0, respectively; p < 0.0001) and neurologic disease (20, 17.3 and 4.5, respectively; p=0.02). American patients were treated with more prednisone and less colchicine (p < 0.0001 and 0.0009, respectively). Other disease-modifying medication use did not differ. Disease activity scores were worse in the US compared to Turkey, with mean BSAS values of 42.5 at the NIH, 36.5 at NYU and 30.4 at the University of Istanbul (p=0.01) and mean BDCAF values of 5.9 at the NIH, 5.7 at NYU and 3.3 at the University of Istanbul (p < 0.0001). No significant differences were seen between the NIH and NYU. Quality of life was also worse in the US, with mean BDQOL scores of 16.1 at the NIH compared to 12.5 in Istanbul (NS). Multivariable regression models accounting for age, sex, atypical ethnic background, and country of origin showed worse scores in ethnically atypical patients for BSAS and BDCAF (p=0.04 and p=0.01), patients from the US for BDCAF (p=0.001), older age for BDCAF (p=0.005) and women for BDQOL (p=0.01). (c) Enrollment has begun in an open label treatment study of mucocutaneous BD followed by a randomized withdrawal phase. One patient has been enrolled with several more planned over the next few months. Preliminarily, our first patient showed improvement in the number of oral ulcers and global disease activity. More definitive conclusions will be made after further patient enrollment. LABORATORY (a) The microbiome was compared between 6 Turkish paired patient samples of affected, ulcerated BD mucosa and unaffected, non-ulcerated BD mucosa and 4 healthy ethnically, age- and sex-matched control mucosa samples. 16S rDNA sequencing was performed. For most patients and controls, Streptococcus was the most common organism followed by a mix of anaerobes. No unique bacterial organisms were found in patients compared to controls. Microbial community membership did not differ between affected patient samples, unaffected patient samples, and healthy controls as analyzed by clustering analysis with Jaccard tree grouping. Based on this, we did not find a clear alteration in bacterial colonization in BD patients or controls and suspect that pathology may be due to an abnormal host response to bacteria in BD or other triggers rather than bacterial colonization itself. (b) RNA Sequencing of 17 paired Turkish oral mucosal affected and unaffected samples and 4 ethnically, age- and sex-matched controls has been performed. Principal Component Analysis (PCA) revealed that affected samples clustered together whereas unaffected samples clustered with controls. An Ingenuity canonical pathway analysis revealed that the most statistically significant and largest fold differences between affected and unaffected mucosa samples occurred in inflammatory pathways. Of the 34,799 reads, 4595 transcripts were two-fold or greater upregulated in ulcerated compared to unaffected BS samples, with 971 downregulated greater than two-fold. GSEA of NLR, TLR, IL-1 receptor and IL-10 pathways all showed enrichment in ulcerated compared to unaffected samples with normalized enrichment scores of 1.45, 1.48, 1.39 and 1.36 and nominal p-values of 0.02, 0.02, 0.11 and 0.05, respectively. These pathways did not differ between unaffected and control samples. (c) Serum samples have been obtained for all American patients with BD evaluated at the NIH under our protocols. It will be possible to evaluate cytokine profiles in the future and correlate these results with clinical parameters and results from RNA Sequencing and cell immunophenotyping studies. Adult Onset Still's Disease CLINICAL (a) The pilot study of rilonacept in AOSD has been completed. The data from this study have been monitored and the database is now locked. Preliminary analyses are now underway showing that three patients responded well to rilonacept. The two non-responders were switched to tocilizumab, an IL-6 receptor blocker, and are now showing clinical benefit. (b) Data from a preliminary study of the effect of treatment with IL-6 blockade are being analyzed for the two patients who were treated with this medication. So far, one patient showed clinical benefit whereas the other was limited by toxicity. We are considering expanding this study to more patients in order to study this more systematically. Other considerations for treatment include the use of JAK inhibitors for AOSD. LABORATORY (a) Serum samples at different time intervals and disease activity states have been obtained from patients with AOSD treated with rilonacept. These samples have been run and the analysis phase is beginning. Particular cytokines of interest are those that are implicated in the IL-1, IL-18 and IL-6 pathways, as well as other pathways known to be of importance in autoinflammation. We will correlate cytokine results with markers of clinical disease activity. CONCLUSIONS AND SIGNIFICANCE Methods similar methods to those used in the monogenic auto-inflammatory disorders NOMID and DIRA are employed to characterize clinical and inflammatory pathways in Behcets Disease and AOSD, polygenic autoinflammatory diseases in adults. 1. A clinical comparison has been made between patients with Behcet's Disease in the US and Turkey. American patients appear to report worse disease activity and worse quality of life when compared to those from Turkey. The etiology behind these findings remains to be determined. 2. A pilot treatment study of BD is underway with Anakinra, an IL-1 blocking medication. Preliminary results are encouraging. 3. Microbiome studies do not show differences in microbial colonization between BD patients and normal controls. 4. RNA sequencing results in BD show abnormalities in inflammatory pathways that are important in pathways of pathogen recognition 5. Cell immunophenotyping in BD is underway. 6. A pilot study of IL-1 inhibition with rilonacept has been completed in AOSD. Three of five patients showed good response to IL-1 blockade, whereas the remaining two patients responded well to a change of therapy to the IL-6 receptor blocker, tocilizumab. 7. Cytokine profiles will be analyzed from longitudinal serum samples collected from AOSD patients in an effort to better understand the underlying inflammatory pathophysiology.

研究成果 白塞病 临床 Sibley 博士于 2010 年 12 月前往伊斯坦布尔收集患者疾病问卷数据、血液、DNA、RNA 和组织标本。纽约大学 (NYU) 的 Yusuf Yazici 博士、伊斯坦布尔大学和 NIAMS 的 Hasan Yazici 博士对患者队列之间的器官表现和患者问卷进行了比较。 虽然不同地点的平均年龄没有差异，但美国 (US) 的女性人数多于土耳其 (p < 0.0001)。口腔溃疡、生殖器溃疡、皮肤病、关节痛、眼部疾病和血栓形成的既往器官表现相似。然而，NIH、纽约大学和伊斯坦布尔大学的胃肠道疾病患者（分别为 42.9、37 和 0；p < 0.0001）和神经系统疾病患者（分别为 20、17.3 和 4.5；p=0.02）的百分比有所不同。美国患者接受较多的泼尼松治疗和较少的秋水仙碱治疗（分别为 p < 0.0001 和 0.0009）。其他疾病缓解药物的使用没有差异。 与土耳其相比，美国的疾病活动评分较差，NIH 的平均 BSAS 值为 42.5、纽约大学的 36.5 和伊斯坦布尔大学的 30.4 (p=0.01)，NIH 的平均 BDCAF 值为 5.9、纽约大学的 5.7 和伊斯坦布尔大学的 3.3 (p < 0.0001)。美国国立卫生研究院和纽约大学之间没有发现显着差异。美国的生活质量也较差，NIH 的平均 BDQOL 得分为 16.1，而伊斯坦布尔 (NS) 的平均 BDQOL 得分为 12.5。 考虑了年龄、性别、非典型种族背景和原籍国的多变量回归模型显示，非典型种族患者的 BSAS 和 BDCAF 得分较差（p=0.04 和 p=0.01），美国患者的 BDCAF 得分（p=0.001）、年龄较大的 BDCAF 得分（p=0.005）和女性的 BDQOL 得分较差（p=0.01）。 (c) 皮肤粘膜 BD 开放标签治疗研究已开始入组，随后是随机退出阶段。已招募一名患者，并计划在未来几个月内招募更多患者。初步而言，我们的第一位患者的口腔溃疡数量和总体疾病活动度均有所改善。进一步的患者入组后将得出更明确的结论。 实验室 (a) 对 6 例土耳其配对患者受影响、溃疡性 BD 粘膜和未受影响、非溃疡性 BD 粘膜样本以及 4 例健康的种族、年龄和性别匹配的对照粘膜样本进行微生物组比较。进行16S rDNA测序。对于大多数患者和对照组来说，链球菌是最常见的微生物，其次是厌氧菌混合物。与对照组相比，患者中没有发现独特的细菌微生物。通过杰卡德树分组聚类分析进行分析，受影响的患者样本、未受影响的患者样本和健康对照之间的微生物群落成员没有差异。基于此，我们没有发现 BD 患者或对照组的细菌定植发生明显变化，并怀疑病理可能是由于 BD 或其他触发因素的宿主对细菌的异常反应，而不是细菌定植本身。 (b) 对 17 配对土耳其口腔粘膜受影响和未受影响的样本以及 4 个种族、年龄和性别匹配的对照样本进行了 RNA 测序。主成分分析 (PCA) 显示受影响的样本聚集在一起，而未受影响的样本与对照样本聚集在一起。 Ingenuity 经典通路分析显示，受影响和未受影响的粘膜样本之间最具统计学意义和最大的倍数差异发生在炎症通路中。在 34,799 个读数中，与未受影响的 BS 样本相比，有 4595 个转录本在溃疡样本中上调两倍或更多，其中 971 个转录本下调超过两倍。与未受影响的样本相比，溃疡样本中 NLR、TLR、IL-1 受体和 IL-10 通路的 GSEA 均表现出富集，标准化富集得分分别为 1.45、1.48、1.39 和 1.36，名义 p 值分别为 0.02、0.02、0.11 和 0.05。这些途径在未受影响的样本和对照样本之间没有差异。 (c) 已根据我们的方案在 NIH 评估的所有美国 BD 患者中获取了血清样本。未来将有可能评估细胞因子谱，并将这些结果与临床参数以及 RNA 测序和细胞免疫表型研究的结果相关联。 成人斯蒂尔病 临床 (a) 利洛西普在 AOSD 中的试点研究已经完成。这项研究的数据已受到监控，数据库现已锁定。目前正在进行的初步分析显示，三名患者对利洛西普反应良好。两名无反应者改用托珠单抗（一种 IL-6 受体阻滞剂），目前已显示出临床获益。 (b) 正在对两名接受该药物治疗的患者分析 IL-6 阻断治疗效果的初步研究数据。到目前为止，一名患者显示出临床获益，而另一名患者则受到毒性的限制。我们正在考虑将这项研究扩展到更多患者，以便更系统地研究这一点。治疗的其他考虑因素包括使用 JAK 抑制剂治疗 AOSD。 实验室 (a) 从接受利洛西普治疗的 AOSD 患者中获得了不同时间间隔和疾病活动状态的血清样本。这些样本已经运行，分析阶段即将开始。特别感兴趣的细胞因子是与 IL-1、IL-18 和 IL-6 途径以及已知在自身炎症中重要的其他途径有关的细胞因子。我们将把细胞因子结果与临床疾病活动标记相关联。 结论及意义 方法采用与单基因自身炎症性疾病 NOMID 和 DIRA 中使用的方法类似的方法来表征白塞病和成人多基因自身炎症性疾病 AOSD 的临床和炎症途径。 1. 对美国和土耳其的白塞氏病患者进行了临床比较。与土耳其患者相比，美国患者的疾病活动度和生活质量似乎更差。这些发现背后的病因仍有待确定。 2. 一项使用 Anakinra（一种 IL-1 阻断药物）治疗 BD 的试验性研究正在进行中。初步结果令人鼓舞。 3. 微生物组研究并未显示 BD 患者和正常对照之间的微生物定植存在差异。 4. BD 中的 RNA 测序结果显示炎症途径异常，这对于病原体识别途径很重要 5. BD 的细胞免疫表型分析正在进行中。 6. 利洛那西普抑制 IL-1 的初步研究已在 AOSD 中完成。五名患者中的三名对 IL-1 阻断剂表现出良好的反应，而其余两名患者对 IL-6 受体阻断剂托珠单抗治疗的改变反应良好。 7. 将从 AOSD 患者收集的纵向血清样本中分析细胞因子谱，以更好地了解潜在的炎症病理生理学。