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Journal of Peking University (Health Sciences) ›› 2024, Vol. 56 ›› Issue (6): 972-979. doi: 10.19723/j.issn.1671-167X.2024.06.005

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Immunological characteristics of patients with anti-synthetase syndrome overlap with rheumatoid arthritis

Liang ZHAO1, Chenglong SHI1,2, Ke MA3, Jing ZHAO1, Xiao WANG4, Xiaoyan XING1, Wanxing MO1, Yirui LIAN1, Chao GAO1, Yuhui LI1,3,*()   

  1. 1. Department of Rheumatology and Immunology, Peking University People' s Hospital, Beijing 100044, China
    2. Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing 100142, China
    3. Department of Rheumatology and Immunology, Peking University People' s Hospital, Qingdao, Qingdao 266111, Shandong, China
    4. Department of Hematology and Rheumatology, the People' s Hospital of Xishuangbanna Dai Nationality Autonomous Prefecture, Xishuangbanna 666100, Yunnan, China
  • Received:2024-07-25 Online:2024-12-18 Published:2024-12-18
  • Contact: Yuhui LI E-mail:liyuhui84@163.com
  • Supported by:
    the National Natural Science Foundation of China(82371804);the Beijing Natural Science Foundation(L222017);the Peking University People' s Hospital Scientific Research and Development Foundation(RDX2023-03);the Peking University People' s Hospital Scientific Research and Development Foundation(RZ2024-02)

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Abstract:

Objective: To investigate the clinical and immunological characteristics of anti-synthetase syndrome (ASS) patients overlap with rheumatoid arthritis (RA). Methods: A retrospective analysis was conducted on ASS patients with arthritis who were treated at Peking University People' s Hospital. Data collected included demographic information, clinical manifestations, laboratory features, lymphocyte subsets in peripheral blood, and treatments. The patients with ASS were divided into two groups based on the presence or absence of RA for comparative analysis. Results: A total of 104 ASS patients with arthritis were included, among whom 23.1% (24/104) were diagnosed with RA. The ASS with RA group had a significantly higher incidence of rapidly progressive interstitial lung disease (RP-ILD) (41.7% vs. 17.6%, P=0.032), number of tender joints [10 (7, 14) vs. 4 (0, 8), P < 0.001], number of swollen joints [4 (2, 8) vs. 2 (0, 4), P=0.012], and rate of bone erosion (47.8% vs. 2.5%, P < 0.001) compared with the non-RA group. Levels of platelets [(289.57±68.74)×103/μL vs. (247.94±77.04)×103/μL, P=0.022], erythrocyte sedimentation rate (ESR) [43 (19, 59) mm/h vs. 18 (10, 44) mm/h, P=0.019], and C-reactive protein (CRP) [19.20 (4.80, 55.36) mg/L vs. 5.68 (1.10, 14.96) mg/L, P=0.006] were found significantly higher in the ASS with RA group than those in non-RA group. Analysis of immune cells in peripheral blood mononuclear cell (PBMC) showed that significantly decreased proportions of CLA+ Treg cells [(11.12±4.10)% vs. (17.22±8.49)%, P=0.003], B cells [8.56% (4.80%, 11.90%) vs. 14.55% (8.75%, 20.29%), P=0.025], and natural killer (NK) cells [7.56% (4.65%, 13.20%) vs. 13.25% (7.46%, 19.25%), P=0.045] in the overlap group compared with non-RA group. Proportion of Naïve Th cells [(52.66±17.66)% vs. (40.76±14.96)%, P=0.033)] was significantly increased in overlap group compared with non-RA group. Overlap group had lower rate of complete clinical response than non-RA group (16.7% vs. 43.8%, P=0.031). Conclusion: Among ASS patients with arthritis, those with RA have more severe lung and joint involvement and a lower treatment response rate, highlighting the need for early recognition and aggressive intervention.

Key words: Anti-synthetase syndrome, Rheumatoid arthritis, Lymphocyte subsets, Complete clinical response

CLC Number: 

  • R593.2

Table 1

Clinical features of patients with ASS overlap with RA and non-RA"

Variables ASS overlap RA (n=24) ASS with arthritis (n=80) P value
Demographic data
   Onset age/years 48.00 (40.50, 55.50) 49.00 (40.50, 57.00) 0.802
   Female 20 (83.3) 62 (77.5) 0.742
   Disease duration/months 3 (1, 28) 9 (2, 24) 0.260
General
   Fever 13 (54.2) 30 (38.0) 0.241
Mucocutaneous
   Heliotropic rash 2 (8.3) 18 (22.5) 0.212
   Gottron’s sign/papule 13 (54.2) 49 (61.2) 0.702
   V sign 3 (12.5) 19 (23.8) 0.369
   Shawl sign 0 (0) 11 (13.8) 0.123
   Mechanic’s hands 9 (37.5) 41 (51.2) 0.342
   Skin ulcer 1 (4.2) 1 (1.2) 0.948
   Periungual erythema 3 (12.5) 5 (6.2) 0.568
Interstitial lung disease
   RP-ILD 10 (41.7) 13 (17.6) 0.032
   C-ILD 14 (58.3) 55 (74.3) 0.217
Musculoskeletal
   Muscle weakness 11 (45.8) 42 (52.5) 0.734
   Myalgia 8 (33.3) 38 (47.5) 0.322
   Dysphagia 2 (8.3) 7 (9.3) >0.999
   Tender joint count 10 (7, 14) 4 (0, 8) ＜0.001
   Swollen joint count 4 (2, 8) 2 (0, 4) 0.012
   Bone erosion 11 (47.8) 2 (2.5) ＜0.001

Table 2

Distribution of joint involvement in patients with ASS overlap with RA and non-RA"

Joint involvement ASS overlap RA (n=24), n (%) ASS with arthritis (n=80), n (%) P value
Temporomandibular joints 1 (4.2) 2 (2.5) >0.999
Sternoclavicular joints 1 (4.2) 1 (1.2) 0.948
Shoulder 13 (54.2) 17 (21.2) 0.004
Elbow 9 (37.5) 14 (17.5) 0.073
Wrist 14 (58.3) 31 (38.8) 0.143
Metacarpophalangeal joints 13 (54.2) 33 (41.2) 0.377
Proximal interphalangeal joints 20 (83.3) 55 (68.8) 0.255
Distal interphalangeal joints 4 (16.7) 10 (12.5) 0.854
Knee 13 (54.2) 39 (48.8) 0.816
Ankle 6 (25.0) 12 (15) 0.408

Table 3

Laboratory characteristics of patients with ASS overlap with RA and non-RA"

Variables ASS overlap RA (n=24) ASS with arthritis (n=80) P value
WBC/(×103/μL) 8.78 (7.21, 9.88) 7.90 (5.70, 9.94) 0.553
Lymphocyte/(×103/μL) 1.40 (1.08, 1.83) 1.60 (1.15, 2.30) 0.576
Platelet/(×103/μL) 289.57±68.74 247.94±77.04 0.022
CK/(U/L) 166.0 (37.5, 1 074.0) 210.0 (80.5, 1 020.5) 0.386
ESR/(mm/h) 43 (19, 59) 18 (10, 44) 0.019
CRP/(mg/L) 19.20 (4.80, 55.36) 5.68 (1.10, 14.96) 0.006
Elevated ferritina 3 (27.3) 11 (28.9) >0.999
Anti-CCP positivity 18 (75.0) 1 (1.2) ＜0.001
RF positivity 19 (79.2) 6 (7.5) ＜0.001
AKA positivityb 2 (28.6) 1 (5.9) 0.396
APF positivityc 11 (52.4) 0 (0) ＜0.001
HRF positivityd 1 (5.0) 0 (0) 0.753
GPI positivityc 4 (19.0) 1 (2.6) 0.093
Anti-MCV positivitye 7 (58.3) 3 (11.1) 0.007
Anti-Ro-52 positivityf 14 (66.7) 45 (73.8) 0.731
Anti-Jo-1 positivityg 13 (56.5) 48 (60.8) 0.902
Anti-PL-7 positivityg 0 (0) 13 (16.5) 0.084
Anti-PL-12 positivityg 6 (26.1) 11 (13.9) 0.289
Anti-EJ positivityg 3 (13.0) 9 (11.4) >0.999
Anti-OJ positivityg 0 (0) 1 (1.3) >0.999

Table 4

Comparison of peripheral blood lymphocyte subsets in patients with ASS overlap with RA and non-RA"

Variables ASS overlap RA (n=16) ASS with arthritis (n=45) P value
CD3+ total T/% 75.90 (66.64, 83.87) 68.80 (60.11, 75.55) 0.083
CD3+ total T/(/μL) 1 108.43±385.28 1 156.27±532.71 0.757
CD4+ helper T/% 46.30±18.23 40.78±11.39 0.270
CD4+ helper T/(/μL) 650.00 (357.00, 947.00) 610.00 (393.00, 984.50) 0.849
CD8+ cytotoxic T/% 24.35 (18.11, 32.66) 23.30 (16.84, 31.30) 0.887
CD8+ cytotoxic T/(/μL) 279.00 (254.00, 477.00) 377.20 (233.50, 500.80) 0.414
CD4+/CD8+ T ratio 1.85 (1.34, 2.63) 1.78 (1.31, 2.92) 0.758
CD4+CD25highCD127low Treg/% 7.90 (4.65, 9.75) 8.20 (6.35, 10.00) 0.463
CD4+CD25highCD127lowCD161+Treg/% 10.90 (8.60, 15.45) 11.50 (7.20, 13.25) 0.487
CD4+CD25highCD127lowCLA+Treg/% 11.12±4.10 17.22±8.49 0.003
CD4+CXCR5+PD-1+ pTfh/% 1.10 (0.80, 2.35) 2.60 (1.60, 3.10) 0.053
CD4+CD45RA- Naïve Th/% 52.66±17.66 40.76±14.96 0.033
CD4+CD25highFoxP3+ Treg/% 6.14 (4.04, 7.66) 7.00 (5.46, 8.78) 0.220
CD4+Foxp3-Teff/% 93.00 (91.60, 95.45) 91.20 (89.15, 93.30) 0.078
CD19+B/% 8.56 (4.80, 11.90) 14.55 (8.75, 20.29) 0.025
CD56+CD16+ NK/% 7.56 (4.65, 13.20) 13.25 (7.46, 19.25) 0.045
Th1 (TNF-α)/% 33.04±12.31 32.85±10.97 0.963
Th1 (IFN-γ)/% 6.88 (5.51, 9.70) 8.70 (6.65, 13.21) 0.257
Th1 (IL-2)/% 46.52±11.50 44.57±14.24 0.694
Th2 (IL-4)/% 1.54±0.69 1.63±0.86 0.774
Th-17 (IL-17)/% 1.18±0.69 1.38±0.56 0.358

Table 5

Comparison of treatment in patients with ASS overlap with RA and non-RA"

Variables ASS overlap RA (n=24), n (%) ASS with arthritis (n=80), n (%) P value
Glucocorticoids 24 (100.0) 80 (100.0) >0.999
CTX 9 (37.5) 34 (42.5) 0.842
MMF 3 (12.5) 16 (20.0) 0.594
CSA 12 (50.0) 25 (31.2) 0.150
TAC 5 (20.8) 7 (8.8) 0.207
AZA 0 (0) 7 (8.8) 0.300
MTX 2 (8.3) 5 (6.2) >0.999
LEF 0 (0) 1 (1.2) >0.999
IVIG 9 (37.5) 10 (12.5) 0.013
Tocilizumab 1 (4.2) 5 (6.2) >0.999
Rituximab 2 (8.3) 2 (2.5) 0.485
TOF 1 (4.2) 2 (2.5) >0.999
Monotherapy (glucocorticoids) 2 (8.3) 5 (6.2) >0.999
Glucocorticoids+immunosuppressants 20 (83.3) 67 (83.8) >0.999
Glucocorticoids+biologics 0 (0) 1 (1.2) >0.999
Glucocorticoids+immunosuppressants+biologics 2 (8.3) 7 (8.8) >0.999

Figure 1

Proportion of complete clinical response in patients with ASS overlap with RA and non-RA Patients with CCR were composed of following groups: (1) stabilization of muscle strength and function; (2) disappearance of extramuscular manifestations; (3) normalization of creatine kinase levels; (1)+(2) simultaneous stabilization of muscle strength and function, and disappearance of extramuscular manifestations; (1)+(3) simultaneous stabilization of muscle strength and function, and normalization of creatine kinase levels; (2)+(3) simultaneous disappearance of extramuscular manifestations, and normalization of creatine kinase levels; (1)+(2)+(3) simultaneous stabilization of muscle strength and function, disappearance of extramuscular manifestations, and normalization of creatine kinase levels. ASS, anti-synthetase syndrome; RA, rheumatoid arthritis; NCCR, non complete clinical response; CCR, complete clinical response."

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