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The Chemistry of Explosives by J. Results evidenced archetypal structures type II-S in all isolates with the exception of a sequence isolated from a plasma sample, that corresponds to the type II-R found in PML subjects. Finally, the viral protein 1 VP1 genotyping was performed and results showed the prevalence of the European genotypes 1A, 1B, and 4.
Further investigations are necessary in order to recognize the real impact of biologics on JCPyV life cycle and to identify possible and specific viral variants related to increased virulence in CIRDs patients.
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Rheumatic Arthritis RA is a multiple joints inflammatory disease associated with an increased mortality when autoantibodies can be detected in the serum Gerlag et al. Pathogenesis causes destruction and fusion of the spinal vertebrae and sacroiliac joints and the ligament calcification process, which results in pain Ghasemi-Rad et al. Psoriatic arthritis PsA is a systemic inflammatory arthritis characterized by chronic and progressive disease leading to lost productivity and reduced quality of life. PsA affects men and women equally Dewing, PsA is a distinct disease respect to RA and AS, nevertheless, disease-modifying anti-rheumatic drugs DMARDs were introduced into the therapy of all these inflammatory rheumatic diseases to provide symptomatic improvement and to progress or maintain quality of life Moll and Wright, ; Bijlsma, Pro-inflammatory cytokines are also involved in the pathogenesis of many inflammatory and autoimmune diseases since their overexpression.
Therefore, to counteract this phenomenon, synthetic glucocorticoids GCs are widely used, unfortunately, many patients show unresponsiveness called GC resistance GCR Dejager et al. PML occurs as a consequence of lytic infection of oligodendrocytes with a tumultuous disease course and poor prognosis within a few months. It is still unclear whether the virus seeds into the Central Nervous System CNS during primary viremia or following latency escape secondary viremia , in fact, whether JCPyV is carried into the brain by infected lymphocyte or whether it directly crosses the brain barrier, is a matter of debate Hirsch et al.
JCPyV is a non-enveloped icosahedron constituted by three viral proteins VP with VP1 being the major constituent and determines receptor specificity and viral genotypes Agostini et al. There are several distinct PML risk populations.
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The largest is the human immunodeficiency virus positive PML population. Because of the low PML incidence reported in patients with RA, the potential positive predictive value of the anti-JCV assay would be too low to serve as a valuable risk-mitigation option. Cases of rituximab-associated PML have often been characterized by underlying diagnoses and prior immunosuppressant use Borie and Kremer, Poor data are present in literature regarding the possible link between administration of etanercept and JCV infection or reactivation in treated patients.
However, in , Nardis et al. In an observational study published in by Bellizzi et al. In 2 CD subjects a rearranged form of the viral non-coding control region NCCR was also found in colon-rectal biopsies after 16 months of therapy Bellizzi et al. Each box contains binding sites for transcriptional cell factors involved in viral transcription. These binding sites undergo to deletion and enhancement process generating variants that could up-modulate viral expression in a specific anatomical site and could alter the cellular host range Jensen and Major, ; Tan and Koralnik, Mad-1 strain was isolated from tissues of PML patients Jensen and Major, ; Tan and Koralnik, and it was named on the hypothesis that it results from a rearrangement of the archetype Marshall and Major, Although viral infection and replication occurs at very high incidence, as demonstrated by Egli et al.
Therefore, continued research and a more detailed understanding of JCPyV biology, epidemiology and pathology are of increasing importance.
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In this study, 34 subjects affected by CIRDs 12 males, 22 females were dynamically enrolled. Among these 34 outpatients, 8 were affected by RA 8 females , 8 were affected by AS 4 males, 4 females and 18 patients were affected by PsA 10 males, 8 females.
After obtaining informed consent, basic demographic data including concomitant medications and disease activity measures, were collected and recorded on a standardized form, just before the beginning of biologic therapy. All patients were classified according to standard criteria Van der Linden et al. Each patient was evaluated by the same rheumatologist. The HAQ scores range from 0 to 3, with a higher score indicating a higher level of disability Lesuis et al. Clinical data of patients affected by CIRDs at baseline and during follow-up.
In particular, 33 urine and blood samples were collected from 33 patients at T3, 31 urine and 32 blood samples were collected from 32 patients at T6, 31 urine and 32 blood samples were collected from 32 patients at T12 and finally 32 urine and blood samples were collected from 32 patients at T A, Italy according to the manufacturer's instructions.
A, Italia , were centrifuged at 1. A, Milan, Italy. A, Milan, Italy according to the manufacturer's instruction. Each sample was analyzed in duplicate and the viral loads were given as the mean of at least two positive reactions. Standard precautions designed to prevent contamination were followed and a negative control was included in each run. Viral DNA was quantified using a standard curve consisted of serial dilutions at known titer of a plasmid containing the entire JCPyV genome.
Standard precautions designed to prevent contamination were followed and a negative control was included in each run Kwok and Higuchi, DNA sequencing was performed in service BioFab research s. If Z -test indicated a non-normal distribution, we used non-parametric tests such as Mann—Whitney U -test and Kruskal—Wallis test.
These outpatients were divided in three different classes on the basis of their pathology: 8 RA 8 females , 8 AS 4 males, 4 females and 18 PsA 8 males, 10 females. None of the patients developed neurological symptoms suggestive of PML at any time point of this 18 month follow-up study. JC viral load in biological specimens collected from patients with Chronic Inflammatory Rheumatic Diseases at baseline and during the follow-up. JC viral load in biological samples collected from patients with psoriatic arthritis, rheumatoid arthritis and ankylosing spondylitis at baseline and during the follow-up.
JCPyV urine loads vs. The values of JCPyV viruria for each patient at the different time-points were reported on the x-axis whereas the corresponding viremia values on the y-axis. Viremia was mainly associated to viruria during the entire follow-up. Regarding PBMCs, 3 out of 33 9. JCPyV viruria was found in 13 out of 31 Both patients were also JCPyV-positive in urine samples data not showed. In addition, a relative risk RR of viral reactivation with urinary shedding equal to 2.
Therefore, JCPyV shedding in the urine is favored respect to JCPyV circulation in the blood compartment where the virus is detected at very low incidence. At T3, At T6, in Results showed that all sequences belonged to type II-S archetype CY , with the exception of a sequence isolated from a plasma sample characterized by the subsequent structure: the entire box A is directly followed by a complete box C because of the whole box B was deleted, then a rearranged box C was present and it was tailed by shortened sequence of boxes D and E.
In particular, the prototype Mad-1 was isolated from tissues of patients with PML Tan and Koralnik, and it was named on the hypothesis that the prototype results from a rearrangement of the archetype sequence Comar et al. It was isolated by Yogo et al. Each box contains binding sites for transcriptional cell factors involved in viral early and late transcription.
These binding sites undergo to deletion and enhancement process that could generate variants that could up-modulate viral expression in a specific anatomical site Jensen and Major, B In B , the rearranged sequence found in plasma at T3 is reported. This rearrangement presents the entire boxes A and C followed by a rearranged box C, shortened sequences of boxes D and E, a new duplication of box C complete and rearranged , incomplete boxes D and E and finally the entire box F.
Asterisks represent single nucleotide point mutations or deletions. Italicized capital letters indicate mutated nucleotides. Boxes division from A to F is also shown.
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The main binding sites for transcriptional cell factors are also indicated and the corresponding nucleotides sequences are underlined. Finally, the nucleotides sequences for the transcriptional factor Spi-B are also shown in higher font. Nevertheless, treatments with biological drugs are associated with an increased susceptibility to viral infections including that by JCPyV, the etiological agent of the demyelinating disease named PML Comar et al.
The incidence of PML in immune-mediated diseases has recently increased as a consequence of an improved use of biologics and other potent immune-modulatory medications Berger, Therefore, it could be interesting to understand whether there is a correlation between biologics administered for CIRDs and the opportunity that the virus escapes from latency, replicates actively and spreads to the brain causing PML.
In fact, despite the limited range of species and permissive cell types for viral replication, JCPyV is a very successful pathogen because of it is able to tightly regulate its life cycle in the infected host. Conversely, a previous study demonstrated a positive correlation between the JCPyV DNA detection in the urine and the number of biologics consecutively used for RA treatment Verheyen et al.
In addition, the effect of an ongoing immunosuppression on the JCPyV replication is confirmed by the striking number of urine positive samples detected at T These data allow an intriguing speculation: JCPyV might directly trigger joint inflammation. Indeed, it is well-known that viral infections can directly act on the immune system through the secretion of pro-inflammatory cytokines or favoring the production of autoantibodies Franssila and Hedman, Therefore, urine JCPyV loads not only could be supported by inflammatory state but also could be continuous due to this insult.
The hypothesis of a role of biologics in promoting viruria is also sustained by the results of an our previous study, in which we observed a significantly increased JC viruria in young patients with Crohn's disease treated with infliximab respect to those receiving a standard therapy Bellizzi et al. Hence, monitoring urine JCPyV replication is a good, non-invasive method to check viral pathogenic potential.
In conclusion, results evidenced how viral replication and spreading could be cumulatively influenced by the use of various immune-suppressants, including biologics, rather than by a specific medications, also considering their sequential administration in the treatment refractory patients. However, due to the low number of patients analyzed in this study, how cumulative effect of various immunosuppressive agents really influence JCPyV pathogenesis, need further validation.
Therefore, the cohort of studied subjects is being expanded. Interestingly, this type II-R rearrangement resembles the viral variants isolated in subjects who developed PML, and it is characterized by a marked neurotropism Agostini et al. Moreover, it is noteworthy that this NCCR structure presents a high-affinity binding site for the specific hematopoietic transcriptional factor Spi-B.
Therefore, it is possible to hypothesize that this neurovirulent variant could enter PBMCs, using them as a carrier to disseminate in the bloodstream and to reach the brain Kumar et al. Furthermore, it is well-known that detecting viral genome in cerebrospinal fluid lied on PML diagnosis, however, its failure does not rule out the possibility that a patient might have PML, particularly in the earlier stages Mischitelli et al.
Hence, identifying in the blood a virus with PML-associated NCCR rearrangements should alert clinicians, favoring an individual management of the patient. Type 1 and type 4 are generally associated with Europeans and European-Americans, whereas type 2B and 2E were typical of Asians and Eurasians and of Western Pacific populations, respectively Agostini et al.
Moreover, type 1 and type 4 were found in urine of Italian patients affected by immune-mediated diseases, suggesting a possible JCPyV genotype selection in response to pressure by immunomodulatory drugs Zanotta et al. Recently, observations of point mutations in the VP1 capsid gene have also been shown to be associated with PML Delbue et al. Although VP1 gene is highly polymorphic, mutations appear to be strongly patient-related and they have been observed in virus characterized by rearranged NCCR.
Practically, their arising is only noted in a neuro aggressive viral variant evolved by the non-pathogenic form, according to cell alterations or global environment changes. In conclusion, since biological therapies are promising for the treatment of immune-mediated disorders, little is known about their contribution to the development of PML.
To date, epidemiology of PML has been poorly characterized among patients with rheumatic diseases due to little population-based data existing. Therefore, this study contributes to enrich literature insight on JCPyV biology in this cluster of patients, considering that the involvement of JC virus in development of adverse events in CIRDs is probably underestimated since few studies have been done about.
All authors analyzed data. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.