Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and toll-like receptor 4 in juvenile idiopathic arthritis children

The Egyptian Rheumatologist xxx (xxxx) xxx

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Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and toll-like receptor 4 in juvenile idiopathic arthritis children Wasan W. Al-Bassam a, Ali H. Ad’hiah b,⇑, Khadier Z. Mayouf c a

Department of Biotechnology, College of Science, University of Baghdad, Baghdad, Iraq Tropical-Biological Research Unit, College of Science, University of Baghdad, Baghdad, Iraq c College of Medicine, University of Baghdad, Baghdad, Iraq b

a r t i c l e

i n f o

Article history: Received 27 August 2019 Accepted 27 August 2019 Available online xxxx Keywords: Juvenile idiopathic arthritis JADAS27 Calgranulins Ferritin Toll-like receptor 4

a b s t r a c t Aim of the work: To evaluate role of calgranulins (S100A8, S100A9, and S100A12), ferritin and toll-like receptor 4 (TLR4) in juvenile idiopathic arthritis (JIA) children. Patients and methods: Sera of 59 JIA Iraqi patients and 58 healthy-matched children were studied and serum levels of S100A8, S100A9, S100A12, ferritin and TLR4 assessed. Juvenile arthritis disease activity score-27 (JADAS27) was assessed. Results: The mean age of the patients was 10.1 ± 4.2 year; they were 40 females and 19 males with disease duration of 2.4 ± 2.6 years. The levels of S100A9 and ferritin were significantly increased in JIA patients compared to control (98 ± 63 vs. 65 ± 53 ng/ml; p = 0.004 and 57 ± 52 vs. 33 ± 31 ng/ml; p = 0.003, respectively), while S100A8, S100A12 and TLR4 levels showed no significant differences. Significant correlations were found; S100A8 with S100A9 (r = 0.27; p = 0.036) and TLR4 (r = 0.73; p = 0.001), S100A9 with TLR4 (r = 0.29; p = 0.026), and S100A12 with ferritin (r = 0.58; p = 0.001). S100A8, S100A9 and ferritin could significantly discriminate JIA from control (p = 0.035, p = 0.001, and p = 0.001, respectively). Corresponding sensitivities of S100A8, S100A9 and ferritin were 63%, 70% and 61%, and specificities were 60%, 66% and 60% at cutoff values of 28.3, 68.4 and 29.6 ng/ml, respectively. On multinomial logistic regression analysis, S100A9 and ferritin were significant predictors especially in those with positive C-reactive protein (CRP) and rheumatoid factor (RF), low JADAS27 and persistent oligoarthritis subtype. Conclusions: S100A8, S100A9 and ferritin were upregulated in sera of JIA patients. Their significance as predicting biomarkers of disease outcome was augmented, especially in CRP- and RF-seropositive, low JADAS27 and persistent oligoarticular JIA patients. Ó 2019 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Juvenile idiopathic arthritis (JIA), the most common pediatric arthropathy, is a chronic autoimmune inflammatory disease with arthritis developing before the age of 16 years and lasts for at least 6 weeks [1]. Based on the classification of the International League of Associations for Rheumatology (ILAR), seven clinical JIA subtypes are recognized; oligoarthritis (oJIA: persistent or extended), polyarthritis (pJIA: rheumatoid factor-positive or negative), psoriatic arthritis, systemic JIA (sJIA), enthesitis-related arthritis (ERA)

Peer review under responsibility of Egyptian Society of Rheumatic Diseases. ⇑ Corresponding author at: Tropical-Biological Research Unit, College of Science, University of Baghdad, Al-Jadriya, Baghdad, Iraq. E-mail address: [email protected] (A.H. Ad’hiah).

and undifferentiated arthritis [2]. These subtypes may represent different disease entities; however, all share the characterization of persistent joint swelling due to a synovial thickening and effusion [3]. The interplay of genetic and environmental factors in JIA leads to immune dysregulation [4,5]. Different immune components and cells are involved in the pathogenesis of the disease [6] and an upregulation of different cytokines and chemokines has been observed in serum and synovium of JIA patients [7,8]. In this context, different innate and adaptive immune biomarkers have been investigated in order to determine their predictive role in the pathogenesis of JIA and its subtypes [9–11]. The S100 calcium-binding proteins are potential biomarkers and are multifunctional implicated in regulation of a variety of cellular activities. Calgranulins are the most familiar S100 proteins and are known as myeloid-related proteins (MRPs). They include

https://doi.org/10.1016/j.ejr.2019.08.005 1110-1164/Ó 2019 Egyptian Society of Rheumatic Diseases. Publishing services provided by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: W. W. Al-Bassam, A. H. Ad’hiah and K. Z. Mayouf, Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and tolllike receptor 4 in juvenile idiopathic arthritis children, The Egyptian Rheumatologist, https://doi.org/10.1016/j.ejr.2019.08.005

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W.W. Al-Bassam et al. / The Egyptian Rheumatologist xxx (xxxx) xxx

S100A8 (calgranulin A), S100A9 (calgranulin B) and S100A12 (calgranulin C) [11]. The relation of S100 proteins to disease characteristics in JIA has not been well-defined; S100 proteins were not considered as predictors of remission or disease flare in patients with pJIA over an 8-month period following the withdrawal of anti-TNF therapy [12], while others reported that S100A8/A9 and S100A12 levels reflected activity of joint and eye disease and notably increased in patients with JIA-associated uveitis [13]; thus mandating further investigations to define the role of these biomarkers in the etiopathogenesis of JIA. Ferritin is an important inflammatory marker and is the major storage protein of intracellular iron in all organisms. It is nature’s unique approach to the controlled, safe use of iron and oxygen and antioxidant metabolism. During inflammation, macrophage ferritin is accumulated when iron decreases in serum and increases in specific cells [14]. Its synthesis is regulated by different cytokines during development, cellular differentiation and proliferation, and inflammation [15]. Ferritin influences different immunological functions [16] and has been implicated in pathogenesis of autoimmune diseases including JIA. Besides the above mentioned serum markers, toll-like receptor 4 (TLR4) has been linked with arthritis via its promoting effects on induction of proinflammatory cytokines and TLR4 gene polymorphisms may contribute to the pathogenesis of JIA [17]. An interlinked association of S100 proteins, ferritin and TLR4 has been proposed. S100A8/A9 and ferritin are related and S100 proteins are also considered as proinflammatory ligands of TLR4 [11]. A collective evaluation of this panel of biomarkers in JIA may shed light on their role in the etiology and activity of the disease. In line with these findings, the present study objectives were to estimate the serum levels of S100A8, S100A9, S100A12, ferritin and TLR4 in a sample of JIA Iraqi children to determine their role in the pathogenesis of the disease. Disease activity, clinical subtypes and laboratory investigations of the patients were also considered.

tively) were used to determine their serum levels and instructions of manufacturer were followed. 2.1. Statistical analysis Serum levels were presented as mean ± standard deviation (SD). Analysis of variance (ANOVA) post-hoc by the least significant difference (LSD) test was used for comparisons between subgroups. Pearson’s correlation was used. Receiver operating characteristic (ROC) curve was carried out, and area under curve (AUC), sensitivity and specificity were accordingly determined for each parameter. Multinomial logistic regression (MLR) analysis was employed to assess the association between serum markers and JIA or its laboratory and clinical characteristics, and the results were presented as odds ratios (OR). A p-value  0.05 was considered significant. The statistical package SPSS (version 19.0) was used. 3. Results Demographic, laboratory and clinical characteristics of JIA patients and control are given in Table 1. No medications were provided for newly diagnosed cases (n = 4); while methylprednisolone (50 mg/day), methotrexate (MTX) (5–15 mg/week), etanercept (ETN) (25 mg/week), or adalimumab (ADA) (20 mg/week) were received by 4, 20, 22 and 9 patients, respectively, and there was no overlap in the medication received. Serum levels of studied parameters are presented in Table 2. Increased S100A9 and ferritin were observed in JIA patients compared to control (p = 0.004 and p = 0.003, respectively). The S100A8 tended to be higher and S100A12 lower than the corresponding levels in the control. The

Table 1 Demographic, laboratory and clinical characteristics of juvenile idiopathic arthritis patients and control. Characteristic n (%) or mean ± SD (range)

JIA patients (n = 59)

Control (n = 58)

Age (year)

10.1 ± 4.2(1–16)

Sex (F:M) Disease duration (year) Hb (mg/dl)

40:19 (2.1:1) 2.4 ± 2.6 (<1–12) 11.2 ± 1.5 (7–14)

WBC (109/L) ESR (mm/hour) CRP+ve RF+ve CRP and RF+ve

10.0 ± 3.6 (4–21) 39.5 ± 29.5 (4– 123) 34 (57.6) 16 (27.1) 7 (11.9)

12.4 ± 3.2(3– 16) 34:24 (1.4:1) – 11.5 ± 1.6 (9– 14) 8.9 ± 1.7 (6–12) 7.5 ± 3.5 (2–15)

JADAS27 Low Medium High

9.7 ± 12.7 (1–54) 29 (49.2) 14 (23.7) 16 (27.1)

– – –

Medication Untreated Methylprednisolone Methotrexate Etanercept Adalimumab

4 (6.8) 4 (6.8) 20 (33.9) 22 (37.3) 9 (15.2)

– – – – –

Clinical subtypes oJIA (persistent) oJIA (extended) pJIA (RF ve) pJIA (RF+ve) sJIA ERA

17 (28.8) 14 (23.7) 13 (22.0) 7 (11.9) 6 (10.2) 2 (3.4)

– – – – – –

2. Patients and methods A case-control study was conducted during January-April 2018 on 59 JIA patients who were referred to the Rheumatology Unit at Baghdad Teaching Hospital, Iraq. The patients were clinically evaluated and diagnosed by consultant rheumatologists, and the ILAR classification criteria for chronic JIA and subtypes were considered [18]. The study was approved by the Ethical Committee of Baghdad Teaching Hospital (Iraqi Ministry of Health) and informed consent was obtained from all subjects guardians according to the 2008 Declaration of Helsinki. The erythrocyte sedimentation rate (ESR), hemoglobin (Hb), white blood cell (WBC) count, C-reactive protein (CRP) and rheumatoid factors (RF) were measured, and the medications received were recorded. The juvenile arthritis disease activity score-27 (JADAS27) was assessed [19]. A control sample of 58 healthy age and sex matched children was also included. They were referred to the Healthcare Units in Baghdad for a routine health check, and based on a clinical evaluation of physicians, their health status were ascertained. They were seronegative for CRP and RF, and their Hb, WBC and ESR values were within normal ranges. The CRP and RF were qualitatively assessed by slide agglutination test using commercial kits (CRP-Latex, Spinreact Spain; Ref. ID: 1200305 and RF-Immuno-Latex, La Wama Diagnostica, Brazil; Ref. ID: 28100-L respectively). For S100A8, S100A9, S100A12, ferritin and TLR4, enzyme-linked immunosorbent assay (ELISA) kits (MyBioSource, USA; Catalogue N: MBS773256, MBS773257, MBS773252, MBS771449 andMBS773729, respec-

– – –

JIA: juvenile idiopathic arthritis; Hb: hemoglobin; WBC: white blood cell; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; RF: rheumatoid factor; JADAS27: Juvenile arthritis activity score; oJIA: oligoarthritis JIA; RF: rheumatoid factor; pJIA: polyarthritis JIA; sJIA: systemic JIA; ERA: enthesitis-related arthritis.

Please cite this article as: W. W. Al-Bassam, A. H. Ad’hiah and K. Z. Mayouf, Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and tolllike receptor 4 in juvenile idiopathic arthritis children, The Egyptian Rheumatologist, https://doi.org/10.1016/j.ejr.2019.08.005

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W.W. Al-Bassam et al. / The Egyptian Rheumatologist xxx (xxxx) xxx Table 2 Serum levels of S100A8, S100A9, S100A12, ferritin and Toll-like receptor (TLR4) in juvenile idiopathic arthritis patients and control. Parameter (mean ± SD)

S100A8 S100A9 S100A12 Ferritin TLR4

Serum level (ng/ml)

p

JIA patients (n = 59)

Control (n = 58)

100 ± 167 98 ± 63 169 ± 472 57 ± 52 45 ± 82

58 ± 128 65 ± 53 312 ± 706 33 ± 31 46 ± 86

(0.14) (0.004) (0.2) (0.003) (0.95)

JIA: juvenile idiopathic arthritis; TLR4: Toll-like receptor; SD: Standard deviation. Bold values are significant at p  0.05.

measured parameters in view of the patients’ characteristics are presented in Table 3. Level of ferritin was increased in patients with a positive CRP compared to those without (p = 0.02) and similarly in those with both positive CRP and RF (p = 0.016). Untreated patients and those receiving ADA had higher S100A9 compared to those receiving methylprednisolone (p = 0.012 and p = 0.033, respectively). S100A8 and TLR4 levels showed a remarkable increase in the two ERA patients. Low JADAS27 patients tended to have a higher S100A8/A9/A12 and TLR4 compared to medium or high. S100A8 significantly correlated with S100A9 (r = 0.27, p = 0.036) and with TLR4 (r = 0.73, p = 0.001). S100A9 significantly correlated with TLR4 (r = 0.29, p = 0.026) and S100A12 with ferritin (r = 0.58, p = 0.001). None of the studied parameters correlated with the disease duration or activity. On MLR analysis, S100A9 and ferritin were significant predictors of JIA (p = 0.008 and p = 0.006, respectively), but the prediction was more pronounced

in CRP and RF positive, low JADAS27 and persistent oJIA patients. The disease JIA or its laboratory and clinical characteristics were the independent variables in this analysis (Table 4). ROC analysis revealed that S100A8, S100A9 and ferritin significantly predicted JIA disease (p = 0.035, p = 0.001 and p = 0.001, respectively) (Fig. 1). S100A8 had an AUC of 0.64 (p = 0.035) at a cutoff value 28.3 ng/ml (63% sensitivity; 60% specificity). For S100A9 the AUC was 0.69 (p = 0.001) at a cutoff value 68.4 ng/ml (70% sensitivity; 66% specificity). Ferritin had an AUC of 0.69 (p = 0.001) at a cutoff value 29.6 ng/ml (sensitivity 61%; specificity 60%). S100A12 and TLR4 showed a non-significant AUC (0.54 and 0.52, respectively).

4. Discussion In JIA, there are no reliable biomarkers for diagnosis or monitoring of disease as there are for rheumatoid arthritis in adults making the JIA classifications less clinically effective and informative; also presenting a situation of a lost opportunity for early aggressive therapy [20]. Many biomarkers have been investigated to optimize the outcome and predict therapeutic response in JIA [11]. Cytokines [21,22], adipokines [23], and markers of apoptosis [24] have all been investigated and implicated in the pathogenesis of JIA. Investigating an interconnected panel of biomarkers in JIA is gaining attention to undermine the multifaces of the disease. Understanding the utility of individual biomarkers and careful selection of the assay are important to achieve the best disease outcomes [20]. Calgranulens act as phagocyte activation markers and proinflammatory ligands for TLR4, which are constitutively and predominantly expressed in phagocytic myeloid cells [11,25]. The S100

Table 3 Serum levels of S100A8, S100A9, S100A12, ferritin and Toll-like receptor (TLR4) in juvenile idiopathic arthritis patients distributed according to certain characteristics. Group

Serum level mean ± SD (ng/ml) S100A8

S100A9

S100A12

Ferritin

TLR4

Sex

Male Female p

144 ± 224 79 ± 129 (0.16)

98 ± 64 98 ± 64 (0.99)

124 ± 135 190 ± 568 (0.62)

65.8 ± 48 54.1 ± 54 (0.43)

70.7 ± 133 32.9 ± 38 (0.1)

CRP

+ve ve p

77 ± 143 131 ± 193.3 (0.23)

100 ± 64 94.4 ± 63.6 (0.7)

226 ± 619 91 ± 45 (0.28)

71 ± 61 39 ± 29 (0.02)

43 ± 97 47 ± 59 (0.88)

RF

+ve ve p Both+ve Both ve p

156 ± 216 79 ± 141 (0.18) 201 ± 292 137 ± 220 (0.38)

116 ± 73 91 ± 59 (0.18) 109 ± 65 78 ± 45 (0.3)

102 ± 64 194 ± 552 (0.51) 111 ± 75 89 ± 39 (0.92)

70 ± 39 53 ± 56 (0.26) 85 ± 41 28 ± 19 (0.016)

72 ± 144 34 ± 40 (0.12) 109 ± 213 48 ± 64 (0.1)

JADAS27

Low Medium High p

125 ± 185 90 ± 171 63 ± 124 (0.49)

103 ± 74 100 ± 62 87 ± 41 (0.73)

214 ± 668 140 ± 149 114 ± 33 (0.77)

57 ± 59 51 ± 40 63 ± 51 (0.83)

52 ± 108 44 ± 65 32 ± 27 (0.76)

Medication

no MP MTX ETN ADA p

177 ± 244 150 ± 267 39 ± 30 98 ± 137 148 ± 282 (0.18)

161 ± 132 58 ± 35 88 ± 58 89 ± 55 132 ± 42 (0.05)

72 ± 22 109 ± 19 123 ± 131 267 ± 764 102 ± 69 (0.83)

57 ± 48 75 ± 86 46 ± 30 56 ± 65 80 ± 44 (0.55)

25 ± 2 29 ± 5 26 ± 2 39 ± 39 116 ± 196 (0.08)

Clinical subtype

oJIA (persistent) oJIA (extended) pJIA (RF ve) pJIA (RF+ve) sJIA ERA p

86 ± 162 123 ± 164 77 ± 144 106 ± 197 44 ± 45 354 ± 429 (0.32)

107 ± 46 113 ± 106 89 ± 39 88 ± 42 60 ± 27 110 ± 80 (0.58)

306 ± 868 97 ± 75 151 ± 157 104 ± 79 98 ± 61 68 ± 8 (0.84)

77 ± 67 48 ± 42 50 ± 42 63 ± 68 43 ± 20 26 ± 25 (0.51)

60 ± 137 46 ± 48 26 ± 3 27 ± 4 25 ± 2 148 ± 172 (0.42)

CRP: C-reactive protein; RF: rheumatoid factor; JADAS27: Juvenile arthritis activity score; MP: methylprednisolone; MTX: methotrexate; ETN: etanercept; ADA: adalimumab; oJIA: oligoarthritis JIA; pJIA: polyarthritis JIA; RF: rheumatoid factor; sJIA: systemic JIA; ERA: enthesitis-related arthritis; SD: Standard deviation. Bold values are significant at p  0.05.

Please cite this article as: W. W. Al-Bassam, A. H. Ad’hiah and K. Z. Mayouf, Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and tolllike receptor 4 in juvenile idiopathic arthritis children, The Egyptian Rheumatologist, https://doi.org/10.1016/j.ejr.2019.08.005

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W.W. Al-Bassam et al. / The Egyptian Rheumatologist xxx (xxxx) xxx

Table 4 Multinomial logistic regression analysis of S100A8, S100A9, S100A12, ferritin and TLR4 serum levels as predictor variables in JIA patients. Category*

S100A8

S100A9

S100A12

Ferritin

TLR4

OR

p

OR

p

OR

p

OR

p

OR

p

CRP+ve RF+ve

1.001 1.003

0.487 0.040

1.012 1.014

0.009 0.004

1.000 0.998

0.556 0.414

1.022 1.020

0.001 0.004

1.000 1.002

0.892 0.358

JADAS27 Low Medium High

1.003 1.002 1.000

0.074 0.393 0.879

1.012 1.012 1.009

0.008 0.028 0.110

1.000 0.999 0.999

0.529 0.447 0.406

1.016 1.014 1.018

0.012 0.075 0.010

1.001 1000 0.996

0.676 0.956 0.657

Clinical subtypes pOJIA eOJIA RF ve-pJIA RF+ve-pJIA sJIA

1.003 1.002 1.001 1.002 0.998

0.425 0.134 0.602 0.344 0.752

1.014 1.015 1.010 1.010 0.964

0.008 0.006 0.101 0.187 0.750

1.000 0.998 0.999 0.998 0.998

0.975 0.414 0.477 0.575 0.588

1.023 1.012 1.014 1.019 1.009

0.001 0.131 0.088 0.032 0.452

1.002 1.000 0.942 0.986 0.862

0.572 0.990 0.466 0.642 0.424

* Control was the reference category; CRP: C-reactive protein; RF: rheumatoid factor; JADAS27: juvenile arthritis activity score; pOJIA: persistent oligoarthritis; eOJIA: extended oligoarthritis; RF ve-pJIA: RF-negative polyarthritis; RF+ve-pJIA: RF-positive polyarthritis; sJIA: systemic JIA; OR: odds ratio; p: probability. Bold values are significant at p  0.05.

Fig. 1. Receiver operating characteristic (ROC) curve for S100A8, S100A9, S100A12, ferritin and Toll-like receptor (TLR4) to detect the best cutoff value in the prediction of juvenile idiopathic arthritis (JIA).

family proteins have a wide spectrum of cellular functions through regulating calcium balance, apoptosis, migration, proliferation, differentiation, energy metabolism, and inflammation. The S100 proteins could also be released from the cytoplasm, induced by tissue/cell damage and cellular stress serving as a danger signal, are key in regulating immune homeostasis and inflammation [26]. These biomarkers are also considered biomarkers for some specific diseases [26] and the role of these proteins in JIA has been substantiated and the functions of S100A8, S100A9 and S100A12 in the prognosis and activity of the disease augmented [12,13]. Their relation with some inflammatory markers such as the ESR and CRP [6,27] has been suggested. Presented results suggest a role for S100A8, S100A9 and ferritin in the pathogenesis of JIA, because they were upregulated in sera of JIA patients. In terms of biological functions, it is critical for S100A8 and S100A9 to form heterodimers (S100A8/S100A9) and upon secretion during inflammation, inflammatory actions are triggered [28]. In the present study, they were individually assessed, but they showed significant relations which may reflect the prerequisite for their non-covalent associa-

tion. Both proteins have been demonstrated as the most abundant S100 proteins in many inflammatory disorders; including JIA [27]. In agreement with such findings, Frosch and co-workers demonstrated that serum level of S100A8/S100A9 heterodimer was significantly increased in patients with active sJIA compared to healthy children or patients with other inflammatory diseases (systemic infections, acute lymphoblastic and myeloblastic leukemia, and neonatal-onset multisystem inflammatory disease). It was concluded that S100A8/S100A9 is an excellent marker for the diagnosis of sJIA, which can be early differentiated from other diseases [29]. It has also been found that S100A8/S100A9 concentrations were significantly increased in sJIA patients during disease flares compared to patients with inactive disease. Moreover, they were decreased in response to successful therapy; therefore their correlation with response to medication and disease activity was suggested [30]. Further investigation on calgranulins as important biomarkers of inflammation is encouraged to determine the relapse risk in JIA patients after stopping anti-inflammatory medications [31]. However, S100A12 showed a tendency to a decreased level in JIA patients but was associated with CRP and RF, and an increased level was observed in seropositive patients. Serum level of S100A12 measured at the time of medication withdrawal predicted the flare development in JIA patients, and it was also elevated in patients with good response to intra-articular glucocorticoids, methotrexate or biologic therapy. It was therefore suggested that S100A12 may be considered as an important parameter influencing decisions on aggressiveness of JIA therapy [32,33]. In the present investigation, there was a tendency for S100A12 to increase in high JADAS27 and etanercept-treated patients. Recently it has been mentioned that S100A8/A9 or S100A12 would not predict the evolution of pJIA in patients with clinical remission achieved with anti-TNF medications [34]. However, the involvement of neutrophils, a major source of S100A8/9/12, in the active inflammatory phase of sJIA is compelling. Significant improvement in treatment outcomes of JIA has been witnessed since the introduction of biologics [35]. Ferritin is a biomarker of JIA, and its serum level was significantly increased in patients compared to control. The increase was more pronounced in patients seropositive for CRP and RF. It is an intracellular protein that stores iron, but in inflammatory conditions, the ferritin is markedly synthesized and released from activated macrophages due inducing effects of IL-1b and TNF-a [36]. Therefore, it might be expected that its serum level is increased in an inflammatory disease like JIA. Increased serum level of ferritin in sJIA patients compared to healthy control [37] or to children with Kawasaki disease has been reported [38]. Extremely

Please cite this article as: W. W. Al-Bassam, A. H. Ad’hiah and K. Z. Mayouf, Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and tolllike receptor 4 in juvenile idiopathic arthritis children, The Egyptian Rheumatologist, https://doi.org/10.1016/j.ejr.2019.08.005

W.W. Al-Bassam et al. / The Egyptian Rheumatologist xxx (xxxx) xxx

increased ferritin has been considered a feature of macrophage activation syndrome (MAS) in a febrile patient with known or suspected sJIA [39]. TLR4 endogenous ligand S100A8/A9 levels are associated with arthritis [40]. The TLR4 serum marker showed no significant difference between JIA patients and control, and there were also no clinical- or laboratory-related variations. No previous investigations that confirm or refute such findings, but it has been suggested that TLR4 gene polymorphisms may contribute to JIA susceptibility [17]. However, TLR4 significantly correlated with S100A8 and S100A9. In this context, it has been depicted that S100 (S100A8, S100A9 and S100A12) proteins act as phagocyte activation marker and proinflammatory ligand for TLR4; therefore, there may be functional inter-relationship between these proteins [11,25]. The small sample size is among this study limitation. The potential of S100 proteins and ferritin as biomarkers for diagnosis of JIA children has been presented. In addition, they may prove to be useful biomarkers in future applications and S100 proteintargeted therapies may emerge as useful opportunities in specific clinical settings. In conclusion, S100A8, S100A9 and ferritin were upregulated in sera of JIA patients. Their significance as predicting biomarkers of disease was also augmented. Such prediction was more pronounced in CRP and RF seropositive, low JADAS27 and pOJIA patients.

[11] [12]

[13]

[14] [15] [16]

[17]

[18]

[19]

[20] [21]

Declaration of Competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

[22]

Funding

[24]

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

[25]

Acknowledgments

[26]

The authors would like to thank the medical staff at the Rheumatology Units of Baghdad Teaching Hospital and Imamein Kadhimein Medical City in Baghdad for their cooperation to achieve the study.

[27]

[23]

[28]

[29]

References [1] Giancane G, Consolaro A, Lanni S, Davì S, Schiappapietra B, Ravelli A. Juvenile idiopathic arthritis: diagnosis and treatment. Rheumatol Ther 2016;3:187–207. [2] Huang JL. New advances in juvenile idiopathic arthritis. Chang Gung Med J 2011;35:1–14. [3] Naz S, Mushtaq A, Rehman S, Bari A, Maqsud A, Khan M, et al. Juvenile rheumatoid arthritis. J Coll Physicians Surg Pakistan 2013;23:409–12. [4] Hersh AO, Prahalad S. Immunogenetics of juvenile idiopathic arthritis: A comprehensive review. J Autoimmun 2015;64:113–24. [5] El Razek Abd, Hafez E, Mosaad H. CD226 and CD40 gene polymorphism in Egyptian juvenile idiopathic arthritis children: Relation to disease susceptibility and activity. Egypt. Rheumatol 2018;40:59–62. [6] Leong JY, Guan YJ, Albani S, Arkachaisri T. Recent advances in our understanding of the pathogenesis of juvenile idiopathic arthritis and their potential clinical implications. Expert Rev Clin Immunol 2018;14:933–44. [7] Vanoni F, Minoia F, Malattia C. Biologics in juvenile idiopathic arthritis: a narrative review. Eur J Pediatr 2017;176:1147–53. [8] Muhsin HY, Kadri ZHMAH, Ad’hiah, Mayouf KZ. Predictive significance of CXCL8, CXCL10 and CXCL16 in juvenile idiopathic and rheumatoid arthritis Iraqi patients. Egypt Rheumatol 2019 (in press). [9] Alkady EAM, Rashad SM, Khedr TM, Mosad E, Abdel-Wahab N. Early predictors of increased bone resorption in juvenile idiopathic arthritis: OPG/RANKL ratio, as a key regulator of bone metabolism. Egypt Rheumatol 2011;33:217–23. [10] Gheith RE, El Gazzar II, Bahgat DMR, Nour El-Din AM. Elevated tissue transglutaminase antibodies in juvenile idiopathic arthritis children:

[30]

[31]

[32]

[33]

[34]

[35]

[36] [37]

5

Relation to neutrophil-to-lymphocyte ratio and disease activity. Egypt Rheumatol 2017;39:233–7. Vojinovic J. Toward a multibiomarker panel to optimize outcome and predict response in juvenile idiopathic arthritis. J Rheumatol 2018;45:451–3. Hinze CH, Foell D, Johnson AL, Spalding SJ, Gottlieb BS, Morris PW, et al. Serum S100A8/A9 and S100A12 levels in children with polyarticular forms of juvenile idiopathic arthritis: relationship to maintenance of clinically inactive disease during anti-tumor necrosis factor therapy and occurrence of disease flare after discontinuation of anti-TNF therapy. Arthritis Rheumatol 2019;71:451–9. Walscheid K, Heiligenhaus A, Holzinger D, Roth J, Heinz C, Tappeiner C, et al. Elevated S100A8/A9 and S100A12 Serum Levels Reflect Intraocular Inflammation in Juvenile Idiopathic Arthritis-Associated Uveitis: Results from a pilot study. Investig Opthalmology Vis Sci 2015;56:7653. Hintze KJ, Theil EC. Cellular regulation and molecular interactions of the ferritins. Cell Mol Life Sci 2006;63:591–600. Torti FM, Torti SV. Regulation of ferritin genes and protein. Blood 2002;99:3505–16. Recalcati S, Invernizzi P, Arosio P, Cairo G. New functions for an iron storage protein: The role of ferritin in immunity and autoimmunity. J Autoimmun 2008;30:84–9. Wang Y, Chen L, Li F, Bao M, Zeng J, Xiang J, et al. TLR4 rs41426344 increases susceptibility of rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) in a central south Chinese Han population. Pediatr Rheumatol 2017;15:1–8. Petty RE, Southwood TR, Manners P, Baum J, Glass DN, Goldenberg J, et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol 2004;31:390–2. Consolaro A, Ruperto N, Bazso A, Pistorio A, Magni-Manzoni S, Filocamo G, et al. Development and validation of a composite disease activity score for juvenile idiopathic arthritis. Arthritis Rheum 2009;61:658–66. Patwardhan A. The utility and experience with disease biomarkers in juvenile onset arthritis vs. adult onset arthritis. Cureus 2019;11(7):e5131. El Gazzar II, Fathy HM, Gheita TA, Nour El-Din AM, Rasheed EA, Bassyouni RH, et al. Tumor necrosis factor-a -308 A/G gene polymorphism in children with juvenile idiopathic arthritis: relation to disease activity, damage, and functional status. Clin Rheumatol 2017;36(8):1757–63. Gheita T, Kamel S, Helmy N, El-Laithy N, Monir A. Omega-3 fatty acids in juvenile idiopathic arthritis: effect on cytokines (IL-1 and TNF-a), disease activity and response criteria. Clin Rheumatol 2012;31(2):363–6. Gheita TA, El-Gazzar II, El Shazly RI, El-Din AM, Abdel-Rasheed E, Bassyouni RH. Elevated serum resistin in juvenile idiopathic arthritis: relation to categories and disease activity. J Clin Immunol 2013;33(1):297–301. Gheita TA, Bassyouni IH, Emad Y, el-Din AM, Abdel-Rasheed E, Hussein H. Elevated BAFF (BLyS) and APRIL in Juvenile idiopathic arthritis patients: relation to clinical manifestations and disease activity. Joint Bone Spine 2012;79(3):285–90. Kessel C, Holzinger D, Foell D. Phagocyte-derived S100 proteins in autoinflammation: Putative role in pathogenesis and usefulness as biomarkers. Clin Immunol 2013;147:229–41. Xia C, Braunstein Z, Toomey AC, Zhong J, Rao X. S100 proteins as an important regulator of macrophage inflammation. Front Immunol 2018;8:1–11. Holzinger D, Tenbrock K, Roth J. Alarmins of the S100-family in juvenile autoimmune and auto-inflammatory diseases. Front Immunol 2019;10:182. Leukert N, Sorg C, Roth J. Molecular basis of the complex formation between the two calcium-binding proteins S100A8 (MRP8) and S100A9 (MRP14). Biol Chem 2005;386:429–34. Frosch M, Ahlmann M, Vogl T, Wittkowski H, Wulffraat N, Foell D, et al. The myeloid-related proteins 8 and 14 complex, a novel ligand of toll-like receptor 4, and interleukin-1b form a positive feedback mechanism in systemic-onset juvenile idiopathic arthritis. Arthritis Rheum 2009;60:883–91. Holzinger D, Frosch M, Kastrup A, Prince FHM, Otten MH, Van Suijlekom-Smit LWA, et al. The Toll-like receptor 4 agonist MRP8/14 protein complex is a sensitive indicator for disease activity and predicts relapses in systemic-onset juvenile idiopathic arthritis. Ann Rheum Dis 2012;71:974–80. Rothmund F, Gerss J, Ruperto N, Däbritz J, Wittkowski H, Frosch M, et al. Validation of relapse risk biomarkers for routine use in patients with juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2014;66:949–55. Gohar F, Anink J, Moncrieffe H, Van Suijlekom-Smit LWA, Prince FHM, van Rossum MAJ, et al. S100A12 is associated with response to therapy in juvenile idiopathic arthritis. J Rheumatol 2018;45:547–54. Orczyk K, Smolewska E. A Granulocyte-specific protein S100A12 as a potential prognostic factor affecting aggressiveness of therapy in patients with juvenile idiopathic arthritis. J Immunol Res 2018;2018:1–7. Rochette E, Pereira B, Merlin E. Questions regarding the relationship between serum levels of S100A8/A9 and S100A12 and the maintenance of clinically inactive disease in JIA: Comment on the article by Claas H. Hinze et al.. Arthritis Rheumatol 2019. epub ahead of print. Leong JY, Guan YJ, Albani S, Arkachaisri T. Recent advances in our understanding of the pathogenesis of juvenile idiopathic arthritis and their potential clinical implications. Expert Rev Clin Immunol 2018;14(11):933–44. Wang W, Knovich MA, Coffman LG, Torti FM, Torti SV. Serum ferritin: past, present, future. Biochim Biophys Acta 2010;1800:760–9. Sarkar S, Alam MM, Das G, Datta S. Inflammatory markers and disease activity in juvenile idiopathic arthritis. Indian J Pediatr 2017;84:349–56.

Please cite this article as: W. W. Al-Bassam, A. H. Ad’hiah and K. Z. Mayouf, Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and tolllike receptor 4 in juvenile idiopathic arthritis children, The Egyptian Rheumatologist, https://doi.org/10.1016/j.ejr.2019.08.005

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[38] Mizuta M, Shimizu M, Inoue N, Kasai K, Nakagishi Y, Takahara T, et al. Serum ferritin levels as a useful diagnostic marker for the distinction of systemic juvenile idiopathic arthritis and Kawasaki disease. Mod Rheumatol 2016;26:929–32. [39] Schulert GS, Minoia F, Bohnsack J, Cron RQ, Hashad S, KonÉ-Paut I, et al. Effect of biologic therapy on clinical and laboratory features of macrophage

activation syndrome associated with systemic juvenile idiopathic arthritis. Arthritis Care Res (Hoboken) 2018;70(3):409–19. [40] Kim HA, Han J, Kim WJ, Noh H, An JM, Yim H, et al. TLR4 endogenous ligand S100A8/A9 levels in adult-onset Still’s disease and their association with disease activity and clinical manifestations. Int J Mol Sci 2016;17:1342.

Please cite this article as: W. W. Al-Bassam, A. H. Ad’hiah and K. Z. Mayouf, Significance of calgranulins (S100A8, S100A9 and S100A12), ferritin and tolllike receptor 4 in juvenile idiopathic arthritis children, The Egyptian Rheumatologist, https://doi.org/10.1016/j.ejr.2019.08.005