Objective: In this study we aimed to evaluate the effects of casein and whey protein supplementation on examination stress. We have investigated different parameters of oxidative stress and immune function.Materials and Methods: The participants were divided into three groups: control, casein and whey. Casein and whey groups were supplemented with either casein or whey protein for 15 days. Blood samples were obtained at the beginning of the study (Day 0), on the examination day (Day 16) and five days after the examination (Day 21). Antioxidant capacity, glutathione, cortisol and cytokine levels (TNF-a, IL-6, IL-12) were measured.Results: An increase in antioxidant capacity and glutathione levels of the participants using whey protein was observed. Whey protein supplementation did not affect cortisol levels, but participants taking whey protein showed an increase in serum TNF-a and IL-6 levels. Conclusion:It is suggested that the use of whey protein strengthens the response to oxidative stress by increasing antioxidant capacity and glutathione levels, while supporting the immune system via cytokine release.

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IgG4-related disease: a giant cell arteritis mimicThe patient, a 57-year-old African American man, presented with a 7-month history of malaise, weight loss, diarrhea, headache, and intermittent vision loss. Laboratory evaluation was significant for markedly elevated serum IgG4 (4,030 mg/dl; normal <121 mg/dl), polyclonal hypergammaglobulinemia, eosinophilia, increased inflammation markers (erythrocyte sedimentation rate 135 mm/hour, C-reactive protein 10.1 mg/liter), and fat-soluble vitamin deficiencies (reflecting probable pancreatic insufficiency). Left temporal artery biopsy revealed active arteritis. Hematoxylin and eosin staining of the temporal artery biopsy tissue (A, panel a) showed increased numbers of IgG4-positive cells (A, panel c) relative to IgG-positive cells (A, panel b), at an IgG4:IgG ratio of nearly 50% (asterisk denoting the adventitial-medial junction; original magnification ×200). Computed tomography angiogram showed diffuse coronary periarteritis (B; yellow arrow denoting right coronary artery, blue arrow denoting left coronary artery) and a 5-cm ascending aortic aneurysm. Assessment by 18 F-fluorodeoxyglucose (FDG) positron emission tomography showed numerous avid lymph nodes above and below the diaphragm (denoted by white arrow in C) and increased splenic FDG uptake. Pelvic lymph node biopsy revealed a reactive lymph node with follicular lymphoid hyperplasia and moderate polytypic plasmacytosis with an IgG4:IgG ratio of 40% and >100 IgG4-positive cells per high-power field. The patient was diagnosed as having IgG4-related disease (IgG4-RD). He was started on treatment with high-dose glucocorticoids and was enrolled in a clinical trial evaluating an investigational agent for IgG4-RD. Temporal and coronary artery involvement in IgG4-RD is rare (1,2). To the best of our knowledge, concomitant involvement of the temporal artery with coronary periarteritis due to IgG4-RD has not been previously reported. In conclusion, IgG4-RD may mimic giant cell arteritis and other vasculitides (3).

BackgroundAnti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is currently categorized under the small vessel vasculitides and includes granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) [1]. There is limited knowledge about large vessel involvement in AAV (L-AAV); mainly described in case reports and small series. L-AAV can involve temporal arteries (TA-AAV), aorta (A-AAV), and periaortic soft tissue (PA-AAV).ObjectivesThe objective of this study was to investigate the characteristics of L-AAV.MethodsPatients older than 18 years at diagnosis of TA-AAV, A-AAV and PA-AAV seen at a single institution between January 1, 2000, and December 31, 2021, were identified through a proprietary medical text search algorithm. Patients were included if diagnosed with L-AAV by the treating physician, fulfilled 2022 American College of Rheumatology/ European Alliance of Associations for Rheumatology classification criteria for GPA, MPA or EGPA, had positive ANCA, and had more than one outpatient or inpatient visit. Arteritis of the temporal artery was based on histopathology whereas the diagnosis of aortitis and periaortitis could be either based on radiology or histopathology.ResultsThe study cohort consists of 36 patients with L-AAV. Of those, 23 had p-ANCA/ MPO-ANCA and 13 had c-ANCA/ PR3- ANCA. Mean (SD) age at AAV diagnosis was 63.4 (12.79); 20 (56%) were male. Seventeen patients had TA-AAV, 10 had A-AAV and 9 had PA-AAV (Table 1). Most of the patients (n=25, 69%) were diagnosed with large vessel involvement and AAV within a one-year timespan. Inflammatory markers were elevated at the time of diagnosis of large vessel involvement. Twenty-five (69%) patients had histopathologic confirmation of AAV diagnosis. There was no overlap between TA-AAV, A-AAV and PA-AAV groups. Of the 17 patients with TA-AAV, 6 had inflammation of a temporal artery branch vessel. The most frequent site of involvement in the A-AAV group was the ascending thoracic aorta, whereas in the PA-AAV group, the abdominal aorta was most frequently involved. Glucocorticoids (36/36), rituximab (19/36), and methotrexate (18/36) were the most frequent treatments. During the study period 8 patients died (4 in TA-AAV, 3 in A-AAV, and 1 in PA-AAV). There was no difference in mortality between this cohort of L-AAV patients and the general population (standardized mortality ratio: 0.98; 95% CI, 0.42- 1.93).ConclusionThis is the largest single-center cohort of patients with L-AAV to date. Clinicians should consider L-AAV in the differential diagnosis of vasculitides especially in the context of positive ANCA and atypical organ manifestations.References[1]Jennette JC, Falk RJ, Bacon PA,et al.2012 revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides.Arthritis Rheum2013;65:1–11. doi:10.1002/art.37715Table 1.Features of L-AAV cohortTemporal Artery Vasculitis (N=17)Aortitis (N=10)Periaortitis (N=9)Total (N=36)DemographicsMean (SD) age at AAV diagnosis68.8 (7.07)56.2 (16.64)61.2 (13.05)63.4 (12.79)Sex, male n (%)9 (53)4 (40)7 (78)20 (56)Race, white n (%)17 (100)9 (90)7 (78)33 (92)Duration of follow-up from AAV diagnosis years, median (IQR)4.5 (0.1- 12.6)9.5 (2.2 – 16.9)4.7 (1.8 – 6.2)4.7 (1.0 – 11.8)AAVGPA, n (%)3 (18)6 (60)6 (67)15 (42)MPA, n (%)13 (76)4 (40)3 (33)20 (56)EGPA, n (%)1 (6)0 (0)0 (0)1 (3)Histological confirmation of AAV, n (%) *11 (65)6 (60)8 (89)25 (69)Clinical manifestations before or at AAV diagnosisConstitutional symptoms, n (%)16 (94)6 (60)7 (78)29 (81)Cutaneous, n (%)1 (6)1 (10)0 (0)2 (6)Mucous membranes/ eyes, n (%)1 (6)2 (20)1 (11)4 (11)ENT, n (%)5 (29)8 (80)5 (56)18 (50)Cardiovascular, n (%)1 (6)0 (0)0 (0)1 (3)Gastrointestinal, n (%)0 (0)1 (10)0 (0)1 (3)Pulmonary, n (%)5 (29)2 (20)5 (56)12 (33)Renal, n (%)6 (35)0 (0)4 (44)10 (28)Nervous system, n (%)8 (47)1 (10)0 (0)9 (25)*Histological confirmation of AAV, other than large vessel pathologyAcknowledgements:NIL.Disclosure of InterestsMahmut Kaymakci: None declared, Mohanad Elfishawi: None declared, Hannah Langenfeld: None declared, Andrew Hanson: None declared, Cynthia S. Crowson: None declared, Umar Ghaffar: None declared, Matthew Koster: None declared, Ulrich Specks Shareholder of: AbbVie, Pfizer, Johnson & Johnson, Consultant of: AstraZeneca, ChemoCentryx, Grant/research support from: Genentech, AstraZeneca, GSK, Bristol Myer Squibb, Kenneth J Warrington Consultant of: Chemocentryx, Sanofi, Grant/research support from: Eli Lilly, Kiniksa, GSK.

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