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Brichova M, Klimova A, Heissigerova J, Svozilkova P, Vaneckova M, Dolezalova P, Nemcova D, Michalickova M, Jedlickova J, Dudakova L, Liskova P. Blau Syndrome: Challenging Molecular Genetic Diagnostics of Autoinflammatory Disease. Genes (Basel) 2024; 15:799. [PMID: 38927735 PMCID: PMC11203189 DOI: 10.3390/genes15060799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/13/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
The aim of this study was to describe the clinical and molecular genetic findings in seven individuals from three unrelated families with Blau syndrome. A complex ophthalmic and general health examination including diagnostic imaging was performed. The NOD2 mutational hot spot located in exon 4 was Sanger sequenced in all three probands. Two individuals also underwent autoinflammatory disorder gene panel screening, and in one subject, exome sequencing was performed. Blau syndrome presenting as uveitis, skin rush or arthritis was diagnosed in four cases from three families. In two individuals from one family, only camptodactyly was noted, while another member had camptodactyly in combination with non-active uveitis and angioid streaks. One proband developed two attacks of meningoencephalitis attributed to presumed neurosarcoidosis, which is a rare finding in Blau syndrome. The probands from families 1 and 2 carried pathogenic variants in NOD2 (NM_022162.3): c.1001G>A p.(Arg334Gln) and c.1000C>T p.(Arg334Trp), respectively. In family 3, two variants of unknown significance in a heterozygous state were found: c.1412G>T p.(Arg471Leu) in NOD2 and c.928C>T p.(Arg310*) in NLRC4 (NM_001199139.1). In conclusion, Blau syndrome is a phenotypically highly variable, and there is a need to raise awareness about all clinical manifestations, including neurosarcoidosis. Variants of unknown significance pose a significant challenge regarding their contribution to etiopathogenesis of autoinflammatory diseases.
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Affiliation(s)
- Michaela Brichova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Aneta Klimova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Jarmila Heissigerova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Petra Svozilkova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Katerinska 30, 128 21 Prague, Czech Republic;
| | - Pavla Dolezalova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Dana Nemcova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Marcela Michalickova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Jana Jedlickova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Lubica Dudakova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Petra Liskova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
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Zhong L, Wang W, Tang X, Zhang Y, Gou L, Wang L, Wang C, Jian S, Quan M, Zhang Z, Yu Z, Qiu Z, Wei M, Song H. Phenotype of Takayasu-like vasculitis and cardiopathy in patients with Blau syndrome. Clin Rheumatol 2024; 43:1171-1181. [PMID: 38253779 DOI: 10.1007/s10067-024-06876-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 12/24/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVES We aimed to determine the prevalence of cardiovascular involvement in our Blau syndrome (BS) cohort and provide detailed analysis of their cardiovascular manifestations and outcome. We also tried to find out the risk factors for developing cardiovascular involvement. METHODS Clinical manifestations, laboratory findings, and treatments were reviewed. Clinical features were compared between children with cardiovascular involvement and those without angiocardiopathy. RESULTS A total of 38 BS children were eligible for final analysis. Among them, 13 (34.2%) developed Takayasu-like vasculitis and/or cardiopathy. Compared with those without angiocardiopathy, recurrent fever was more frequent in BS patients with cardiovascular involvement (p < 0.001). What is more, tumor necrosis factor alpha antagonists (anti-TNF) were more urgently needed in children with cardiovascular involvement (p = 0.015). BS patients with cardiovascular involvement include 4 with Takayasu-like vasculitis and 9 with cardiopathy. The onset of cardiovascular manifestations ranged from 0.75 to 18.5 years of age, with most cases occurring before school period. Symptoms were elusive and lacked specificity, such as dizziness, short of breath, and edema. Some patients were even identified because of the unexpected hypertension during follow-up. Cardiopathy and vasculitis occurred in patients with different genotypes. Imaging changes were discovered before the presentation of the typical triad in 3/4 patients with Takayasu-like vasculitis. Three children developed left ventricular dysfunction with decreased left ventricular ejection fraction. Combination of glucocorticoids and methotrexate with anti-TNF agents is a common treatment option for these BS patients. In the cohort, BS-related cardiovascular involvement was controlled well, with cardiac structural and functional abnormalities completely recovered and slower progression of vasculitis lesions. CONCLUSION Cardiovascular manifestations is not rare in BS patients. Because of its insidious onset, a systematic and comprehensive assessment of cardiovascular involvement should be performed in newly diagnosed patients with BS. Aggressive initiation of anti-TNF agents may be beneficial to improve the prognosis. Key Points • About 34.2% patients with Blau syndrome developed Takayasu-like vasculitis and/or cardiopathy. • Compared with those without angiocardiopathy, recurrent fever and application of anti-TNF agents were more frequent in BS patients with cardiovascular involvement (p < 0.001, p = 0.015) • Regular assessment of cardiovascular involvement is extremely necessary because of its insidious onset.
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Affiliation(s)
- Linqing Zhong
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Wei Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xiaoyan Tang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yu Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lijuan Gou
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lin Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Changyan Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Shan Jian
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Meiying Quan
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhenjie Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhongxun Yu
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhengqing Qiu
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Min Wei
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Hongmei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Lassoued Ferjani H, Kharrat L, Ben Nessib D, Kaffel D, Maatallah K, Hamdi W. Management of Blau syndrome: review and proposal of a treatment algorithm. Eur J Pediatr 2024; 183:1-7. [PMID: 37735224 DOI: 10.1007/s00431-023-05204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/16/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
Blau syndrome is a rare genetic granulomatosis affecting children. It could be responsible for vision-threatening complications and articular deformation. Due to the rarity of this disease, there are no standardized guidelines for its management. This work aimed to provide an updated overview of the different therapeutic options for Blau syndrome. We conducted research in the PubMed database for the different treatments used in Blau syndrome patients, and we proposed a therapeutic algorithm for disease management. High doses of corticosteroids are considered as a bridging therapy in Blau syndrome. Methotrexate should be initiated if the patient has articular or ocular involvement. An anti-tumor necrosis factor α should be added for patients with uveitis or residual arthritis. If the patient remains symptomatic, a switch to another anti-tumor necrosis factor α is the best option. In non-responders to the first- and second-line biotherapies, a switch to an anti-interleukin 1, an anti-interleukin 6, or tofacitinib is necessary. CONCLUSION This article suggested an algorithm for the treatment of Blau syndrome. Other studies are necessary to confirm the efficacy of these treatments. WHAT IS KNOWN • Blau syndrome is a rare but severe granulomatosis that could be responsible for vision-threatening complications and articular deformation. • Blau syndrome seems to be refractory to treatments. WHAT IS NEW • High doses of corticosteroids are usually insufficient and should be considered only as a bridging therapy. • Blau syndrome could be considered as a poor factor for uveitis, thus, an anti-tumor necrosis factor α should be initiated for patients with uveitis or with residual arthritis.
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Affiliation(s)
- Hanene Lassoued Ferjani
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Lobna Kharrat
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Dorra Ben Nessib
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Dhia Kaffel
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Kaouther Maatallah
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Wafa Hamdi
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
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Maghsoudlou P, Abraham AR, El-Ashry M, Chew C, Mohd N, Ramanan AV, Dick AD. Uveitis Associated with Monogenic Autoinflammatory Syndromes in Children. Ocul Immunol Inflamm 2023; 31:1930-1943. [PMID: 38051595 PMCID: PMC11166052 DOI: 10.1080/09273948.2023.2282610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/07/2023] [Indexed: 12/07/2023]
Abstract
Monogenic autoinflammatory syndromes (MAISs), are caused by pathogenic genetic variants in the innate immune system, leading to dysregulation and aberrant inflammasome activation spontaneously or with minimal triggering. The diagnosis and treatment of MAISs can be intricate, relying on an increased recognition of potential differential diagnoses. This review examines the clinical features of MAIS, with a special focus on uveitis. It also evaluates treatment options and assesses the effects of activating molecular and cytokine pathways.
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Affiliation(s)
- P Maghsoudlou
- Academic Unit of Ophthalmology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - A R Abraham
- Academic Unit of Ophthalmology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - M El-Ashry
- Department of Paediatric Ophthalmology, Bristol Eye Hospital, Bristol, UK
| | - C Chew
- Department of Paediatric Rheumatology, University of Bristol, Bristol, UK
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, Bristol, UK
| | - N Mohd
- Department of Paediatric Ophthalmology, Bristol Eye Hospital, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, University of Bristol, Bristol, UK
| | - A D Dick
- Academic Unit of Ophthalmology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- School of Cellular and Molecular Medicine, University of Bristol, University Walk, Bristol, UK
- UCL Institute of Ophthalmology, London, UK
- NIHR - Biomedical Research Centre, Moorfields and UCL - Institute of Ophthalmology, London, UK
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Jensen ME, Harrell K, McBride JD. Case Report: Methotrexate and hydroxychloroquine in combination for the treatment of NOD2-mutation-associated Blau syndrome. Front Immunol 2023; 14:1279329. [PMID: 37868966 PMCID: PMC10585138 DOI: 10.3389/fimmu.2023.1279329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/11/2023] [Indexed: 10/24/2023] Open
Abstract
Mutations in nucleotide binding oligomerization domain containing 2 receptor (NOD2) are associated with Blau syndrome (also known as early-onset sarcoidosis)-a rare autosomal dominant, chronic granulomatous disease that typically presents before 5 years of age. Blau syndrome is characterized by the clinical triad of arthritis, granulomatous dermatitis, and recurrent uveitis. Here, we report a case of NOD2-mutation-associated early-onset sarcoidosis in which a combination of methotrexate and hydroxychloroquine was used to achieve improvement in arthritis, granulomatous dermatitis, and uveitis. A 13-month-old boy presented with a sudden-onset cutaneous eruption affecting the face, trunk, and extremities that initially mimicked papular atopic dermatitis but progressively worsened despite topical steroid therapy. The patient had no other known medical comorbidities or abnormalities except for heterochromia of the right eye. However, prior to presentation to dermatology, the patient began experiencing frequent falls, conjunctival injection, and apparent eye and joint pain. Skin biopsy from the right shoulder demonstrated rounded aggregates of epithelioid histiocytes and multinucleated giant cells without a significant lymphocytic component ("naked granulomas"), consistent with sarcoidal granulomatous dermatitis. Given the concern for Blau syndrome, the patient was sent for evaluation by ophthalmology and was found to have bilateral subconjunctival nodules. Our patient underwent genetic testing and was found to have a mutation in codon 1000 C > T (protein R334W) in the NOD2 gene. The patient responded to oral prednisolone 2 mg/kg/day for 8 weeks, but quickly relapsed, requiring a second 8-week course with taper upon starting methotrexate 7.5 mg subcutaneously weekly with 1 mg folic acid orally daily. After 8 weeks on methotrexate, due to persistent arthritis, conjunctival injection, and pruritus, and in consultation with rheumatology, the patient was started on hydroxychloroquine 75 mg orally daily along with continuation of 7.5 mg methotrexate subcutaneously weekly for 8 weeks, achieving significant reduction in arthritis, pruritus, and uveitis. After 8 weeks of this combination therapy, due to concerns of long-term macular toxicity, hydroxychloroquine was discontinued in favor of continuing methotrexate alone. The patient has remained free of significant side effects and stable with good disease control on 7.5 mg methotrexate weekly injected subcutaneously.
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Affiliation(s)
- Mary Ellen Jensen
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Katelin Harrell
- Department of Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Jeffrey D. McBride
- Department of Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Yao F, Tan B, Wu D, Shen M. Blau syndrome with hypertension and hepatic granulomas: a case report and literature review. Front Pediatr 2023; 11:1063222. [PMID: 37576148 PMCID: PMC10415045 DOI: 10.3389/fped.2023.1063222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 07/05/2023] [Indexed: 08/15/2023] Open
Abstract
Background Blau syndrome (BS) is a monogenic disorder caused by NOD2 gene variants characterized by the triad of granulomatous polyarthritis, rash, and uveitis. Atypical symptoms were recognized in one-third to one-half of individuals with BS. This study aims to describe the clinical features of BS patients with hypertension and digestive system involvement. Methods The complete clinical data of a BS patient complicated with hypertension and hepatic granulomas were collected and documented. We also performed a literature search to find all reported cases of BS with hypertension and digestive system involvement. Results We reported the case of a 19-year-old man who presented with early onset symmetric polyarthritis and hypertension at age 5 and hepatic granulomas and cirrhosis at age 19. He was diagnosed with BS by the finding of a variant of the NOD2 gene (R334W). Through the literature review, 24 patients with BS were found who were reported to have hypertension, and 38 patients were found who had different digestive system manifestations such as hepatic granulomas, hepatosplenomegaly, diverticulitis, and intestinal granuloma. Among the 38 BS patients with digestive system involvement, 14 had hepatic granulomas proven by liver biopsy. Conclusions Hypertension and digestive system involvement are rare manifestations of BS. Clinicians, especially rheumatologists, must be aware of atypical symptoms of BS.
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Affiliation(s)
- Fangling Yao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- Department of Rheumatology and Immunology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Bei Tan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Di Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Min Shen
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Kumrah R, Pilania RK, Menia NK, Rawat A, Sharma J, Gupta A, Vignesh P, Jindal AK, Rikhi R, Agarwal A, Gupta V, Singh S, Suri D. Blau syndrome: Lessons learned in a tertiary care centre at Chandigarh, North India. Front Immunol 2022; 13:932919. [PMID: 36189202 PMCID: PMC9521334 DOI: 10.3389/fimmu.2022.932919] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Blau syndrome (BS) is a rare autoinflammatory disease characterized by arthritis, dermatitis, and granulomatous uveitis in early childhood. The study presents the clinical experience of patients with BS at a tertiary care centre in Chandigarh, North India. Methods Analysis of the clinical profile of patients of BS with NOD2 gene mutations under follow-up was carried out. Results Diagnosis of BS was genetically confirmed in 11 patients (10 children and one adult; six male and five female patients) from 10 families. The median age of onset of symptoms was 12 months (range, 4 months–4 years), while the age at diagnosis ranged from 2.3 to 26 years. The classic triad of arthritis, dermatitis, and uveitis was present in 6/11 (54.5%) patients. The frequency of arthritis, dermatitis, and uveitis was 100%, 81.8%, and 72.7%, respectively. The median age at diagnosis of ocular symptoms was 4 years (range, 2–26 years). Family history was noted in six families. Renal involvement was observed in two children. All patients in our cohort had the R334W variant in NOD2 gene. An asymptomatic carrier sibling with R334W mutation was identified in one family. Methotrexate was used as a first-line agent in all children. Adalimumab, which was commenced in five patients with uveitis, resulted in significant improvement in four patients. The total follow-up duration of the present cohort is 1,063.8 patient-months. Conclusions The possibility of BS should always be considered in patients with arthritis and early ocular involvement. Uveitis is often progressive and refractory to currently available therapies. Systemic involvement appears to remain a significant cause of morbidity and mortality.
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Affiliation(s)
- Rajni Kumrah
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kumar Pilania
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nitin Kumar Menia
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jyoti Sharma
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anju Gupta
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pandiarajan Vignesh
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rashmi Rikhi
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aniruddha Agarwal
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishali Gupta
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- *Correspondence: Deepti Suri,
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Matsuda T, Kambe N, Takimoto-Ito R, Ueki Y, Nakamizo S, Saito MK, Takei S, Kanazawa N. Potential Benefits of TNF Targeting Therapy in Blau Syndrome, a NOD2-Associated Systemic Autoinflammatory Granulomatosis. Front Immunol 2022; 13:895765. [PMID: 35711422 PMCID: PMC9195515 DOI: 10.3389/fimmu.2022.895765] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
Blau syndrome is a systemic autoinflammatory granulomatous disease caused by mutations in the nucleotide-binding oligomerization domain 2 (NOD2) gene. NOD2 is an intracellular pathogen recognition receptor. Upon binding to muramyl dipeptide (MDP), NOD2 activates the NF-κB pathway, leading to the upregulation of proinflammatory cytokines. Clinical manifestations of Blau syndrome appear in patients before the age of four. Skin manifestations resolve spontaneously in some cases; however, joint and eye manifestations are progressive, and lead to serious complications, such as joint contracture and blindness. Currently, there is no specific curative treatment for the disease. Administration of high-dose oral steroids can improve clinical manifestations; however, treatments is difficult to maintain due to the severity of the side effects, especially in children. While several new therapies have been reported, including JAK inhibitors, anti-IL-6 and anti-IL-1 therapies, anti-TNF therapy plays a central role in the treatment of Blau syndrome. We recently performed an ex vivo study, using peripheral blood and induced pluripotent stem cells from patients. This study demonstrated that abnormal cytokine expression in macrophages from untreated patients requires IFNγ stimulation, and that anti-TNF treatment corrects the abnormalities associated with Blau syndrome, even in the presence of IFNγ. Therefore, although the molecular mechanisms by which the genetic mutations in NOD2 lead to granuloma formation remain unclear, it is possible that prior exposure to TNFα combined with IFNγ stimulation may provide the impetus for the clinical manifestations of Blau syndrome.
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Affiliation(s)
- Tomoko Matsuda
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Naotomo Kambe
- Department of Dermatology, Kansai Medical University, Hirakata, Japan.,Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Riko Takimoto-Ito
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Ueki
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Satoshi Nakamizo
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumu K Saito
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Syuji Takei
- Department of Pediatrics, Kagoshima University, Kagoshima, Japan
| | - Nobuo Kanazawa
- Department of Dermatology, Hyogo Medical University, Nishinomiya, Japan
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Álvarez-Reguera C, Prieto-Peña D, Herrero-Morant A, Sánchez-Bilbao L, Martín-Varillas JL, González-López E, Gutiérrez-Larrañaga M, San Segundo D, Demetrio-Pablo R, Ocejo-Vinyals G, González-Gay MA, Blanco R. Clinical and immunological study of Tofacitinib and Baricitinib in refractory Blau syndrome: case report and literature review. Ther Adv Musculoskelet Dis 2022; 14:1759720X221093211. [PMID: 35510170 PMCID: PMC9058350 DOI: 10.1177/1759720x221093211] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Blau syndrome (BS) is an autoinflammatory disorder characterized by non-caseating granulomatous dermatitis, arthritis, and uveitis. We present a case of refractory and severe BS that was treated with the Janus kinase inhibitors (JAKINIBS), Tofacitinib (TOFA) and then Baricitinib (BARI). Our aim was to describe the clinical and immunological outcomes after treatment with JAKINIBS. Blood tests and serum samples were obtained during follow-up with TOFA and BARI. We assessed their effects on clinical outcomes, acute phase reactants, absolute lymphocyte counts (ALCs), lymphocyte subset counts, immunoglobulins, and cytokine levels. A review of the literature on the use of JAKINIBS for the treatment of uveitis and sarcoidosis was also conducted. TOFA led to a rapid and maintained disease control and a steroid-sparing effect. A decrease from baseline was observed in ALC, CD3+, CD4+, CD8+, and natural killer (NK) cell counts. B-cells were stable. Serum levels of interleukin (IL)-4 and tumor necrosis factor alpha (TNF-α) increased, whereas IL-2, IL-6, IL-10, and IL-17 maintained stable. TOFA was discontinued after 19 months due to significant lymphopenia. The initiation of BARI allowed maintaining adequate control of disease activity with an adequate safety profile. The literature review showed seven patients with uveitis and five with sarcoidosis treated with JAKINIBS. No cases of BS treated with JAKINIBS were found. We report the successful use of JAKINIBS in a patient with refractory and severe BS.
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Affiliation(s)
- Carmen Álvarez-Reguera
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Diana Prieto-Peña
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Alba Herrero-Morant
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Lara Sánchez-Bilbao
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | | | - Elena González-López
- Department of Immunology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - David San Segundo
- Department of Immunology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Rosalía Demetrio-Pablo
- Department of Ophthalmology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Gonzalo Ocejo-Vinyals
- Department of Immunology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Miguel A. González-Gay
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Avda. Valdecilla s/n., Santander ES-39008, Spain
| | - Ricardo Blanco
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, Avda. Valdecilla s/n., Santander ES-39008, Spain
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10
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Royle LN, Muthee BW, Rosenbaum DG. Inflammatory conditions of the pediatric hand and non-inflammatory mimics. Pediatr Radiol 2022; 52:104-121. [PMID: 34415360 DOI: 10.1007/s00247-021-05162-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/18/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
Hand involvement can assume an outsized role in the perception and presentation of disease as a result of functional impairment, visual conspicuity and susceptibility to early structural damage. Rheumatologic referral for inflammatory conditions can be delayed because of assumptions of a traumatic, infectious or neoplastic etiology; conversely, initial rheumatologic evaluation might be pursued for many of the same non-inflammatory causes. This pictorial essay highlights inflammatory conditions affecting the pediatric hand, including juvenile idiopathic arthritis, infectious arthritis, systemic connective tissue disorders, and a variety of less common inflammatory diseases, as well as non-inflammatory congenital, vascular, neoplastic and metabolic differential considerations.
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Affiliation(s)
- Leanne N Royle
- Department of Radiology, British Columbia Children's Hospital, University of British Columbia, 4500 Oak St., Vancouver, BC, V6H 3N1, Canada
| | - Bernadette W Muthee
- Department of Radiology, British Columbia Children's Hospital, University of British Columbia, 4500 Oak St., Vancouver, BC, V6H 3N1, Canada
| | - Daniel G Rosenbaum
- Department of Radiology, British Columbia Children's Hospital, University of British Columbia, 4500 Oak St., Vancouver, BC, V6H 3N1, Canada.
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11
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Bikouli EDC, Vazeou A, Xatzipsalti M, Servos G, Delis D, Maritsi DN. Blau Syndrome Complicated by Atypical Type IIa Takayasu Arteritis. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1740463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractBlau syndrome (BS) is a rare, autosomal dominant monogenic autoinflammatory disease, usually presenting as a triad of symptoms (granulomatous dermatitis, uveitis, and nonerosive arthritis) and caused by gain-of-function mutations in the nucleotide oligomerization domain 2 (NOD2) gene. However, very few reports in children of copresence of BS with large vessel vasculitis exist. We hereby describe a case of BS associated with clinical features of Takayasu arteritis. An 8.5-year-old boy presented with hypertension, cardiac insufficiency, arthritis, and ocular disease. Among other investigations, he underwent cervical and chest computed tomography and computed tomography angiography scans that revealed the presence of type IIa Takayasu arteritis lesions. Genetic analysis revealed a heterozygous mutation of NOD2 gene leading to the amino acid exchange Arg-587-Cys in the NACHT domain of the NOD2 protein (R587C) as pathogenic cause of BS. He received treatment with prednisolone, methotrexate, and infliximab (antitumor necrosis factor-α) in addition to antihypertensive medication with a favorable clinical response. Cases of BS should be investigated for the coexistence of Takayasu arteritis. However, further research is required to delineate a possible common pathogenic mechanism between the two clinical entities.
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Affiliation(s)
| | - Andriani Vazeou
- First Department of Pediatrics, “P. & A. Kyriakou” Children's Hospital, Athens, Greece
| | - Maria Xatzipsalti
- First Department of Pediatrics, “P. & A. Kyriakou” Children's Hospital, Athens, Greece
| | - Georgios Servos
- Department of Pediatric Cardiology, “P. & A. Kyriakou” Children's Hospital, Athens, Greece
| | - Dimitrios Delis
- First Department of Pediatrics, “P. & A. Kyriakou” Children's Hospital, Athens, Greece
| | - Despoina N. Maritsi
- Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), “P.& A. Kyriakou” Children's Hospital, Athens, Greece
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12
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Zhang S, Cai Z, Mo X, Zeng H. Tofacitinib effectiveness in Blau syndrome: a case series of Chinese paediatric patients. Pediatr Rheumatol Online J 2021; 19:160. [PMID: 34781959 PMCID: PMC8594202 DOI: 10.1186/s12969-021-00634-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/25/2021] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Blau syndrome (BS), a rare, autosomal-dominant autoinflammatory syndrome, is characterized by a clinical triad of granulomatous recurrent uveitis, dermatitis, and symmetric arthritis and associated with mutations of the nucleotide-binding oligomerization domain containing 2 (NOD2) gene. Aim of this study was to assess the efficacy of tofacitinib in Chinese paediatric patients with BS. METHODS Tofacitinib was regularly administered to three BS patients (Patient 1, Patient 2, and Patient 3) at different dosages: 1.7 mg/day (0.11 mg/kg), 2.5 mg/day (0.12 mg/kg), and 2.5 mg/day (0.33 mg/kg). The clinical manifestations of the patients, magnetic resonance imaging results, serological diagnoses, therapeutic measures and outcomes of treatments are described in this report. RESULTS The clinical characteristics and serological diagnoses of all BS patients were greatly improved after the administration of tofacitinib treatment. All patients reached clinical remission of polyarthritis and improvements in the erythrocyte sedimentation rate (ESR) and levels of C-reactive protein (CRP) and inflammatory cytokines. CONCLUSION Tofacitinib, a Janus kinase (JAK) inhibitor, is a promising agent for BS patients who have unsatisfactory responses to corticosteroids, traditional disease-modifying antirheumatic drugs, and biological agents.
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Affiliation(s)
- Song Zhang
- grid.413428.80000 0004 1757 8466Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children’s Medical Center, Guangzhou, 510120 Guangdong China
| | - Zhe Cai
- grid.413428.80000 0004 1757 8466Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children’s Medical Center, Guangzhou, 510120 Guangdong China
| | - Xiaolan Mo
- grid.410737.60000 0000 8653 1072Department of Pharmacy, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huasong Zeng
- Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children's Medical Center, Guangzhou, 510120, Guangdong, China.
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13
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Maccora I, Marrani E, Mastrolia MV, Abu-Rumeileh S, Maniscalco V, Fusco E, Barbati F, Pagnini I, Simonini G. Ocular involvement in monogenic autoinflammatory disease. Autoimmun Rev 2021; 20:102944. [PMID: 34509650 DOI: 10.1016/j.autrev.2021.102944] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/27/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Monogenic Autoinflammatory diseases (AIDs) are a broad spectrum of rare hereditary diseases whose ocular involvement has not been well characterized yet. This systematic review aims to provide an overview of the current knowledge about ocular findings in AIDs. METHODS A systematic literature review was conducted using 2 electronic databases, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A combination of AIDs and ophthalmology-related search terms were used. All articles were screened by 2 independent reviewers for title, abstract and full text level. We included solely studies that investigated ocular findings in AIDs. RESULTS 198 papers of 4268 records were retained. Data about 1353 patients with a diagnosis of autoinflammatory disease and ocular involvement were collected (680 CAPS, 211 FMF, 138 TRAPS, 238 Blau, 32 MKD, 21 SIFD, 7 Aicardi Goutières, 3 CANDLE, 8 DADA2, 9 HA20, 6 APLAID). Conjunctivitis was significantly more frequent in CAPS (p < 0.00001), uveitis in Blau, MKD, HA20 and CANDLE (p < 0.00001), papillitis/papilledema in CAPS (p < 0.00001), optic neuritis in Aicardi and DADA2 (p < 0.008), retinal vasculitis in FMF (p < 0.00001), progressive reduction in choroidal thickness in FMF and DADA2 (p < 0.00001), periorbital oedema in TRAPS (p < 0.00001) and retinitis in SIFD (p < 0.00001). Among AIDs with uveitis, granulomatous inflammation was more common in Blau syndrome (p < 0.00001). CONCLUSION This systematic literature review characterized the ocular involvement of several AIDs, and the present data may encourage to consider a timely ophthalmological screening program for these rare diseases.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, Meyer Children's University Hospital, NEUROFARBA Department, University of Florence, Florence, Italy.
| | - Edoardo Marrani
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy
| | - Maria Vincenza Mastrolia
- Rheumatology Unit, Meyer Children's University Hospital, NEUROFARBA Department, University of Florence, Florence, Italy.
| | - Sarah Abu-Rumeileh
- Pediatric Rheumatology Unit, Meyer Children's University Hospital, School of Human Health Science, Florence, Italy
| | - Valerio Maniscalco
- Pediatric Rheumatology Unit, Meyer Children's University Hospital, School of Human Health Science, Florence, Italy
| | - Eleonora Fusco
- Pediatric Rheumatology Unit, Meyer Children's University Hospital, School of Human Health Science, Florence, Italy
| | - Federica Barbati
- Pediatric Rheumatology Unit, Meyer Children's University Hospital, School of Human Health Science, Florence, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, Meyer Children's University Hospital, Florence, Italy.
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children's University Hospital, NEUROFARBA Department, University of Florence, Florence, Italy.
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14
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Leyens J, Bender TTA, Mücke M, Stieber C, Kravchenko D, Dernbach C, Seidel MF. The combined prevalence of classified rare rheumatic diseases is almost double that of ankylosing spondylitis. Orphanet J Rare Dis 2021; 16:326. [PMID: 34294115 PMCID: PMC8296612 DOI: 10.1186/s13023-021-01945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rare diseases (RDs) affect less than 5/10,000 people in Europe and fewer than 200,000 individuals in the United States. In rheumatology, RDs are heterogeneous and lack systemic classification. Clinical courses involve a variety of diverse symptoms, and patients may be misdiagnosed and not receive appropriate treatment. The objective of this study was to identify and classify some of the most important RDs in rheumatology. We also attempted to determine their combined prevalence to more precisely define this area of rheumatology and increase awareness of RDs in healthcare systems. We conducted a comprehensive literature search and analyzed each disease for the specified criteria, such as clinical symptoms, treatment regimens, prognoses, and point prevalences. If no epidemiological data were available, we estimated the prevalence as 1/1,000,000. The total point prevalence for all RDs in rheumatology was estimated as the sum of the individually determined prevalences. RESULTS A total of 76 syndromes and diseases were identified, including vasculitis/vasculopathy (n = 15), arthritis/arthropathy (n = 11), autoinflammatory syndromes (n = 11), myositis (n = 9), bone disorders (n = 11), connective tissue diseases (n = 8), overgrowth syndromes (n = 3), and others (n = 8). Out of the 76 diseases, 61 (80%) are classified as chronic, with a remitting-relapsing course in 27 cases (35%) upon adequate treatment. Another 34 (45%) diseases were predominantly progressive and difficult to control. Corticosteroids are a therapeutic option in 49 (64%) syndromes. Mortality is variable and could not be determined precisely. Epidemiological studies and prevalence data were available for 33 syndromes and diseases. For an additional eight diseases, only incidence data were accessible. The summed prevalence of all RDs was 28.8/10,000. CONCLUSIONS RDs in rheumatology are frequently chronic, progressive, and present variable symptoms. Treatment options are often restricted to corticosteroids, presumably because of the scarcity of randomized controlled trials. The estimated combined prevalence is significant and almost double that of ankylosing spondylitis (18/10,000). Thus, healthcare systems should assign RDs similar importance as any other common disease in rheumatology.
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Affiliation(s)
- Judith Leyens
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Neonatology and Pediatric Care, Children's University Hospital, Bonn, Germany
| | - Tim Th A Bender
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Institute of Human Genetics, University Hospital, Bonn, Germany
| | - Martin Mücke
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
| | - Christiane Stieber
- Institute of General Practice and Family Medicine, University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dmitrij Kravchenko
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Radiology, University Hospital, Bonn, Germany
| | - Christian Dernbach
- Division of Medical Psychology and Department of Psychiatry, University Hospital, Bonn, Germany
| | - Matthias F Seidel
- Department of Rheumatology, Spitalzentrum-Centre hospitalier, Biel-Bienne, Switzerland.
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15
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El Jammal T, Jamilloux Y, Gerfaud-Valentin M, Richard-Colmant G, Weber E, Bert A, Androdias G, Sève P. Challenging Mimickers in the Diagnosis of Sarcoidosis: A Case Study. Diagnostics (Basel) 2021; 11:diagnostics11071240. [PMID: 34359324 PMCID: PMC8304686 DOI: 10.3390/diagnostics11071240] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous disease of unknown cause characterized by a wide variety of presentations. Its diagnosis is based on three major criteria: a clinical presentation compatible with sarcoidosis, the presence of non-necrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. Many conditions may mimic a sarcoid-like granulomatous reaction. These conditions include infections, neoplasms, immunodeficiencies, and drug-induced diseases. Moreover, patients with sarcoidosis are at risk of developing opportunistic infections or lymphoma. Reliably confirming the diagnosis of sarcoidosis and better identifying new events are major clinical problems in daily practice. To address such issues, we present seven emblematic cases, seen in our department, over a ten-year period along with a literature review about case reports of conditions misdiagnosed as sarcoidosis.
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Affiliation(s)
- Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Gaëlle Richard-Colmant
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Emmanuelle Weber
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Arthur Bert
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Géraldine Androdias
- Department of Neurology, Service Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon University Hospital, F-69677 Bron, France;
| | - Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
- Research on Healthcare Performance (RESHAPE), INSERM U1290, 69373 Lyon, France
- Correspondence: ; Tel.: +33-426-732-636
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16
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Rodrigues FG, Petrushkin H, Webster AR, Bickerstaff M, Moraitis E, Rowczenio D, Aróstegui JI, Westcott M. A Novel Pathogenic NOD2 Variant in a Mother and Daughter with Blau Syndrome. Ophthalmic Genet 2021; 42:753-764. [PMID: 34251956 DOI: 10.1080/13816810.2021.1946701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Blau syndrome (BS) is a rare dominantly-inherited autoinflammatory disorder characterized by the triad of arthritis, uveitis and dermatitis that is consequence of gain-of-function NOD2 mutations. We describe the clinical features and genetic basis of a family with two affected members in consecutive generations affected with childhood onset arthritis and uveitis. MATERIALS AND METHODS Clinical features were retrospectively collected from clinical records. Genetic studies were performed using the Sanger method of DNA sequencing. RESULTS The proband is a 44 years-old female, who was diagnosed with juvenile onset arthritis at the age of 9 years. She subsequently developed uveitis at age 12 and since then she was managed between the uveitis and rheumatology services. The proband's daughter developed episcleritis at the age of 7 years, and arthritis with bilateral intermediate uveitis two years later. NOD2 analyses revealed in both patients the heterozygous c.1494A>C transversion, predicted to lead the novel, missense p.E498D variant in the NOD2 protein. Additional studies including databases searches and in silico bioinformatic predictions strongly support the "likely pathogenic" classification for this novel variant. CONCLUSIONS We report a novel pathogenic NOD2 variant in a multiplex family with clinical features compatible with the BS diagnosis. This condition is inherited as a dominant trait in its familial form and should be considered in patients with granulomatous uveitis in association with arthritis and/or dermatitis. Further insight into NOD2 variants and their downstream effects may have implications in the treatment of BS and other inflammatory granulomatous diseases.
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Affiliation(s)
- Filipa G Rodrigues
- Uveitis and Scleritis Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.,UCL Institute of Ophthalmology, London, UK
| | - Harry Petrushkin
- Uveitis and Scleritis Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Rheumatology Department, Great Ormond Street Hospital for Children, London, UK
| | - Andrew R Webster
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.,UCL Institute of Ophthalmology, London, UK.,Genetics Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Elena Moraitis
- Rheumatology Department, Great Ormond Street Hospital for Children, London, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, University College London, London, UK
| | - Juan I Aróstegui
- Department of Immunology, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain.,School of Medicine, Universitat De Barcelona, Barcelona, Spain
| | - Mark Westcott
- Uveitis and Scleritis Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,UCL Institute of Ophthalmology, London, UK
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17
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Xu Q, Zhang J, Qin T, Bao J, Dong H, Zhou X, Hou S, Mao L. The role of the inflammasomes in the pathogenesis of uveitis. Exp Eye Res 2021; 208:108618. [PMID: 33989670 DOI: 10.1016/j.exer.2021.108618] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/05/2021] [Accepted: 05/05/2021] [Indexed: 01/01/2023]
Abstract
Uveitis is a diverse group of sight-threatening intraocular inflammatory diseases usually causing eye redness, pain, blurred vision, and sometimes blindness. Although the exact pathogenesis of uveitis is not yet clear, accumulating evidences have shown that an imbalanced regulation of immune responses caused by a combination of genetic and environmental factors are implicated in the pathogenesis of this disease. As critical regulators of inflammation, inflammasomes have been assumed to play a role in the pathogenesis of uveitis. Recent studies have reported the association between a number of genetic variants in inflammasome related genes (such as NLRP3, NLRP1, NLRC4 and AIM2) with increased risk to uveitis. Mounting evidence have shown an aberrant activation of the NLRP3 inflammasome in both uveitis patients and murine models of uveitis. Some studies explored the intervention of uveitis via modulating inflammasome activity in the eye. This review aims at summarizing the main findings of these studies, proposing the possible mechanism whereby inflammasomes affect the susceptibility to develop uveitis, and giving a perspective for future studies, which may further improve our understanding about the role of inflammasomes and related cytokines in the pathogenesis of uveitis, and may hopefully lead to new therapeutics by targeting inflammasomes.
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Affiliation(s)
- Qiuyun Xu
- Department of Immunology, School of Medicine, Nantong University, 19 Qixiu Road, Nantong, Jiangsu, 226001, China
| | - Jie Zhang
- Department of Immunology, School of Medicine, Nantong University, 19 Qixiu Road, Nantong, Jiangsu, 226001, China
| | - Tingyu Qin
- Department of Ophthalmology, The First Affiliated Hospital of Zhengzhou University, 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Jingyin Bao
- Basic Medical Research Center, School of Medicine, Nantong University, Nantong, 226001, China
| | - Hongtao Dong
- Department of Ophthalmology, The First Affiliated Hospital of Zhengzhou University, 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Xiaorong Zhou
- Department of Immunology, School of Medicine, Nantong University, 19 Qixiu Road, Nantong, Jiangsu, 226001, China.
| | - Shengping Hou
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Eye Institute, Chongqing Key Laboratory of Ophthalmology, Chongqing, 400016, China; Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, 400016, China.
| | - Liming Mao
- Department of Immunology, School of Medicine, Nantong University, 19 Qixiu Road, Nantong, Jiangsu, 226001, China; Basic Medical Research Center, School of Medicine, Nantong University, Nantong, 226001, China.
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18
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Stefania S, Colia R, Cinzia R, Corrado A, Cantatore FP. Off-label use of anti-IL-1 drugs in rheumatic diseases. Int J Immunopathol Pharmacol 2021; 35:20587384211006584. [PMID: 33855881 PMCID: PMC8056561 DOI: 10.1177/20587384211006584] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Interleukin-1 (IL-1) plays a key role in the pathogenesis of different rheumatic diseases. There are now several agents available on the market capable of blocking IL-1. The proven effectiveness and excellent safety of these drugs makes them a possible therapeutic option in the treatment of IL-1 driven diseases, when previous therapies are contraindicated or ineffective. This article discusses the European wide off-label use of these drugs for the treatment of rheumatic diseases.
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Affiliation(s)
- Silvia Stefania
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Ripalta Colia
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Rotondo Cinzia
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Addolorata Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Francesco Paolo Cantatore
- Rheumatology Clinic, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Su J, Liu D. Blau syndrome with pulmonary nodule in a child. Australas J Dermatol 2021; 62:217-220. [PMID: 33742458 DOI: 10.1111/ajd.13551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 12/07/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
Blau syndrome (BS) is a rare monogenic disease caused by mutation of NOD2/CARD15 gene. A case of Blau syndrome in a 4-year-old Chinese boy c.1001G > A(p.R334Q) mutation in the NOD2 genes reported. Imaging revealed a nodule at the tip of the right lung.
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Affiliation(s)
- Jinping Su
- Department of Dermatology/Venerology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Donghua Liu
- Department of Dermatology/Venerology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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20
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Sinharay R, McKeown L, Phillips C, Li A, Duckworth A, Hall F, Griffiths WJH. First report of liver transplantation in Blau syndrome: The challenges faced in this rare granulomatous liver disease. Transpl Immunol 2021; 65:101378. [PMID: 33621644 DOI: 10.1016/j.trim.2021.101378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022]
Abstract
Blau syndrome is a rare autoinflammatory granulomatous disease caused by variants in the NOD2 gene, classically presenting in childhood. Hepatic manifestations are recognized including cholestasis and granulomatous liver disease. We describe a novel NOD2 gene variant c.1471A > C, p.(Met491Leu) in an adult who developed cirrhotic complications despite selective immunotherapy, including recurrent esophageal bleeding and spontaneous bacterial peritonitis which resulted in liver transplantation. He required a second liver transplant as his first graft failed due to ischemic cholangiopathy. Disease recurrence has been observed (hitherto unreported). Of 84 patients with Blau syndrome treated with antibody therapy, five hepatic cases responded to anti-TNF therapy, with promising results if instigated before decompensation occurs. We report the first case of liver transplantation for Blau syndrome in an adult with a novel NOD2 variant. Blau related liver disease can reoccur post transplantation and is an important consideration for any future graft. LAY SUMMARY: Blau syndrome is a rare immune disease which presents in childhood. We describe the first liver transplant for this condition following development of progressive liver disease in adulthood. The patient had a newly described variant in the Blau gene (NOD2). We discuss the effectiveness of antibody therapy currently being used to control the disease, and the role of liver transplantation in Blau syndrome.
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Affiliation(s)
- Ricky Sinharay
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Lorcán McKeown
- University of Cambridge, School of Clinical Medicine, UK
| | | | - Alice Li
- University of Cambridge, School of Clinical Medicine, UK
| | - Adam Duckworth
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Frances Hall
- Department of Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - William J H Griffiths
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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21
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Okazaki F, Wakiguchi H, Korenaga Y, Nakamura T, Yasudo H, Uchi S, Yanai R, Asano N, Hoshii Y, Tanabe T, Izawa K, Honda Y, Nishikomori R, Uchida K, Eishi Y, Ohga S, Hasegawa S. A novel mutation in early-onset sarcoidosis/Blau syndrome: an association with Propionibacterium acnes. Pediatr Rheumatol Online J 2021; 19:18. [PMID: 33602264 PMCID: PMC7890802 DOI: 10.1186/s12969-021-00505-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early-onset sarcoidosis (EOS) and Blau syndrome (BS) are systemic inflammatory granulomatous diseases without visible pulmonary involvement, and are distinguishable from their sporadic and familial forms. The diseases are characterized by a triad of skin rashes, symmetrical polyarthritis, and recurrent uveitis. The most common morbidity is ocular involvement, which is usually refractory to conventional treatment. A gain-of-function mutation in the nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene has been demonstrated in this disease; however, little is known about the relationship between the activation of NOD2 and the pathophysiology of EOS/BS. Here we describe EOS/BS with a novel mutation in the NOD2 gene, as well as detection of Propionibacterium acnes (P. acnes) in the granulomatous inflammation. CASE PRESENTATION An 8-year-old Japanese girl presented with refractory bilateral granulomatous panuveitis. Although no joint involvement was evident, she exhibited skin lesions on her legs; a skin biopsy revealed granulomatous dermatitis, and P. acnes was detected within the sarcoid granulomas by immunohistochemistry with P. acnes-specific monoclonal (PAB) antibody. Genetic analyses revealed that the patient had a NOD2 heterozygous D512V mutation that was novel and not present in either of her parents. The mutant NOD2 showed a similar activation pattern to EOS/BS, thus confirming her diagnosis. After starting oral prednisolone treatment, she experienced an anterior vitreous opacity relapse despite gradual prednisolone tapering; oral methotrexate was subsequently administered, and the patient responded positively. CONCLUSIONS We presented a case of EOS/BS with a novel D512V mutation in the NOD2 gene. In refractory granulomatous panuveitis cases without any joint involvement, EOS/BS should be considered as a differential diagnosis; genetic analyses would lead to a definite diagnosis. Moreover, this is the first report of P. acnes demonstrated in granulomas of EOS/BS. Since intracellular P. acnes activates nuclear factor-kappa B in a NOD2-dependent manner, we hypothesized that the mechanism of granuloma formation in EOS/BS may be the result of NOD2 activity in the presence of the ligand muramyl dipeptide, which is a component of P. acnes. These results indicate that recognition of P. acnes through mutant NOD2 is the etiology in this patient with EOS/BS.
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Affiliation(s)
- Fumiko Okazaki
- grid.268397.10000 0001 0660 7960Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, 755-8505 Ube, Yamaguchi Japan
| | - Hiroyuki Wakiguchi
- Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, 755-8505, Ube, Yamaguchi, Japan.
| | - Yuno Korenaga
- grid.268397.10000 0001 0660 7960Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, 755-8505 Ube, Yamaguchi Japan
| | - Tamaki Nakamura
- grid.268397.10000 0001 0660 7960Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, 755-8505 Ube, Yamaguchi Japan
| | - Hiroki Yasudo
- grid.268397.10000 0001 0660 7960Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, 755-8505 Ube, Yamaguchi Japan
| | - Shohei Uchi
- grid.268397.10000 0001 0660 7960Department of Ophthalmology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Ryoji Yanai
- grid.268397.10000 0001 0660 7960Department of Ophthalmology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Nobuyuki Asano
- grid.268397.10000 0001 0660 7960Department of Dermatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Yoshinobu Hoshii
- grid.268397.10000 0001 0660 7960Department of Diagnostic Pathology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Tsuyoshi Tanabe
- grid.268397.10000 0001 0660 7960Department of Public Health and Preventive Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kazushi Izawa
- grid.258799.80000 0004 0372 2033Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitaka Honda
- grid.258799.80000 0004 0372 2033Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryuta Nishikomori
- grid.258799.80000 0004 0372 2033Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan ,grid.410781.b0000 0001 0706 0776Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Keisuke Uchida
- grid.265073.50000 0001 1014 9130Department of Human Pathology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yoshinobu Eishi
- grid.265073.50000 0001 1014 9130Department of Human Pathology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Shouichi Ohga
- grid.177174.30000 0001 2242 4849Department of Pediatrics, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Shunji Hasegawa
- grid.268397.10000 0001 0660 7960Department of Pediatrics, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, 755-8505 Ube, Yamaguchi Japan
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22
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Kaufman KP, Becker ML. Distinguishing Blau Syndrome from Systemic Sarcoidosis. Curr Allergy Asthma Rep 2021; 21:10. [PMID: 33560445 DOI: 10.1007/s11882-021-00991-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a framework to distinguish Blau syndrome/Early Onset Sarcoidosis and Sarcoidosis clinically. We also discuss relevant differences in genetics, pathogenesis, and management of these diseases. RECENT FINDINGS Blau syndrome and Sarcoidosis share the characteristic histologic finding of noncaseating granulomas as well as some similar clinical characteristics; nevertheless, they are distinct entities with important differences between them. Blau syndrome and Early Onset Sarcoidosis are due to one of numerous possible gain-of-function mutations in NOD2, commonly presenting before age 5 with a triad of skin rash, arthritis, and uveitis. However, as more cases are reported, expanded clinical manifestations have been described. In systemic Sarcoidosis, there are numerous susceptibility genes that have been identified, and disease is thought to result from an environmental exposure in a genetically susceptible host. It most often presents with constitutional symptoms and pulmonary involvement and typically affects adolescents and adults. This paper reviews the similarities and differences between Blau syndrome and Sarcoidosis. We also discuss the importance of distinguishing between them, particularly with regard to prognosis and outcomes.
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Affiliation(s)
- Katherine P Kaufman
- Department of Pediatrics, Division of Rheumatology and Nephrology, Duke University Medical Center, Durham, NC, USA.
- CarolinaEast Internal Medicine, Pollocksville, NC, USA.
| | - Mara L Becker
- Department of Pediatrics, Division of Rheumatology and Nephrology, Duke University Medical Center, Durham, NC, USA
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23
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Rahman N, Petrushkin H, Solebo AL. Paediatric autoimmune and autoinflammatory conditions associated with uveitis. Ther Adv Ophthalmol 2020; 12:2515841420966451. [PMID: 33225212 PMCID: PMC7649876 DOI: 10.1177/2515841420966451] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/21/2020] [Indexed: 01/21/2023] Open
Abstract
Childhood uveitis comprises a collection of heterogenous ocular phenotypes which are associated with a diverse range of childhood autoimmune and autoinflammatory disorders. Of these genetic and/or acquired disorders, juvenile idiopathic arthritis is the most common, affecting 30-80% of children with uveitis. Up to a third of children with uveitis have 'isolated' idiopathic disease and do not have an associated systemic disease which manifests in childhood. However, uveitis may be the presenting manifestation of disease; thus, the apparently well child who presents with uveitis may have isolated idiopathic disease, but they may have an evolving systemic disorder. The diagnosis of most of the associated disorders is reliant on clinical features rather than serological or genetic investigations, necessitating detailed medical history taking and systemic examination. Adequate control of inflammation is key to good visual outcomes, and multidisciplinary care is key to good broader health outcomes.
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Affiliation(s)
- Najiha Rahman
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Ameenat Lola Solebo
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
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24
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Abstract
PURPOSE OF REVIEW This article summarizes the systemic and ocular manifestations of Blau syndrome, its genetic basis, and reviews recently published literature. RECENT FINDINGS A large multicenter prospective case series is underway, with 3-year preliminary results indicating the prevalence of uveitis, clinical characteristics and early data on its visual prognosis. Case reports have demonstrated the successful use of newer biologic agents. SUMMARY Blau syndrome is an exceedingly rare autoinflammatory disorder with skin, joint and eye manifestations. It is caused by autosomal dominant mutations of the NOD2 protein. Eye involvement is typically a chronic bilateral granulomatous iridocyclitis, often with multifocal choroiditis in the posterior segment. Treatment starts with topical and systemic steroids and often requires antimetabolites or biologic agents.
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Affiliation(s)
- Sandip Suresh
- UCLA Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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25
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Papatesta EM, Kossiva L, Tsolia M, Maritsi D. Persistent Tenosynovitis, Steroid Dependency and a Hyperpigmented Scaly Macular Rash in a Child With Juvenile Idiopathic Arthritis. Cureus 2020; 12:e11208. [PMID: 33269139 PMCID: PMC7704009 DOI: 10.7759/cureus.11208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Blau syndrome is a rare autoinflammatory disease, characterized by granulomatous symmetric arthritis, skin rash and uveitis. It is caused by mutations in the CARD15/NOD2 gene, which is a significant part of innate immunity. We describe the case of a patient with Blau syndrome, initially misdiagnosed as juvenile idiopathic arthritis. Genetic analysis showed R334Q mutation in the NOD2 gene that is known to be linked to Blau syndrome. Our patient was successfully treated with the IL-1β blocking agent canakinumab, with clinical and laboratory remission without any adverse effects. To our knowledge this is one of the rare cases of Blau syndrome successfully treated with canakinumab. After moving abroad, canakinumab was discontinued and she was treated with adalimumab instead. Change in her treatment resulted in a relapse of her disease. Prompt recognition of Blau syndrome and the optimal treatment, are vital for the prevention of severe sequelae such as vision loss and joint deformities. Canakinumab constitutes a promising therapeutic approach for Blau syndrome and requires further investigation.
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Affiliation(s)
| | - Lydia Kossiva
- Pediatrics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
| | - Maria Tsolia
- Pediatrics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
| | - Despoina Maritsi
- Pediatrics, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, GRC
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26
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Trindade BC, Chen GY. NOD1 and NOD2 in inflammatory and infectious diseases. Immunol Rev 2020; 297:139-161. [PMID: 32677123 DOI: 10.1111/imr.12902] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/12/2022]
Abstract
It has been long recognized that NOD1 and NOD2 are critical players in the host immune response, primarily by their sensing bacterial peptidoglycan-conserved motifs. Significant advances have been made from efforts that characterize their upstream activators, assembly of signaling complexes, and activation of downstream signaling pathways. Disruption in NOD1 and NOD2 signaling has also been associated with impaired host defense and resistance to the development of inflammatory diseases. In this review, we will describe how NOD1 and NOD2 sense microbes and cellular stress to regulate host responses that can affect disease pathogenesis and outcomes.
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Affiliation(s)
- Bruno C Trindade
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Grace Y Chen
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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27
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Matsuda T, Kambe N, Ueki Y, Kanazawa N, Izawa K, Honda Y, Kawakami A, Takei S, Tonomura K, Inoue M, Kobayashi H, Okafuji I, Sakurai Y, Kato N, Maruyama Y, Inoue Y, Otsubo Y, Makino T, Okada S, Kobayashi I, Yashiro M, Ito S, Fujii H, Kondo Y, Okamoto N, Ito S, Iwata N, Kaneko U, Doi M, Hosokawa J, Ohara O, Saito MK, Nishikomori R. Clinical characteristics and treatment of 50 cases of Blau syndrome in Japan confirmed by genetic analysis of the NOD2 mutation. Ann Rheum Dis 2020; 79:1492-1499. [DOI: 10.1136/annrheumdis-2020-217320] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/18/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022]
Abstract
ObjectivesTo collect clinical information and NOD2 mutation data on patients with Blau syndrome and to evaluate their prognosis.MethodsFifty patients with NOD2 mutations were analysed. The activity of each NOD2 mutant was evaluated in HEK293 cells by reporter assay. Clinical information was collected from medical records through the attending physicians.ResultsThe study population comprised 26 males and 24 females aged 0–61 years. Thirty-two cases were sporadic, and 18 were familial from 9 unrelated families. Fifteen different mutations in NOD2 were identified, including 2 novel mutations (p.W490S and D512V); all showed spontaneous nuclear factor kappa B activation, and the most common mutation was p.R334W. Twenty-six patients had fever at relatively early timepoints in the disease course. Forty-three of 47 patients had a skin rash. The onset of disease in 9 patients was recognised after BCG vaccination. Forty-five of 49 patients had joint lesions. Thirty-eight of 50 patients had ocular symptoms, 7 of which resulted in blindness. After the diagnosis of Blau syndrome, 26 patients were treated with biologics; all were antitumour necrosis factor agents. Only 3 patients were treated with biologics alone; the others received a biologic in combination with methotrexate and/or prednisolone. None of the patients who became blind received biologic treatment.ConclusionsIn patients with Blau syndrome, severe joint contractures and blindness may occur if diagnosis and appropriate treatment are delayed. Early treatment with a biologic agent may improve the prognosis.
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28
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Marín-Noriega MA, Muñoz-Ortiz J, Mosquera C, de-la-Torre A. Ophthalmological treatment of early-onset sarcoidosis/Blau syndrome in a Colombian child: A case report. Am J Ophthalmol Case Rep 2020; 18:100714. [PMID: 32346654 PMCID: PMC7178324 DOI: 10.1016/j.ajoc.2020.100714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/21/2020] [Accepted: 04/13/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose To report the ophthalmological approach of a patient with Blau syndrome (BS) in Colombia. Observations We describe a 9-year-old Colombian boy with sporadic BS due to a de novo nucleotide-binding oligomerization domain containing 2 (NOD2) mutation, who presented with joint and dermatologic symptoms. He was referred to the uveitis service with a single functional eye, due to retinal detachment in the other eye. Despite treatment with corticosteroids, methotrexate, and adalimumab, the patient continued to exhibit progressive disease. Conclusion BS-related uveitis is characterized by severe ocular morbidity. Appropriate interdisciplinary treatment is necessary for the correct identification and management of the disease, considering the inherent difficulty in its diagnosis due to its diverse clinical manifestations. The severity of BS-related uveitis in this report highlights the need for more effective therapies.
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Affiliation(s)
- María Alejandra Marín-Noriega
- NeURos Research Group. Escuela de Medicina y Ciencias de La Salud, Universidad Del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia
| | - Juliana Muñoz-Ortiz
- NeURos Research Group. Escuela de Medicina y Ciencias de La Salud, Universidad Del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia.,Escuela Barraquer Research Group. Escuela Superior de Oftalmología del Instituto Barraquer de América, Avenida Calle 100 # 18A - 51, Bogotá, Colombia
| | - Catalina Mosquera
- Programa de Reumatología Pediátrica. Universidad Del Bosque, Calle 131A #9-2, Bogotá, Colombia
| | - Alejandra de-la-Torre
- NeURos Research Group. Escuela de Medicina y Ciencias de La Salud, Universidad Del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia
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29
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Navallas M, Inarejos Clemente EJ, Iglesias E, Rebollo-Polo M, Zaki FM, Navarro OM. Autoinflammatory diseases in childhood, part 1: monogenic syndromes. Pediatr Radiol 2020; 50:415-430. [PMID: 32065272 DOI: 10.1007/s00247-019-04536-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/14/2019] [Accepted: 09/10/2019] [Indexed: 02/07/2023]
Abstract
Autoinflammatory diseases constitute a family of disorders defined by aberrant stimulation of inflammatory pathways without involving antigen-directed autoimmunity. They may be divided into monogenic and polygenic types. Monogenic autoinflammatory syndromes are those with identified genetic mutations, such as familial Mediterranean fever, tumor necrosis factor receptor-associated periodic fever syndrome (TRAPS), mevalonate kinase deficiency or hyperimmunoglobulin D syndrome, cryopyrin-associated periodic fever syndromes (CAPS), pyogenic arthritis pyoderma gangrenosum and acne (PAPA) syndrome, interleukin-10 and interleukin-10 receptor deficiencies, adenosine deaminase 2 deficiency and pediatric sarcoidosis. Those without an identified genetic mutation are known as polygenic and include systemic-onset juvenile idiopathic arthritis, idiopathic recurrent acute pericarditis, Behçet syndrome, chronic recurrent multifocal osteomyelitis and inflammatory bowel disease among others. Autoinflammatory disorders are defined by repeating episodes or persistent fever, rash, serositis, lymphadenopathy, arthritis and increased acute phase reactants, and thus may mimic infections clinically. Most monogenic autoinflammatory syndromes present in childhood. However, because of their infrequency, diverse and nonspecific presentation, and the relatively new genetic recognition, diagnosis is usually delayed. In this article, which is Part 1 of a two-part series, the authors update monogenic autoinflammatory diseases in children with special emphasis on imaging features that may help establish the correct diagnosis.
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Affiliation(s)
- María Navallas
- Department of Radiology, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2. 08950 Esplugues de Llobregat, Barcelona, Spain. .,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada. .,Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada.
| | - Emilio J Inarejos Clemente
- Department of Radiology, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2. 08950 Esplugues de Llobregat, Barcelona, Spain
| | | | - Mónica Rebollo-Polo
- Department of Radiology, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2. 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Faizah Mohd Zaki
- Department of Radiology, UKM Medical Center, Kuala Lumpur, Malaysia
| | - Oscar M Navarro
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
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30
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Chen J, Luo Y, Zhao M, Wu D, Yang Y, Zhang W, Shen M. Effective treatment of TNFα inhibitors in Chinese patients with Blau syndrome. Arthritis Res Ther 2019; 21:236. [PMID: 31718710 PMCID: PMC6852754 DOI: 10.1186/s13075-019-2017-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Objectives Blau syndrome (BS) is a rare dominantly inherited autoinflammatory disorder associated with mutations in the nucleotide-binding oligomerization domain containing 2 (NOD2) gene. Biologic therapy of BS yielded diverse results. We aimed to evaluate clinical features and outcomes of Chinese patients with BS who were treated with tumor necrosis factor (TNF)α inhibitors. Methods A total of four patients with BS were diagnosed and treated with infliximab (IFX) at the Peking Union Medical College Hospital during 2015 to 2018 and were followed up for 18 months. All patients were systematically studied for treatment outcomes including the clinical manifestations and inflammatory markers. We also conducted a comprehensive literature review about TNFα inhibitor therapy in BS. Results Four BS patients were all Chinese Han, and three were women. The mean age of disease onset was 4 ± 3.5 years, and the mean time of diagnosis delay was 19 ± 11 years. All patients received IFX plus methotrexate, and all achieved clinical remission of skin lesions and polyarthritis rapidly, as well as normalization of erythrocyte sedimentation rate and C-reactive protein and improvements in inflammatory cytokines, patient visual analogue scale, physician global assessment, and Short Form (SF)-36, at the first follow-up of 6 months. The disease relapsed in two patients after they lengthened the interval of IFX and discontinued methotrexate. According to the 38 English-language publications, 62 patients with BS were reported who underwent TNFα inhibitor therapy, including IFX used in 31, adalimumab in 24, and etanercept in 7. IFX was well tolerated in 27 patients, while 2 still had uveitis, and the other 2 experienced an adverse drug reaction. Conclusions Early recognition and effective treatment of BS are very important to avoid irreversible organ damage. TNFα inhibitors such as IFX may be a promising approach for BS patients who have unsatisfactory response to corticosteroids and traditional disease-modifying antirheumatic drugs.
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Affiliation(s)
- Jing Chen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.,Present Address: Department of Rheumatology, Chongqing Three Gorges Central Hospital, Chongqing, 404000, China
| | - Yi Luo
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Mengzhu Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Di Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yunjiao Yang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China. .,Department of Rheumatology, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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31
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Blau Syndrome and Early-Onset Sarcoidosis: A Six Case Series and Review of the Literature. Arch Rheumatol 2019; 35:117-127. [PMID: 32637927 DOI: 10.5606/archrheumatol.2020.7060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 06/03/2019] [Indexed: 12/27/2022] Open
Abstract
Objectives This study aims to discuss the clinical, laboratory and genetic findings, and treatment options for six patients who were diagnosed with Blau syndrome (BS)/early-onset sarcoidosis (EOS). Patients and methods The study included four patients (2 males,2 females; mean age 7 years; range 4 to 10 years) with EOS and two siblings (1 male, 1 female; mean age 10 years; range, 9 to 11 years) with BS. Age, age of initial symptoms, age of diagnosis; articular involvement, presence of uveitis, dermatitis, or fever, other organ involvement, laboratory findings, results of metabolic tests for mucopolysaccharidosis and mucolipidosis, results of genetic, pathologic, and immunologic tests, radiologic findings to evaluate skeletal dysplasia, and treatment options were collected. Results The median age at diagnosis of all patients was 6 years (range, 1 to 10 years). Five patients had camptodactyly and bilateral boggy synovitis in the wrists and ankles, one had granulomatous inflammatory changes in the liver and kidney biopsy, and one had attacks of fever and granulomatous dermatitis. None had uveitis. The detected mutations in nucleotide-binding oligomerization domain containing 2 (NOD2) were P268S (rs2066842), M513T (rs104895473), R702W (rs2066844), V955I (rs5743291), H343Y (rs199858111), and M491L (16:50745293). The treatments of patients included corticosteroids, non-steroid anti-inflammatory drugs, methotrexate, infliximab, adalimumab, anakinra, and canacinumab. Conclusion Camptodactyly and boggy synovitis are important signs of BS/EOS. Methotrexate and tumor necrosis factor blockers are more effective in patients with predominantly articular symptoms. In patients 5 and 6 and their mother, we determined a novel M491L mutation in the NOD2 gene. Currently, this work is in progress towards identifying the pathogenesis and treatment options for this disease.
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Figueras-Nart I, Mascaró JM, Solanich X, Hernández-Rodríguez J. Dermatologic and Dermatopathologic Features of Monogenic Autoinflammatory Diseases. Front Immunol 2019; 10:2448. [PMID: 31736939 PMCID: PMC6828938 DOI: 10.3389/fimmu.2019.02448] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022] Open
Abstract
Autoinflammatory diseases include disorders with a monogenic cause and also complex conditions associated to polygenic or multifactorial factors. An increased number of both monogenic and polygenic autoinflammatory conditions have been identified during the last years. Although skin manifestations are often predominant in monogenic autoinflammatory diseases, clinical and histopathological information regarding their dermatological involvement is still scarce. Monogenic autoinflammatory diseases with cutaneous expression can be classified based on the predominant lesion: (1) maculopapular rashes or inflammatory plaques; (2) urticarial rashes; (3) pustular, pyogenic or neutrophilic dermatosis-like rashes; (4) panniculitis or subcutaneous nodules; (5) vasculitis or vasculopathy; (6) hyperkeratotic lesions; (7) hyperpigmented lesions; (8) bullous lesions; and (9) aphthous lesions. By using this classification, this review intends to provide clinical and histopathological knowledge about cutaneous involvement in monogenic autoinflammatory diseases.
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Affiliation(s)
- Ignasi Figueras-Nart
- Department of Dermatology, Bellvitge Hospital, University of Barcelona, Barcelona, Spain
| | - José M Mascaró
- Department of Dermatology, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Xavier Solanich
- Department of Internal Medicine, Bellvitge Hospital, University of Barcelona, Barcelona, Spain
| | - José Hernández-Rodríguez
- Clinical Unit of Autoinflammatory Diseases and Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Ellis JC, Faber BG, Uri IF, J. Emerson S. Early onset sarcoidosis (Blau syndrome): erosive and often misdiagnosed. Rheumatology (Oxford) 2019; 59:1179-1180. [DOI: 10.1093/rheumatology/kez484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jessica C Ellis
- Rheumatology Department, North Bristol NHS Foundation Trust, Bristol, UK
| | - Benjamin G Faber
- Rheumatology Department, North Bristol NHS Foundation Trust, Bristol, UK
| | - Ishaq F Uri
- Rheumatology Department, North Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah J. Emerson
- Rheumatology Department, North Bristol NHS Foundation Trust, Bristol, UK
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Leong KF, Sato R, Oh GGK, Surana U, Pramono ZAD. Blau Syndrome Associated with Nucleotide-binding Oligomerization Domain Containing 2 Mutation in a Baby from Malaysia. Indian J Dermatol 2019; 64:400-403. [PMID: 31543536 PMCID: PMC6749758 DOI: 10.4103/ijd.ijd_44_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Blau syndrome (BS) is a very rare autosomal dominant juvenile inflammatory disorder caused by mutation in nucleotide-binding oligomerization domain containing 2 (NOD2). Usually, dermatitis is the first symptom that appears in the 1st year of life. About 220 BS cases with confirmed NOD2 mutation have been reported. However, the rarity and lack of awareness of the disease, especially in the regions where genetic tests are very limited, often result in late diagnosis and misdiagnosis. Here, we report a de novo BS case from Malaysia, which may be the first report from southeast Asia. PCR and DNA sequencing of peripheral blood mononuclear cells were performed to screen the entire coding region of NOD2 gene. A heterozygous c.1000C>T transition in exon 4, p. R334W, of the NOD2 gene was identified in the patient. This report further reaffirms the ubiquitousness of the disease and recurrency of p. R334W mutation.
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Affiliation(s)
- Kin Fon Leong
- Department of Pediatrics, Institute of Pediatric, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur 50586, Malaysia
| | - Reiko Sato
- Department of Research, National Skin Center, Singapore 308205, Singapore
| | | | - Uttam Surana
- Institute of Molecular and Cell Biology, AStar, Proteos, Singapore 138673, Singapore.,Singapore Bioprocessing Technology Institute, Singapore 138668, Singapore.,Department of Pharmacology, National University of Singapore, Singapore 117660, Singapore
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Abstract
The autoinflammatory diseases comprise a broad spectrum of disorders characterized by unchecked activation of the innate immune system. Whereas aberrations in adaptive immunity have long been identified in 'autoimmune' disorders, the concept of 'autoinflammation' emerged relatively recently, first describing a group of clinical disorders characterized by spontaneous episodes of systemic inflammation without manifestations typical of autoimmune disorders. Improved knowledge of innate immune mechanisms, coupled with remarkable progress in genomics and an expanding number of clinical cases, has since led to an increasing number of disorders classified as autoinflammatory or containing an autoinflammatory component. Biologic therapies targeting specific components of the innate immune system have provided immense clinical benefit, and have further elucidated the role of innate immunity in autoinflammatory disorders. This article reviews the basic mechanisms of autoinflammation, followed by an update on the pathophysiology and treatment of the monogenic and multifactorial autoinflammatory diseases, and the common dermatologic conditions in which autoinflammation plays a major role.
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Place DE, Kanneganti TD. Cell death-mediated cytokine release and its therapeutic implications. J Exp Med 2019; 216:1474-1486. [PMID: 31186281 PMCID: PMC6605758 DOI: 10.1084/jem.20181892] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 12/19/2022] Open
Abstract
Targeting apoptosis to treat diseases has seen tremendous success over the past decades. More recently, alternative forms of regulated cell death, including pyroptosis and necroptosis, have been described. Understanding the molecular cascades regulating both pyroptosis and necroptosis will yield even more targets to treat diseases. These lytic forms of cell death are distinct from apoptosis due to their characteristic lysis and release of cellular components that promote disease or direct a beneficial immune response. In this review, we focus on how pyroptosis and necroptosis, which release potent immune cytokines such as IL-1 and IL-18, contribute to various diseases. We also consider the important role that the executioners of these cell death pathways, GSDMD and MLKL, play in the progression of inflammatory diseases. Crosstalk between the different cell death pathways likely plays a major role physiologically. New therapeutic strategies targeting these specific molecules hold enormous potential for managing inflammatory diseases.
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Affiliation(s)
- David E Place
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN
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Szymanski AM, Ombrello MJ. Using genes to triangulate the pathophysiology of granulomatous autoinflammatory disease: NOD2, PLCG2 and LACC1. Int Immunol 2019. [PMID: 29538758 DOI: 10.1093/intimm/dxy021] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The intersection of granulomatosis and autoinflammatory disease is a rare occurrence that can be generally subdivided into purely granulomatous phenotypes and disease spectra that are inclusive of granulomatous features. NOD2 (nucleotide-binding oligomerization domain-containing protein 2)-related disease, which includes Blau syndrome and early-onset sarcoidosis, is the prototypic example of granulomatous inflammation in the context of monogenic autoinflammation. Granulomatous inflammation has also been observed in two related autoinflammatory diseases caused by mutations in PLCG2 (phospholipase Cγ2). More recently, mutations in LACC1 (laccase domain-containing protein 1) have been identified as the cause of a monogenic form of systemic juvenile idiopathic arthritis, which does not itself manifest granulomatous inflammation, but the same LACC1 mutations have also been shown to cause an early-onset, familial form of a well-known granulomatous condition, Crohn's disease (CD). Rare genetic variants of PLCG2 have also been shown to cause a monogenic form of CD, and moreover common variants of all three of these genes have been implicated in polygenic forms of CD. Additionally, common variants of NOD2 and LACC1 have been implicated in susceptibility to leprosy, a granulomatous infection. Although no specific mechanistic link exists between these three genes, they form an intriguing web of susceptibility to both monogenic and polygenic autoinflammatory and granulomatous phenotypes.
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Affiliation(s)
- Ann Marie Szymanski
- Translational Genetics and Genomics Unit, Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, US Department of Health & Human Services, Bethesda, MD, USA
| | - Michael J Ombrello
- Translational Genetics and Genomics Unit, Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, US Department of Health & Human Services, Bethesda, MD, USA
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Jindal AK, Pilania RK, Suri D, Gupta A, Gattorno M, Ceccherini I, Kumar N, Bansal R, Nada R, Singh S. A young female with early onset arthritis, uveitis, hepatic, and renal granulomas: a clinical tryst with Blau syndrome over 20 years and case-based review. Rheumatol Int 2019; 41:173-181. [PMID: 31062074 DOI: 10.1007/s00296-019-04316-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/02/2019] [Indexed: 12/20/2022]
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DeSouza PJ, Shah R. Characterization of Blau syndrome panuveitis with wide-field fluorescein angiography. Am J Ophthalmol Case Rep 2019; 14:92-94. [PMID: 30989150 PMCID: PMC6447728 DOI: 10.1016/j.ajoc.2019.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose To describe a case of Blau panuveitis, characterized on both portable and tabletop wide-field fluorescein angiography, which resolved on systemic immunosuppression. Observations A 5-year-old female presented with bilateral eye pain, redness, and decreased visual acuity due to panuveitis and had a history of arthritis, tenosynovitis, and dermatitis. Similar ocular and systemic findings in the patient's mother and maternal half-brother prompted genetic testing that confirmed the diagnosis of the rare Blau syndrome. Portable Retcam and tabletop Optos wide-field fluorescein angiography congruently demonstrated retinal vascular and peripapillary leakage. The uveitis dramatically resolved after the addition of adalimumab to methotrexate. Quiescence was maintained with the substitution of infliximab for adalimumab. Conclusions and Importance To our knowledge, we are first to characterize Blau panuveitis retinal findings on wide-field fluorescein angiography and with the use of two different photography systems. Additionally, this report underscores the salient clinical findings of a rare disorder and suggests that robust systemic immunosuppression can effectively treat refractory ocular inflammation.
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Affiliation(s)
- Philip J DeSouza
- Department of Ophthalmology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rajiv Shah
- Department of Ophthalmology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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How to prescribe a genetic test for the diagnosis of autoinflammatory diseases? Presse Med 2019; 48:e49-e59. [PMID: 30665783 DOI: 10.1016/j.lpm.2018.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/07/2018] [Indexed: 01/14/2023] Open
Abstract
The systemic autoinflammatory disorders (SAIDs) are associated with dysregulation of the innate immune system, affecting pro-inflammatory cytokines and apoptosis pathways. The spectrum of SAIDs continues to grow with over 30 different disorders identified to date. The main indication for genetic referral is when a patient presents with clinical symptoms consistent with one or more of the SAIDs. Thus, in making a referral for DNA screening, clinical information that supports the choice for screening of one or more SAIDs genes is required. Many of the SAIDs can display overlapping, partial or atypical symptoms, which makes the differential diagnosis extremely difficult and thus heavily dependent on genetic testing. Various attempts have been aimed at improving the efficiency of SAIDs diagnosis by proposing a set of clinical criteria to guide the genetic analysis of the SAIDs. In the last decade, due to application of the next-generation sequencing (NGS) the genetic diagnosis in patients with SAIDs have greatly improved; novel diseases and disease-associated genes have been identified and remarkable progress has been made in the genetic characterization of the undiagnosed patients and the sporadic cases. To date more than 800 variants have been recorded on the Infevers database, an online repository for DNA changes in genes associated with SAIDs (http://fmf.igh.cnrs.fr/ISSAID/infevers/). Recently, it has been updated with the new guidelines for classification of genetic variants pathogenicity in the in four most recognised SAIDs genes: MEFV, TNFRSF1A, NLRP3 and MVK.
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A Case of Sporadic Blau Syndrome with an Uncommon Clinical Course. Case Rep Rheumatol 2018; 2018:6292308. [PMID: 30693132 PMCID: PMC6332973 DOI: 10.1155/2018/6292308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/05/2018] [Indexed: 12/14/2022] Open
Abstract
Background Sporadic Blau syndrome (SBS), a rare systemic inflammatory disease in children, is associated with NOD2 gene mutations. SBS is often misdiagnosed as juvenile idiopathic arthritis (JIA) because of their similar clinical manifestations. Herein, we present a case of SBS with an uncommon clinical course. Case Presentation An 11-year-old girl with recurrent right ankle swelling for 4 years was referred to our hospital. One month before admission, she developed an intermittent high fever. She was diagnosed with systemic-onset JIA on the basis of physical and blood examination results. She was treated with ibuprofen, prednisolone, and methotrexate for 5 years. During this period, her joint lesion showed neither bone destruction nor joint space narrowing on radiography, which are characteristics of JIA. Twelve months after the termination of methotrexate treatment, she presented with bilateral panuveitis. A missense mutation, p.(R587C), was detected in her NOD2 gene, and she was diagnosed with SBS. Then, infliximab treatment was started, and her visual acuity recovered. Conclusion SBS may sometimes be misdiagnosed as JIA. A joint lesion without bone destruction might be a key feature to distinguish SBS from JIA. Analysis of the NOD2 gene is recommended in such cases.
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S100A12 and vascular endothelial growth factor can differentiate Blau syndrome and familial Mediterranean fever from systemic juvenile idiopathic arthritis. Clin Rheumatol 2018; 38:835-840. [DOI: 10.1007/s10067-018-4359-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 11/02/2018] [Indexed: 01/24/2023]
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Cavalli G, Dinarello CA. Anakinra Therapy for Non-cancer Inflammatory Diseases. Front Pharmacol 2018; 9:1157. [PMID: 30459597 PMCID: PMC6232613 DOI: 10.3389/fphar.2018.01157] [Citation(s) in RCA: 170] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/24/2018] [Indexed: 12/14/2022] Open
Abstract
Interleukin-1 (IL-1) is the prototypical inflammatory cytokine: two distinct ligands (IL-1α and IL-1β) bind the IL-1 type 1 receptor (IL-1R1) and induce a myriad of secondary inflammatory mediators, including prostaglandins, cytokines, and chemokines. IL-1α is constitutively present in endothelial and epithelial cells, whereas IL-1β is inducible in myeloid cells and released following cleavage by caspase-1. Over the past 30 years, IL-1-mediated inflammation has been established in a broad spectrum of diseases, ranging from rare autoinflammatory diseases to common conditions such as gout and rheumatoid arthritis (RA), type 2 diabetes, atherosclerosis, and acute myocardial infarction. Blocking IL-1 entered the clinical arena with anakinra, the recombinant form of the naturally occurring IL-1 receptor antagonist (IL-1Ra); IL-1Ra prevents the binding of IL-1α as well as IL-1β to IL-1R1. Quenching IL-1-mediated inflammation prevents the detrimental consequences of tissue damage and organ dysfunction. Although anakinra is presently approved for the treatment of RA and cryopyrin-associated periodic syndromes, off-label use of anakinra far exceeds its approved indications. Dosing of 100 mg of anakinra subcutaneously provides clinically evident benefits within days and for some diseases, anakinra has been used daily for over 12 years. Compared to other biologics, anakinra has an unparalleled record of safety: opportunistic infections, particularly Mycobacterium tuberculosis, are rare even in populations at risk for reactivation of latent infections. Because of this excellent safety profile and relative short duration of action, anakinra can also be used as a diagnostic tool for undefined diseases mediated by IL-1. Although anakinra is presently in clinical trials to treat cancer, this review focuses on anakinra treatment of acute as well as chronic inflammatory diseases.
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Affiliation(s)
- Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Charles A. Dinarello
- Department of Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Medicine, University of Colorado Denver, Denver, CO, United States
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Naik AU, Annamalai R, Biswas J. Uveitis in sporadic Blau syndrome: Long-term follow-up of a refractory case treated successfully with adalimumab. Indian J Ophthalmol 2018; 66:1483-1485. [PMID: 30249847 PMCID: PMC6173012 DOI: 10.4103/ijo.ijo_629_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The classic entity of autosomal dominant Blau syndrome (BS) consists of arthritis, dermatitis, and uveitis, occurring as a result of mutations in the NOD2 gene pattern recognition receptor. Sporadic cases are those in which no known gene mutation is identifiable. Uveitis in BS can be refractory to conventional therapy. We report a case of sporadic Blau uveitis managed with adalimumab monotherapy after failing to respond to topical steroids, systemic steroids, methotrexate, and infliximab therapy sequentially. Uveitis resolved completely with adalimumab and the patient has had a disease-free period over a 2-year follow-up with bi-monthly injections for arthritis control.
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Affiliation(s)
- Anmol U Naik
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Medical Research Foundation, Porur, Tamil Nadu, India
| | - Radha Annamalai
- Department of Ophthalmology, Sri Ramachandra Medical Centre, Sri Ramachandra University, Porur, Tamil Nadu, India
| | - Jyotirmay Biswas
- Department of Uvea and Ocular Pathology, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
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Lu L, Shen M, Jiang D, Li Y, Zheng X, Li Y, Li Z, Zhang L, Tang J, Guo Y, Liu S, Zheng Z, Gao G, Kan Q. Blau syndrome with good Reponses to Tocilizumab: A case report and focused literature review. Semin Arthritis Rheum 2018; 47:727-731. [DOI: 10.1016/j.semarthrit.2017.09.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 09/05/2017] [Accepted: 09/20/2017] [Indexed: 01/15/2023]
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Blau Syndrome-Associated Uveitis: Preliminary Results From an International Prospective Interventional Case Series. Am J Ophthalmol 2018; 187:158-166. [PMID: 28887115 DOI: 10.1016/j.ajo.2017.08.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 08/25/2017] [Accepted: 08/26/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Provide baseline and preliminary follow-up results in a 5-year longitudinal study of Blau syndrome. DESIGN Multicenter, prospective interventional case series. METHODS Baseline data from 50 patients from 25 centers worldwide, and follow-up data for patients followed 1, 2, or 3 years at the end of study enrollment. Ophthalmic data were collected at baseline and yearly visits by means of a standardized collection form. RESULTS Median age at onset of eye disease was 60 months and duration of eye disease at baseline 145 months. At baseline 38 patients (78%) had uveitis, which was bilateral in 37 (97%). Eight patients (21%) had moderate to severe visual impairment. Panuveitis was found in 38 eyes (51%), with characteristic multifocal choroidal infiltrates in 29 eyes (39%). Optic disc pallor in 9 eyes (12%) and peripapillary nodules in 9 eyes (12%) were the commonest signs of optic nerve involvement. Active anterior chamber inflammation was noted in 30 eyes (40%) at baseline and in 16 (34%), 17 (57%), and 11 (61%) eyes at 1, 2, and 3 years, respectively. Panuveitis was associated with longer disease duration. At baseline, 56 eyes (75%) were on topical corticosteroids. Twenty-six patients (68%) received a combination of systemic corticosteroids and immunomodulatory therapy. CONCLUSIONS Blau uveitis is characterized by progressive panuveitis with multifocal choroiditis, resulting in severe ocular morbidity despite continuous systemic and local immunomodulatory therapy. The frequency and severity of Blau uveitis highlight the need for close ophthalmologic surveillance as well as a search for more effective therapies.
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Wlodek C, Clinch J, Planas S, Shaw L. Widespread papular eruption in an infant. Clin Exp Dermatol 2017; 43:212-215. [DOI: 10.1111/ced.13354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- C. Wlodek
- Department of Paediatric Dermatology; Bristol Royal Hospital for Children; Bristol UK
| | - J. Clinch
- Department of Paediatric Rheumatology; Bristol Royal Hospital for Children; Bristol UK
| | - S. Planas
- Department of Histopathology; Southmead Hospital; Bristol UK
| | - L. Shaw
- Department of Paediatric Dermatology; Bristol Royal Hospital for Children; Bristol UK
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Rigante D. New mosaic tiles in childhood hereditary autoinflammatory disorders. Immunol Lett 2017; 193:67-76. [PMID: 29198619 DOI: 10.1016/j.imlet.2017.11.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/29/2017] [Indexed: 12/21/2022]
Abstract
The protean clinical phenotypes of hereditary autoinflammatory disorders (HAID) are caused by abnormal activation of innate immunity and consist of seemingly unprovoked inflammatory flares localized to multiple organs, such as the skin, joints, serosal membranes, gut, and central nervous system. Different mutations in genes implied in activation of the interleukin-1 (IL-1)-structured inflammasome, cytoskeletal signaling and apoptosis contribute to the pathogenesis of different HAID, which mostly start in childhood with self-limited flares unrelated to infectious agents, autoantibody production or autoreactive cells. Though IL-1 remains pivotal in many inflammasome-mediated diseases, other cytokinopathies involving IL-18, nuclear factorκ-B, interferons, and tumor necrosis factor have provided new horizons in the definition of HAID of children: the list of HAID has expanded as a consequence of a better understanding of their pathogenetic molecular mechanisms and also application of new genetic technologies. However, diagnosis of most HAID is clinical and focused on several evidence-based criteria sets: their discrimination remains challenging for unexperienced pediatricians as there are no universally accepted algorithms, and a still relevant number of patients may linger without any clarifying genetic analysis, whose interpretation combined with processing of treatment options should be discussed on a multidisciplinary basis.
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Affiliation(s)
- Donato Rigante
- Institute of Pediatrics, Fondazione Policlinico Universitario "A. Gemelli", Università Cattolica Sacro Cuore, Rome, Italy.
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Autoinflammatory Diseases in Pediatric Dermatology–Part 2: Histiocytic, Macrophage Activation, and Vasculitis Syndromes. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2017.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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50
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Carreño E, Portero A, Herreras JM, García-Vázquez C, Whitcup SM, Stern ME, Calonge M, Enríquez-de-Salamanca A. Cytokine and chemokine tear levels in patients with uveitis. Acta Ophthalmol 2017; 95:e405-e414. [PMID: 27873479 DOI: 10.1111/aos.13292] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/13/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine whether the levels of cytokines and chemokines in tears differ in uveitis patients and healthy subjects. METHODS Ninety-two uveitis patients (mean age 46.4 years) and 157 control healthy subjects (mean age 49.5 years) were recruited. Subjects with ocular surface diseases such as dry eye were excluded from the study. Using multiplex bead-based assays, tears (4 μl) were analysed for the concentration of interleukin (IL)-1β, IL-1RA, IL-2, IL-6, IL-7, IL-8/CXCL8, IL-10, IL-12p70, IL-15, IL-17A, IL-23, epidermal growth factor (EGF), fractalkine/CX3CL1, interferon-γ, IP-10/CXCL10, monocyte chemo-attractant protein (MCP)-1/CCL2, tumour necrosis factor-α, vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-β1, TGF-β2 and TGF-β3. Tear molecule levels were compared between the groups and among the different forms of uveitis and disease severity. RESULTS Epidermal growth factor, IL-1RA, IL-7, IL-8/CXCL8, IP-10/CXCL10, MCP-1/CCL2, TGF-β2 and VEGF were detected in more than 75% of the samples in both groups. Statistically significant differences in percentage of detection between control and patient groups were found for IL-23, IL-1β, IL-15, EGF, fractalkine/CX3CL1 and MCP-1/CCL2. The concentrations of IL-1RA, IL-8/CXCL8, fractalkine/CX3CL1, IP-10/CXCL10, VEGF and TGF-β2 in uveitis tear samples were elevated compared to controls (p < 0.05). Significant differences in tear levels of those molecules and also EGF were also present depending on the anatomic classification of uveitis. CONCLUSION There were significant differences in the levels of several cytokines and chemokines in tears of patients with uveitis compared with healthy subjects. These results can help understand the underlying pathophysiology of the uveitis and could potentially aid in diagnosis.
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Affiliation(s)
- Ester Carreño
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
| | - Alejandro Portero
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
| | - José M. Herreras
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
- University Clinic Hospital; Valladolid Spain
- CIBER-BBN (Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine); Valladolid Spain
| | - Carmen García-Vázquez
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
| | | | | | - Margarita Calonge
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
- CIBER-BBN (Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine); Valladolid Spain
| | - Amalia Enríquez-de-Salamanca
- IOBA (Institute of Applied OphthalmoBiology); University of Valladolid; Valladolid Spain
- CIBER-BBN (Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine); Valladolid Spain
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