1
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Karimzade P, Eghbali A, Keramatipour M, Shiari R, Golchehre Z, Taghizadeh M, Fallahi M, Fallah S, Khakbazan Fard N, Eslami N, Bazgir N, Jamee M, Chavoshzadeh Z. Two Unrelated Iranian Patients with Adenosine Deaminase 2 Deficiency: A Case Report and Review of Treatment. Case Reports Immunol 2024; 2024:4380689. [PMID: 39161369 PMCID: PMC11333127 DOI: 10.1155/2024/4380689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 07/06/2024] [Accepted: 07/24/2024] [Indexed: 08/21/2024] Open
Abstract
Background Adenosine deaminase deficiency 2 (DADA2) is an autoinflammatory disorder, caused by the CECR1 gene mutation. The major clinical manifestations include recurrent vasculitis, neurological disorders such as stroke, hematologic abnormalities, and immunodeficiency. As reported in previous studies, DADA2 may be manifested by ischemic or hemorrhagic strokes. This disorder also includes various hematological manifestations (pure red cell aplasia, pancytopenia, hemolytic anemia, and pancytopenia with bone marrow involvement). Case Presentation. In this case report, we present the clinical and immunological findings of two unrelated patients with DADA2. The first patient was a 7-year-old female who experienced recurrent neurological symptoms such as vertigo, tinnitus, hearing loss, and right-sided hemiparesis. Her brain magnetic resonance imaging (MRI) revealed a left-sided stroke, and she responded well to antitumor necrosis factor alpha agents and plasmapheresis. The second patient was a 6-year-old female who had recurrent fever and bicytopenia, aphthous lesions, cervical lymphadenopathy, and elevated liver enzymes. We also discussed the strategies used to manage the clinical manifestations in these two DADA2 patients. Conclusion In this case report, we discussed two cases with DADA2 deficiency and their respective manifestations. The first case showed neurological symptoms while the second case had hematological symptoms. Although there is no established treatment for DADA2 due to its rarity, steroids are commonly used to treat this disorder. Antitumor necrosis factor is also effective in controlling the symptoms, especially the neurological ones. In cases where there is no appropriate response to these treatments, hematopoietic stem cell transplantation can be beneficial.
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Affiliation(s)
- Parvaneh Karimzade
- Pediatric Neurology Research CenterResearch Institute for Children's HealthShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Aziz Eghbali
- Department of PediatricsSchool of MedicineIran University of Medical Sciences, Tehran, Iran
| | - Mohammad Keramatipour
- Department of Medical GeneticsSchool of MedicineTehran University of Medical Sciences, Tehran, Iran
| | - Reza Shiari
- Division of Pediatric RheumatologyDepartment of PediatricsMofid Children's HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Golchehre
- Department of Medical GeneticsSchool of MedicineTehran University of Medical Sciences, Tehran, Iran
| | | | - Mazdak Fallahi
- Immunology and Allergy DepartmentMofid Children's HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahrzad Fallah
- Immunology and Allergy DepartmentMofid Children's HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasrin Khakbazan Fard
- Immunology and Allergy DepartmentMofid Children's HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Narges Eslami
- Immunology and Allergy DepartmentMofid Children's HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Narges Bazgir
- Hearing Disorders Research CenterLoghman Hakim HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahnaz Jamee
- Immunology and Allergy DepartmentMofid Children's HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Chavoshzadeh
- Immunology and Allergy DepartmentMofid Children's HospitalShahid Beheshti University of Medical Sciences, Tehran, Iran
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2
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Sharabati I, Ayesh BM, Qafesha RM, Rasras H, Abunejma FM, Abdulrazzak M, Jobran AW. Central retinal artery occlusion in a child with ADA2 deficiency: a case report. Ann Med Surg (Lond) 2024; 86:2343-2347. [PMID: 38576931 PMCID: PMC10990381 DOI: 10.1097/ms9.0000000000001857] [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] [Received: 01/16/2024] [Accepted: 02/12/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction and importance Deficiency of ADA2 (DADA2) is the first molecularly described monogenic vasculitis syndrome. During the past decade, DADA2's clinical spectrum has expanded significantly as the number of reported cases has increased. Case presentation A 5-year-old boy with DADA2 who experienced sudden onset left-sided vision loss due to unilateral central retinal artery occlusion. The patient had a history of recurrent fever and arthralgia with high inflammatory markers (C-reactive protein and erythrocyte sedimentation rate). Brain MRI showed mild limbic encephalitis, and MRA was normal. His gene sequencing results demonstrated substitutions mutation in ADA2, and the diagnosis of DADA2 was eventually confirmed. Clinical discussion Central retinal artery occlusion (CRAO) in paediatrics is a very rare condition. Typically, DADA2 presents in childhood as systemic inflammation, vasculitis, humoral immunodeficiency, and/or haematologic abnormalities. The most common phenotype described in the literature is vasculitis, which typically affects the skin and central nervous system, but other systems can also be affected. Ophthalmic manifestations are less common and highly variable. Conclusions DADA2 manifests rarely with central retinal artery occlusion; therefore, physicians should be aware of this manifestation.
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Affiliation(s)
| | | | | | - Heba Rasras
- Faculty of Medicine, Al Quds University, Jerusalem
| | - Fawzy M. Abunejma
- Ahli Hospital, PRCS Hebron Hospital, Hebron University, Hebron, Palestine
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3
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Federici S, Cinicola BL, La Torre F, Castagnoli R, Lougaris V, Giardino G, Volpi S, Caorsi R, Leonardi L, Corrente S, Soresina A, Cancrini C, Insalaco A, Gattorno M, De Benedetti F, Marseglia GL, Del Giudice MM, Cardinale F. Vasculitis and vasculopathy associated with inborn errors of immunity: an overview. Front Pediatr 2024; 11:1258301. [PMID: 38357265 PMCID: PMC10866297 DOI: 10.3389/fped.2023.1258301] [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: 07/13/2023] [Accepted: 11/29/2023] [Indexed: 02/16/2024] Open
Abstract
Systemic autoinflammatory diseases (SAIDs) are disorders of innate immunity, which are characterized by unprovoked recurrent flares of systemic inflammation often characterized by fever associated with clinical manifestations mainly involving the musculoskeletal, mucocutaneous, gastrointestinal, and nervous systems. Several conditions also present with varied, sometimes prominent, involvement of the vascular system, with features of vasculitis characterized by variable target vessel involvement and organ damage. Here, we report a systematic review of vasculitis and vasculopathy associated with inborn errors of immunity.
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Affiliation(s)
- Silvia Federici
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Bianca Laura Cinicola
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco La Torre
- Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - Riccardo Castagnoli
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vassilios Lougaris
- Department of Clinical and Experimental Sciences, Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, University of Brescia and ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Giuliana Giardino
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Stefano Volpi
- Center for Autoinflammatory Diseases and Immunodeficiency, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiency, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Lucia Leonardi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Annarosa Soresina
- Unit of Pediatric Immunology, Pediatrics Clinic, University of Brescia, ASST-Spedali Civili Brescia, Brescia, Italy
| | - Caterina Cancrini
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Academic Department of Pediatrics, Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Marco Gattorno
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Fabio Cardinale
- Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
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4
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Grim A, Veiga KR, Saad N. Deficiency of Adenosine Deaminase 2: Clinical Manifestations, Diagnosis, and Treatment. Rheum Dis Clin North Am 2023; 49:773-787. [PMID: 37821195 DOI: 10.1016/j.rdc.2023.06.004] [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] [Indexed: 10/13/2023]
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is a monogenic vasculitis syndrome caused by biallelic mutations in the adenosine deaminase 2 gene. The diagnosis of DADA2 is confirmed by decreased enzymatic activity of ADA2 and genetic testing. Symptoms range from cutaneous vasculitis and polyarteritis nodosa-like lesions to stroke. The vasculopathy of DADA2 can affect many organ systems, including the gastrointestinal and renal systems. Hematologic manifestations occur early with hypogammaglobulinemia, lymphopenia, pure red cell aplasia, or pancytopenia. Treatment can be challenging. Tumor necrosis factor inhibitors are helpful to control inflammatory symptoms. Hematopoietic stem cell transplant may be needed to treat refractory cytopenias, vasculopathy, or immunodeficiency.
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Affiliation(s)
- Andrew Grim
- Division of Pediatric Rheumatology, Department of Pediatrics, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Keila R Veiga
- Division of Pediatric Rheumatology, Department of Pediatrics, New York Medical College/Maria Fareri Children's Hospital, 100 Woods Road, Valhalla, NY 10595, USA
| | - Nadine Saad
- Division of Pediatric Rheumatology, Department of Pediatrics, Michigan Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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5
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Chen L, Mamutova A, Kozlova A, Latysheva E, Evgeny F, Latysheva T, Savostyanov K, Pushkov A, Zhanin I, Raykina E, Kurnikova M, Mersiyanova I, Platt CD, Jee H, Brodeur K, Du Y, Liu M, Weiss A, Schulert GS, Rodriguez-Smith J, Hershfield MS, Aksentijevich I, Zhou Q, Nigrovic PA, Shcherbina A, Alexeeva E, Lee PY. Comparison of disease phenotypes and mechanistic insight on causal variants in patients with DADA2. J Allergy Clin Immunol 2023; 152:771-782. [PMID: 37150360 DOI: 10.1016/j.jaci.2023.04.014] [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: 06/30/2022] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) results in heterogeneous manifestations including systemic vasculitis and red cell aplasia. The basis of different disease phenotypes remains incompletely defined. OBJECTIVE We sought to further delineate disease phenotypes in DADA2 and define the mechanistic basis of ADA2 variants. METHODS We analyzed the clinical features and ADA2 variants in 33 patients with DADA2. We compared the transcriptomic profile of 14 patients by bulk RNA sequencing. ADA2 variants were expressed experimentally to determine impact on protein production, trafficking, release, and enzymatic function. RESULTS Transcriptomic analysis of PBMCs from DADA2 patients with the vasculitis phenotype or pure red cell aplasia phenotype exhibited similar upregulation of TNF, type I interferon, and type II interferon signaling pathways compared with healthy controls. These pathways were also activated in 3 asymptomatic individuals with DADA2. Analysis of ADA2 variants, including 7 novel variants, showed different mechanisms of functional disruption including (1) unstable transcript leading to RNA degradation; (2) impairment of ADA2 secretion because of retention in the endoplasmic reticulum; (3) normal expression and secretion of ADA2 that lacks enzymatic function; and (4) disruption of the N-terminal signal peptide leading to cytoplasmic localization of unglycosylated protein. CONCLUSIONS Transcriptomic signatures of inflammation are observed in patients with different disease phenotypes, including some asymptomatic individuals. Disease-associated ADA2 variants affect protein function by multiple mechanisms, which may contribute to the clinical heterogeneity of DADA2.
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Affiliation(s)
- Liang Chen
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Anna Mamutova
- Federal State Autonomous Institution "National Medical Research Center for Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Anna Kozlova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | | | - Frolov Evgeny
- NRC Institute of Immunology FMBA of Russia, Moscow, Russia
| | | | - Kirill Savostyanov
- Federal State Autonomous Institution "National Medical Research Center for Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexander Pushkov
- Federal State Autonomous Institution "National Medical Research Center for Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Ilya Zhanin
- Federal State Autonomous Institution "National Medical Research Center for Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Elena Raykina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Maria Kurnikova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Irina Mersiyanova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Hyuk Jee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kailey Brodeur
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Yan Du
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Meng Liu
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Aaron Weiss
- Department of Pediatrics, Maine Medical Center, Portland, Me
| | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jackeline Rodriguez-Smith
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael S Hershfield
- Department of Medicine and Biochemistry, Duke University School of Medicine, Durham, NC
| | - Ivona Aksentijevich
- Inflammatory Disease Section, National Human Genome Research Institute, Bethesda, Md
| | - Qing Zhou
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Mass
| | - Anna Shcherbina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Ekaterina Alexeeva
- Federal State Autonomous Institution "National Medical Research Center for Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia; Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
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6
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Gagne S, Sivaraman V, Akoghlanian S. Interferonopathies masquerading as non-Mendelian autoimmune diseases: pattern recognition for early diagnosis. Front Pediatr 2023; 11:1169638. [PMID: 37622085 PMCID: PMC10445166 DOI: 10.3389/fped.2023.1169638] [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: 02/19/2023] [Accepted: 07/05/2023] [Indexed: 08/26/2023] Open
Abstract
Type I interferonopathies are a broad category of conditions associated with increased type I interferon gene expression and include monogenic autoinflammatory diseases and non-Mendelian autoimmune diseases such as dermatomyositis and systemic lupus erythematosus. While a wide range of clinical presentations among type I interferonopathies exists, these conditions often share several clinical manifestations and implications for treatment. Presenting symptoms may mimic non-Mendelian autoimmune diseases, including vasculitis and systemic lupus erythematosus, leading to delayed or missed diagnosis. This review aims to raise awareness about the varied presentations of monogenic interferonopathies to provide early recognition and appropriate treatment to prevent irreversible damage and improve quality of life and outcomes in this unique patient population.
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Affiliation(s)
- Samuel Gagne
- Division of Pediatric Rheumatology, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Vidya Sivaraman
- Division of Pediatric Rheumatology, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States
| | - Shoghik Akoghlanian
- Division of Pediatric Rheumatology, Nationwide Children’s Hospital, Columbus, OH, United States
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States
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7
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Maccora I, Maniscalco V, Campani S, Carrera S, Abbati G, Marrani E, Mastrolia MV, Simonini G. A wide spectrum of phenotype of deficiency of deaminase 2 (DADA2): a systematic literature review. Orphanet J Rare Dis 2023; 18:117. [PMID: 37179309 PMCID: PMC10183141 DOI: 10.1186/s13023-023-02721-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Deficiency of adenosine deaminase 2 (DADA2) is a rare monogenic autoinflammatory disease, whose clinical phenotype was expanded since the first cases, originally described as mimicker of polyarteritis nodosa, with immunodeficiency and early-onset stroke. METHODS A systematic review according to PRISMA approach, including all articles published before the 31st of August 2021 in Pubmed and EMBASE database was performed. RESULTS The search identified 90 publications describing 378 unique patients (55.8% male). To date 95unique mutations have been reported. The mean age at disease onset was 92.15 months (range 0-720 months), 32 (8.5%) showed an onset of the first signs/symptoms after 18 years old and 96 (25.4%) after 10 years old. The most frequent clinical characteristics described were cutaneous (67.9%), haematological manifestations (56.3%), recurrent fever (51.3%), neurological as stroke and polyneuropathy (51%), immunological abnormalities (42.3%), arthralgia/arthritis (35.4%), splenomegaly (30.6%), abdominal involvement (29.8%), hepatomegaly (23.5%), recurrent infections (18.5%), myalgia (17.9%), kidney involvement (17.7%) etc. Patients with skin manifestations were older than the others (101.1 months SD ± 116.5, vs. 75.3 SD ± 88.2, p 0.041), while those with a haematological involvement (64.1 months SD ± 75.6 vs. 133.1 SD ± 133.1, p < 0.001) and immunological involvement (73.03 months SD ± 96.9 vs. 103.2 SD ± 112.9, p 0.05) are younger than the others. We observed different correlations among the different clinical manifestations. The use of anti-TNFα and hematopoietic cell stems transplantation (HCST) has improved the current history of the disease. CONCLUSION Due to this highly variable phenotype and age of presentation, patients with DADA2 may present to several type of specialists. Given the important morbidity and mortality, early diagnosis and treatment are mandatory.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy.
- NeuroFARBA Department, University of Florence, Florence, Italy.
| | | | - Silvia Campani
- School of Health Science, University of Florence, Florence, Italy
| | - Simona Carrera
- School of Health Science, University of Florence, Florence, Italy
| | - Giulia Abbati
- School of Health Science, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Gabriele Simonini
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
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8
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Sharma V, Deo P, Sharma A. Deficiency of adenosine deaminase 2 (DADA2): Review. Best Pract Res Clin Rheumatol 2023; 37:101844. [PMID: 37328410 DOI: 10.1016/j.berh.2023.101844] [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: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023]
Abstract
The deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive disease caused by loss-of-function (LOF) mutations in the ADA2 gene and was first described in 2014. Initially, it was described as vasculopathy/vasculitis that mostly affected infants and young children and closely resembled polyarteritis nodosa (PAN). Skin rash and ischemic/hemorrhagic stroke are predominant symptoms. However, the clinical spectrum of DADA2 has continued to expand since then. It has now been reported in adults as well. Besides vasculitis-related manifestations, hematological, immunological, and autoinflammatory manifestations are now well recognized. More than 100 disease-causing mutations have been described. The decrease in ADA2 enzyme leads to an increased extracellular adenosine level that, in turn, triggers a proinflammatory cascade. The disease is highly variable, and patients carrying same mutation may have different ages of presentation and clinical features. Anti-tumor necrosis factor (TNF) agents are mainstay of treatment of the vasculitis/vasculopathy phenotype. Hematopoietic stem cell transplant (HSCT) has been performed in patients with severe hematological manifestations. Recombinant ADA2 protein and gene therapy hold a promise for future.
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Affiliation(s)
- Vikas Sharma
- Rheumatology Superspeciality Cell, Department of Medicine, IGMC Shimla and Clinical Immunology and Rheumatology Division, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Prateek Deo
- Rheumatology Superspeciality Cell, Department of Medicine, IGMC Shimla and Clinical Immunology and Rheumatology Division, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Aman Sharma
- Rheumatology Superspeciality Cell, Department of Medicine, IGMC Shimla and Clinical Immunology and Rheumatology Division, Department of Internal Medicine, PGIMER, Chandigarh, India.
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9
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Li GM, Han X, Wu Y, Wang W, Tang HX, Lu MP, Tang XM, Lin Y, Deng F, Yang J, Wang XN, Liu CC, Zheng WJ, Wu BB, Zhou F, Luo H, Zhang L, Liu HM, Guan WZ, Wang SH, Tao PF, Jin TJ, Fang R, Wu Y, Zhang J, Zhang Y, Zhang TN, Yin W, Guo L, Tang WJ, Chang H, Zhang QY, Li XZ, Li JG, Zhou ZX, Yang SR, Yang KK, Xu H, Song HM, Deuitch NT, Lee PY, Zhou Q, Sun L. A Cohort Study on Deficiency of ADA2 from China. J Clin Immunol 2023; 43:835-845. [PMID: 36807221 PMCID: PMC10110724 DOI: 10.1007/s10875-023-01432-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/08/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Deficiency of adenosine deaminase 2 (DADA2), an autosomal recessive autoinflammatory disorder caused by biallelic loss-of-function variants in adenosine deaminase 2 (ADA2), has not been systemically investigated in Chinese population yet. We aim to further characterize DADA2 cases in China. METHODS A retrospective analysis of patients with DADA2 identified through whole exome sequencing (WES) at seventeen rheumatology centers across China was conducted. Clinical characteristics, laboratory findings, genotype, and treatment response were analyzed. RESULTS Thirty patients with DADA2 were enrolled between January 2015 and December 2021. Adenosine deaminase 2 enzymatic activity was low in all tested cases to confirm pathogenicity. Median age of disease presentation was 4.3 years and the median age at diagnosis was 7.8 years. All but one patient presented during childhood and two subjects died from complications of their disease. The patients most commonly presented with systemic inflammation (92.9%), vasculitis (86.7%), and hypogammaglobinemia (73.3%) while one patient presented with bone marrow failure (BMF) with variable cytopenia. Twenty-three (76.7%) patients were treated with TNF inhibitors (TNFi), while two (6.7%) underwent hematopoietic stem cell transplantation (HSCT). They all achieved clinical remission. A total of thirty-nine ADA2 causative variants were identified, six of which were novel. CONCLUSION To establish early diagnosis and improve clinical outcomes, genetic screening and/or testing of ADA2 enzymatic activity should be performed in patients with suspected clinical features. TNFi is considered as first line treatment for those with vascular phenotypes. HSCT may be beneficial for those with hematological disease or in those who are refractory to TNFi.
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Affiliation(s)
- Guo-Min Li
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Xu Han
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Ye Wu
- Peking University First Hospital, Beijing, China
| | - Wei Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong-Xia Tang
- Wuhan Children's Hospital Tongji Medical College Huazhong University of Science & Technology, Wuhan, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xue-Mei Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Lin
- Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fan Deng
- The Children's Hospital of Soochow, Suzhou, China
| | - Jun Yang
- Department of Rheumatology and Immunology, Shenzhen Children's Hospital, Shenzhen, China
| | - Xin-Ning Wang
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Cong-Cong Liu
- Division of Rheumatology, Immunology & Allergy in the Department of Pediatrics, The First Hospital of Jilin University, Changchun, China
| | - Wen-Jie Zheng
- Department of Rheumatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing-Bing Wu
- National Children's Medical Center, Shanghai, China.,Medical Transformation Centre, Children's Hospital of Fudan University, Shanghai, China
| | - Fang Zhou
- No. 960 Hospital of the Joint Service Support Force of the Chinese People's Liberation Army, Jinan, China
| | - Hong Luo
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Liang Zhang
- Hunan Provincial People's Hospital, Hunan, China
| | - Hai-Mei Liu
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Wan-Zhen Guan
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Shi-Hao Wang
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Pan-Feng Tao
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Tai-Jie Jin
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Ran Fang
- Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Yuan Wu
- Peking University First Hospital, Beijing, China
| | - Jie Zhang
- Peking University First Hospital, Beijing, China
| | - Yao Zhang
- Peking University First Hospital, Beijing, China
| | - Tian-Nan Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Yin
- Wuhan Children's Hospital Tongji Medical College Huazhong University of Science & Technology, Wuhan, China
| | - Li Guo
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen-Jing Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Chang
- Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qiu-Ye Zhang
- Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Jian-Guo Li
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Zhi-Xuan Zhou
- Affiliated Children's Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Si-Rui Yang
- Division of Rheumatology, Immunology & Allergy in the Department of Pediatrics, The First Hospital of Jilin University, Changchun, China
| | - Kang-Kang Yang
- Department of Rheumatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hong Xu
- National Children's Medical Center, Shanghai, China.,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Hong-Mei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | | | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Qing Zhou
- Life Sciences Institute, Zhejiang University, Hangzhou, China.
| | - Li Sun
- National Children's Medical Center, Shanghai, China. .,Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China.
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Bowers SM, Ng B, Abdossamadi S, Kariminia A, Cabral DA, Cuvelier GDE, Schultz KR, Brown KL. Elevated ADA2 Enzyme Activity at the Onset of Chronic Graft-versus-Host Disease in Children. Transplant Cell Ther 2023; 29:303.e1-303.e9. [PMID: 36804932 DOI: 10.1016/j.jtct.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/27/2023] [Accepted: 02/12/2023] [Indexed: 02/19/2023]
Abstract
Adenosinergic signaling has potent, context-specific effects on immune cells, particularly on the dysregulation of lymphocytes. This in turn may have a role in immune activation and loss of tolerance in such diseases as chronic graft-versus-host disease (chronic GVHD). We assessed whether changes in the enzymatic activity of adenosine deaminase 2 (ADA2), an enzyme that depletes adenosine in the extracellular space via conversion to inosine, may be associated with the onset of chronic GVHD. ADA2-specific enzyme activity was measured in plasma samples from 230 pediatric hematopoietic stem cell transplantation (HSCT) recipients enrolled on the Applied Biomarkers of Late Effects of Childhood Cancer (ABLE)/Pediatric Blood and Marrow Transplant Consortium (PBMTC) 1202 study and compared between patients developing chronic GVHD and those not developing chronic GVHD within 12 months of transplantation. ADA2 and its relationships with 219 previously measured plasma-soluble proteins, metabolites, and immune cell populations were evaluated as well. Plasma ADA2 enzyme activity was significantly elevated in pediatric HSCT recipients at the onset of chronic GVHD compared to patients without chronic GVHD and was not associated with prior history of acute GVHD or generalized inflammation as measured by C-reactive protein concentration. ADA2-specific enzyme activity met our criteria as a potential diagnostic biomarker of chronic GVHD (effect ratio ≥1.30 or ≤.75; area under the receiver operating characteristic curve ≥.60; P < .05) and was positively associated with markers of immune activation previously identified in pediatric chronic GVHD patients. These results support the potential of ADA2 enzyme activity, in combination with other biomarkers and subject to future validation, to aid the diagnosis of chronic GVHD in children post-HSCT.
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Affiliation(s)
- Sarah M Bowers
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Bernard Ng
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Molecular Medicine and Therapeutics, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Sayeh Abdossamadi
- Michael Cuccione Childhood Cancer Research Program, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Amina Kariminia
- Michael Cuccione Childhood Cancer Research Program, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - David A Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey D E Cuvelier
- Pediatric Blood and Marrow Transplant, Manitoba Blood and Marrow Transplant Program, CancerCare Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kirk R Schultz
- Michael Cuccione Childhood Cancer Research Program, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada; Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kelly L Brown
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada; Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
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11
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Alabbas F, Alanzi T, Alrasheed A, Essa M, Elyamany G, Asiri A, Almutairi S, Al-Mayouf S, Alenazi A, Alsafadi D, Ballourah W, Albalawi N, Hanafy E, Al-Hebshi A, Alrashidi S, Albatniji F, Alfaraidi H, Ali TB, Al Qwaiee M, AlHilali M, Aldeeb H, Alhaidey A, Aljasem H, Althubaiti S, Alsultan A. Genotype and Phenotype of Adenosine Deaminase 2 Deficiency: a Report from Saudi Arabia. J Clin Immunol 2023; 43:338-349. [PMID: 36239861 DOI: 10.1007/s10875-022-01364-9] [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: 03/05/2022] [Accepted: 09/08/2022] [Indexed: 02/04/2023]
Abstract
Adenosine deaminase 2 deficiency (DADA2), a rare and potentially fatal systemic autoinflammatory disease, is characterized by low or lack of ADA2 activity due to ADA2 mutations. DADA2 symptoms are variable and include vasculitis, immunodeficiency, and cytopenia. Minimal data are available from Saudi Arabia. This retrospective study conducted at seven major tertiary medical centers examined the phenotypic and genotypic variabilities, clinical and diagnostic findings, and treatment outcomes among 20 Saudi patients with DADA2 from 14 families. The median age of the study cohort was 9.5 years (4-26 years). The clinical presentation was before the age of 5 months in 25% of patients. Homozygous c.1447-1451del mutation was the most frequent ADA2 alteration (40%), followed by c.882-2A:G (30%). All tested patients exhibited absent or near-absent ADA2 activity. Phenotypic manifestations included stroke (40%), hematological abnormalities (95%), lymphoproliferation (65%), and recurrent infection (45%). Five and three patients had extracranial vasculitis features and Hodgkin lymphoma, respectively. Atypical manifestations included growth retardation (30%) and transverse myelitis. Anti-tumor necrosis factor (anti-TNF) therapy was the main treatment. Some patients underwent blood transfusion, splenectomy, cyclosporine and colony-stimulating factor therapies, and hematopoietic stem cell transplantation due to anti-TNF therapy failure. Fulminant hepatitis and septic multiorgan failure caused mortality in three patients. Thus, this study revealed the variability in the molecular and clinical characteristics of DADA2 in the study cohort with predominant aberrant hematological and immunological characteristics. Consensus diagnostic criteria will facilitate early diagnosis and treatment. Additionally, disease registries or large prospective studies are needed for evaluating rare disease complications, such as cancer.
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Affiliation(s)
- Fahad Alabbas
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia.
- Scientific Research Center, Prince Sultan Medical Military City, Riyadh, Saudi Arabia.
| | - Talal Alanzi
- Department of Inborn Errors of Metabolism and Genetics, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Abdulrahman Alrasheed
- Department of Pediatric Rheumatology, King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia
| | - Mohammed Essa
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, King Abdullah Specialist Children's Hospital, Riyadh, Saudi Arabia
| | - Ghaleb Elyamany
- Department of Central Military Laboratory and Blood Bank, Prince Sultan Medical Military Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Asiri
- Department of Pediatric Rheumatology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Sajdi Almutairi
- Department of Pediatric Rheumatology, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Sulaiman Al-Mayouf
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullatif Alenazi
- Department of Pediatric Rheumatology, Children Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Danyah Alsafadi
- Department of Pediatric Rheumatology, Aziziah Children Hospital, Jeddah, Saudi Arabia
| | - Walid Ballourah
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Naif Albalawi
- Department of Pediatric Hematology and Oncology, Prince Sultan Oncology Center, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Ehab Hanafy
- Department of Pediatric Hematology and Oncology, Prince Sultan Oncology Center, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Abdulqader Al-Hebshi
- Department of Pediatrics, Prince Mohammed Bin Abdulaziz Hospital, Medina, Saudi Arabia
| | - Seham Alrashidi
- Department of Rheumatology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Fatma Albatniji
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Huda Alfaraidi
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Tahani Bin Ali
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Mansour Al Qwaiee
- Department of Pediatric Pulmonology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Maryam AlHilali
- Department of Pediatric Immunology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Hayam Aldeeb
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Prince Sultan Medical Military City (PSMMC), Sulimaniyah RD, Riyadh, 12233, Saudi Arabia
| | - Ali Alhaidey
- Department of Radiology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Hassan Aljasem
- Department of Hematology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Sami Althubaiti
- Department of Pediatric Hematology and Oncology, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Princess Nora Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Abdulrahman Alsultan
- Department of Pediatrics, King Saud University Medical City, Riyadh, Saudi Arabia
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12
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Zhao X, Zhang J, Li C, Kuang W, Deng J, Tan X, Li C, Li S, Wang J. Early onset is an indication of the severity of DADA2 disease. Rheumatology (Oxford) 2023; 62:969-976. [PMID: 35471231 DOI: 10.1093/rheumatology/keac233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/20/2022] [Accepted: 03/20/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To find indicators of disease severity and factors of early remission in patients with deficiency of adenosine deaminase 2 (DADA2). METHODS We enrolled six DADA2 patients from six families. Direct sequencing of adenosine deaminase 2 gene (ADA2) was performed by Sanger analysis. A literature review was conducted for articles regarding paediatric DADA2. RESULTS We found that more organs were involved in early-onset (≤1 year of age) than in late-onset (>1 year of age) DADA2 patients had high level inflammatory responses, such as elevated ESR, SF, serum amyloid A and CRP. Disease severity was not significantly different from missense and frameshift mutation. Early administration of TNF inhibitor might result in better remission and reduce recurrence. In the literature, four articles describing 51 paediatric DADA2 patients were identified. We also found that fever, stroke, peripheral nervous system involvement, hypogammaglobulinaemia and hypertension were more frequent in early onset DADA2 patients. CONCLUSION Early-onset DADA2 may be more severe. Early administration of TNF inhibitor can effectively reduce recurrence and quickly alleviate the disease.
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Affiliation(s)
- Xiaozhen Zhao
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Junmei Zhang
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Caifeng Li
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Weiying Kuang
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jianghong Deng
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Tan
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Chao Li
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shipeng Li
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiang Wang
- Department of Rheumatology, National Centre for Children's Health; Beijing Children's Hospital, Capital Medical University, Beijing, China
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13
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Kalpana D, Thomas D, Kunju MA, Shirin F, Keswani P, M B. Adenosine deaminase 2 deficiency- An under-recognized cause for recurrent stroke in childhood. J Pediatr Neurosci 2023. [DOI: 10.4103/jpn.jpn_28_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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14
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Ikeda T. Recent topics related to etiology and clinical manifestations of cutaneous arteritis. Front Med (Lausanne) 2022; 9:1022512. [PMID: 36300176 PMCID: PMC9589105 DOI: 10.3389/fmed.2022.1022512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/20/2022] [Indexed: 12/02/2022] Open
Abstract
Cutaneous polyarteritis nodosa (cPAN) was first reported by Lindberg in 1931. It has been recognized as a skin-limited vasculitis whose cutaneous histopathological features are indistinguishable from those of PAN. Cutaneous arteritis (CA) was defined as a form of single-organ vasculitis in the revised Chapel Hill Classification and was recognized as the same disease as cPAN. It became known that deficiency of adenosine deaminase 2 (DADA2) cases were included in cases that had been diagnosed with CA. Because of their similarity and differences in the treatment methods, DADA2 should be considered in CA cases, especially if they are diagnosed or developed in early childhood. Cutaneous arteritis may be classified as an immune complex-mediated vasculitis. It was reported that the pathogenesis of anti-lysosomal-associated membrane protein-2 (LAMP-2) antibodies and anti-phosphatidylserine-prothrombin complex (PS/PT) antibodies as good parameters in CA. The main skin manifestations include livedo racemosa, subcutaneous nodules, and ulcers. Although CA is recognized to have a benign clinical course, it has become known that it is easy to relapse. The existence of skin ulcers upon diagnosis or sensory neuropathies was suggested to be a predictor of poor prognosis. Cutaneous arteritis with them may need to be treated with more intensive therapies.
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Cho S, Park S, Lee JS, Ju YS, Choi YJ, Lee S. Adenosine Deaminase 2 Deficiency Caused by Biallele Variants Including Splicing Variant: The First Case in Korea. JOURNAL OF RHEUMATIC DISEASES 2022; 29:254-260. [PMID: 37476427 PMCID: PMC10351412 DOI: 10.4078/jrd.21.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/30/2021] [Accepted: 11/04/2021] [Indexed: 07/22/2023]
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is an autoinflammatory disease caused by pathogenic variants of the ADA2 gene and has similar clinical features to polyarteritis nodosa (PAN). We, herein, report a case of DADA2 in Korea that was diagnosed in a patient with childhood-onset PAN. The patient had a truncal ataxia and facial palsy caused by thalamic infarction at 34 months of age. Livedo reticularis with Raynaud phenomenon and abdominal pain with fever were followed. Radiologic examination showed multiple infarctions in brain and kidney. She was diagnosed with PAN using skin biopsy and angiography. She had severe hemorrhagic strokes despite medical treatments. Her disease activity was controlled after adding a tumor necrosis factor-α inhibitor. Molecular analysis revealed compound heterozygous pathogenic variants of ADA2 gene. This is the first case of DADA2 in Korea. Genetic analysis for ADA2 gene should be considered in patients with childhood-onset PAN.
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Affiliation(s)
- Sun Cho
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
| | | | | | - Young Seok Ju
- GENOME INSIGHT Inc., Daejeon, Korea
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Yun Jung Choi
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
- Hospital Medicine Center, Seoul National University Hospital, Seoul, Korea
| | - Soyoung Lee
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
- GENOME INSIGHT Inc., Daejeon, Korea
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16
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Bowers SM, Sundqvist M, Dancey P, Cabral DA, Brown KL. Pathogenic variant c.1052T>A (p.Leu351Gln) in adenosine deaminase 2 impairs secretion and elevates type I IFN responsive gene expression. Front Immunol 2022; 13:995191. [PMID: 36248868 PMCID: PMC9562767 DOI: 10.3389/fimmu.2022.995191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAdenosine deaminase 2 (ADA2) is a homodimeric, extracellular enzyme and putative growth factor that is produced by cells of the myeloid lineage and, catalytically, deaminates extracellular adenosine to inosine. Loss-of-(catalytic)-function variants in the ADA2 gene are associated with Deficiency of ADA2 (DADA2), an autosomal recessive disease associated with an unusually broad range of inflammatory manifestations including vasculitis, hematological defects and cytopenia. Previous work by our group led to the identification of ADA2 variants of novel association with DADA2, among which was a unique c.1052T>A (p.Leu351Gln; herein referred to as L351Q) variant located in the catalytic domain of the protein.MethodsMammalian (Flp-IN CHO) cells were engineered to stably express wild-type ADA2 and ADA2 protein variants, including the pathogenic L351Q variant identified in DADA2 patients. An enzyme assay and immunoblotting were used to assess ADA2 catalytic activity and secretion, respectively, and the outcome of experimentally induced inhibition of protein processing (Golgi transport and N-linked glycosylation) was assessed. Reverse transcription quantitative real-time PCR (RT-qPCR) was applied to determine the relative expression of Type I Interferon stimulated genes (ISGs), IFIT3 and IRF7.ResultsIn addition to abrogating catalytic activity, the L351Q variant impaired secretion of L351Q ADA2 resulting in an intracellular accumulation of L351Q ADA2 protein that was not observed in cells expressing wild-type ADA2 or other ADA2 protein variants. Retention of L351Q ADA2 was not attributable to impaired glycosylation on neighboring asparagine residues and did not impact cell growth or integrity. Constitutive expression of Type I ISGs IFIT3 and IRF7 was observed in cells expressing L351Q ADA2.ConclusionsThe impaired secretion of L351Q ADA2 may be an important factor leading to the severe phenotype observed in patients with this variant further emphasizing the importance of assessing impacts beyond catalytic activity when evaluating genotype-phenotype relationships in DADA2.
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Affiliation(s)
- Sarah M. Bowers
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Martina Sundqvist
- British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Paul Dancey
- Janeway Children’s Health and Rehabilitation Centre, Saint John’s, NL, Canada
| | - David A. Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Kelly L. Brown
- British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Kelly L. Brown,
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17
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Signa S, Bertoni A, Penco F, Caorsi R, Cafaro A, Cangemi G, Volpi S, Gattorno M, Schena F. Adenosine Deaminase 2 Deficiency (DADA2): A Crosstalk Between Innate and Adaptive Immunity. Front Immunol 2022; 13:935957. [PMID: 35898506 PMCID: PMC9309328 DOI: 10.3389/fimmu.2022.935957] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022] Open
Abstract
Deficiency of Adenosine deaminase 2 (DADA2) is a monogenic autoinflammatory disorder presenting with a broad spectrum of clinical manifestations, including immunodeficiency, vasculopathy and hematologic disease. Biallelic mutations in ADA2 gene have been associated with a decreased ADA2 activity, leading to reduction in deamination of adenosine and deoxyadenosine into inosine and deoxyinosine and subsequent accumulation of extracellular adenosine. In the early reports, the pivotal role of innate immunity in DADA2 pathogenic mechanism has been underlined, showing a skewed polarization from the M2 macrophage subtype to the proinflammatory M1 subtype, with an increased production of inflammatory cytokines such as TNF-α. Subsequently, a dysregulation of NETosis, triggered by the excess of extracellular Adenosine, has been implicated in the pathogenesis of DADA2. In the last few years, evidence is piling up that adaptive immunity is profoundly altered in DADA2 patients, encompassing both T and B branches, with a disrupted homeostasis in T-cell subsets and a B-cell skewing defect. Type I/type II IFN pathway upregulation has been proposed as a possible core signature in DADA2 T cells and monocytes but also an increased IFN-β secretion directly from endothelial cells has been described. So far, a unifying clear pathophysiological explanation for the coexistence of systemic inflammation, immunedysregulation and hematological defects is lacking. In this review, we will explore thoroughly the latest understanding regarding DADA2 pathophysiological process, with a particular focus on dysregulation of both innate and adaptive immunity and their interacting role in the development of the disease.
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Affiliation(s)
- Sara Signa
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Arinna Bertoni
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Federica Penco
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Stefano Volpi
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- *Correspondence: Marco Gattorno,
| | - Francesca Schena
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
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18
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Hashem H, Dimitrova D, Meyts I. Allogeneic Hematopoietic Cell Transplantation for Patients With Deficiency of Adenosine Deaminase 2 (DADA2): Approaches, Obstacles and Special Considerations. Front Immunol 2022; 13:932385. [PMID: 35911698 PMCID: PMC9336546 DOI: 10.3389/fimmu.2022.932385] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/20/2022] [Indexed: 01/07/2023] Open
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is an inherited autosomal recessive disease characterized by autoinflammation (recurrent fever), vasculopathy (livedo racemosa, polyarteritis nodosa, lacunar ischemic strokes, and intracranial hemorrhages, end organ vasculitis), immunodeficiency, lymphoproliferation, immune cytopenias, and bone marrow failure. Allogeneic hematopoietic cell transplantation (HCT) is curative for DADA2 as it reverses the hematological, immune and vascular phenotype of DADA2. The primary goal of HCT in DADA2, like in other non-malignant diseases, is engraftment with the establishment of normal hematopoiesis and normal immune function. Strategies in selecting a preparative regimen should take into consideration the specific vulnerabilities to endothelial dysfunction and liver toxicity in DADA2 patients. Overcoming an increased risk of graft rejection while minimizing organ toxicity, graft-versus-host disease, and infections can be particularly challenging in DADA2 patients. This review will discuss approaches to HCT in DADA2 patients including disease-specific considerations, barriers to successful engraftment, post-HCT complications, and clinical outcomes of published patients with DADA2 who have undergone HCT to date.
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Affiliation(s)
- Hasan Hashem
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Bone Marrow Transplant Unit, King Hussein Cancer Center (KHCC), Amman, Jordan
- *Correspondence: Hasan Hashem, ; Isabelle Meyts,
| | - Dimana Dimitrova
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute of the National Institutes of Health, Bethesda, MD, United States
| | - Isabelle Meyts
- Department of Pediatrics, Microbiology, Immunology, and Transplantation, The European Reference Network Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network (ERN RITA) Core Center, University Hospitals Leuven, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- *Correspondence: Hasan Hashem, ; Isabelle Meyts,
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Gao ZW, Yang L, Liu C, Wang X, Guo WT, Zhang HZ, Dong K. Distinct Roles of Adenosine Deaminase Isoenzymes ADA1 and ADA2: A Pan-Cancer Analysis. Front Immunol 2022; 13:903461. [PMID: 35663977 PMCID: PMC9157497 DOI: 10.3389/fimmu.2022.903461] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Adenosine deaminase (ADA) plays an important role in immune response, which includes two isoenzymes: ADA1 and ADA2. This study aims to explore the roles of ADA1 and ADA2 in cancers. Methods Human Protein Atlas (HPA) and Gene Expression Profiling Interactive Analysis (GEPIA2) databases were used to analyze the mRNA expression of ADA1 and ADA2 in human normal cells and tumor tissues. The enzyme assay was used to detect the ADA1 and ADA2 activities in serum from cancer patients. The Kaplan-Meier (KM) plotter was used to analyze the prognostic value of ADA1 and ADA2. TIMER2.0 was used to explore how ADA1 and ADA2 correlate with immune infiltration and immune checkpoints. cBioPortal database was used to investigate the mutations of ADA1 and ADA2. LinkedOmics was used to screen the ADA1 and ADA2 expression-related genes. Results ADA1 was significantly increased in several tumor tissues, including cholangiocarcinoma (CHOL), lymphoid neoplasm diffuse large B-cell lymphoma (DLBC), head and neck squamous cell carcinoma (HNSC), kidney renal clear cell carcinoma (KIRC), ovarian serous cystadenocarcinoma (OV), pancreatic adenocarcinoma (PAAD), thymoma (THYM), and uterine carcinosarcoma (UCS). ADA2 expression was significantly increased in esophageal carcinoma (ESCA), glioblastoma multiforme (GBM), acute myeloid leukemia (LAML), OV, PAAD, skin cutaneous melanoma (SKCM), and stomach adenocarcinoma (STAD). There were no significant changes in serum ADA1 activities in most cancers, while serum ADA2 activities were increased in most cancers. For prognosis, high ADA1 expression was associated with the poor survival in several cancers, including esophageal squamous cell carcinoma (ESCC), HNSC, KIRC, kidney renal papillary cell carcinoma (KIRP), liver hepatocellular carcinoma (LIHC), lung adenocarcinoma (LUAD), and uterine corpus endometrial carcinoma (UCEC). However, high ADA2 expression showed a favorable prognosis in breast invasive carcinoma (BRCA), cervical squamous cell carcinoma and endocervical adenocarcinoma (CESC), HNSC, KIRC, KIRP, LUAD, OV, PAAD, sarcoma, and THYM. ADA1 showed a moderate positive correlation with multiple infiltrating immune cells in most cancers. ADA2 was positively correlated with B cells, CD8 T cells, monocytes/macrophages, and dendritic cells (DCs) and was strongly negatively correlated with myeloid-derived suppressor cells. Function analysis showed that ADA1 expression-related genes were mainly enriched in cell division biological progression. However, ADA2-related genes were mainly associated with immune response. Conclusion As isoenzymes, ADA1 and ADA2 showed opposite prognostic values and different correlative patterns with immune infiltrating. These data demonstrated the distinct roles of ADA1 and ADA2 in cancer. ADA2 might act as a protective factor in cancer.
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Affiliation(s)
| | | | | | | | | | | | - Ke Dong
- Department of Clinical Laboratory, Tangdu Hospital, Air Force Medical University, Xi’an, China
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20
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Barreiros LA, Sousa JL, Geier C, Leiss-Piller A, Kanegae MPP, França TT, Boisson B, Lima AM, Costa-Carvalho BT, Aranda CS, de Moraes-Pinto MI, Segundo GRS, Ferreira JFS, Tavares FS, Guimarães FATDM, Toledo EC, da Matta Ain AC, Moreira IF, Soldatelli G, Grumach AS, de Barros Dorna M, Weber CW, Di Gesu RSW, Dantas VM, Fernandes FR, Torgerson TR, Ochs HD, Bustamante J, Walter JE, Condino-Neto A. SCID and Other Inborn Errors of Immunity with Low TRECs - the Brazilian Experience. J Clin Immunol 2022; 42:1171-1192. [PMID: 35503492 DOI: 10.1007/s10875-022-01275-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/17/2022] [Indexed: 11/26/2022]
Abstract
Severe combined immunodeficiency, SCID, is a pediatric emergency that represents the most critical group of inborn errors of immunity (IEI). Affected infants present with early onset life-threatening infections due to absent or non-functional T cells. Without early diagnosis and curative treatment, most die in early infancy. As most affected infants appear healthy at birth, newborn screening (NBS) is essential to identify and treat patients before the onset of symptoms. Here, we report 47 Brazilian patients investigated between 2009 and 2020 for SCID due to either a positive family history and/or clinical impression and low TRECs. Based on clinical presentation, laboratory finding, and genetic information, 24 patients were diagnosed as typical SCID, 14 as leaky SCID, and 6 as Omenn syndrome; 2 patients had non-SCID IEI, and 1 remained undefined. Disease onset median age was 2 months, but at the time of diagnosis and treatment, median ages were 6.5 and 11.5 months, respectively, revealing considerable delay which affected negatively treatment success. While overall survival was 51.1%, only 66.7% (30/45) lived long enough to undergo hematopoietic stem-cell transplantation, which was successful in 70% of cases. Forty-three of 47 (91.5%) patients underwent genetic testing, with a 65.1% success rate. Even though our patients did not come from the NBS programs, the diagnosis of SCID improved in Brazil during the pilot programs, likely due to improved medical education. However, we estimate that at least 80% of SCID cases are still missed. NBS-SCID started to be universally implemented in the city of São Paulo in May 2021, and it is our hope that other cities will follow, leading to early diagnosis and higher survival of SCID patients in Brazil.
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Affiliation(s)
- Lucila Akune Barreiros
- Laboratory of Human Immunology, Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, 1730, Av. Professor Lineu Prestes, Sao Paulo, SP, 05508-000, Brazil
| | - Jusley Lira Sousa
- Laboratory of Human Immunology, Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, 1730, Av. Professor Lineu Prestes, Sao Paulo, SP, 05508-000, Brazil
| | | | | | - Marilia Pylles Patto Kanegae
- Laboratory of Human Immunology, Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, 1730, Av. Professor Lineu Prestes, Sao Paulo, SP, 05508-000, Brazil
| | - Tábata Takahashi França
- Laboratory of Human Immunology, Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, 1730, Av. Professor Lineu Prestes, Sao Paulo, SP, 05508-000, Brazil
| | - Bertrand Boisson
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France
- Imagine Institute, University of Paris, Paris, France
| | | | | | | | | | | | | | | | | | | | - Ana Carolina da Matta Ain
- Departamento de Pediatria E Imunologia, Hospital Universitário de Taubaté, Universidade de Taubaté, Taubate, SP, Brazil
| | | | - Gustavo Soldatelli
- Hospital das Clínicas, Universidade Federal de Santa Caratina, Florianopolis, SC, Brazil
| | | | - Mayra de Barros Dorna
- Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil
| | | | | | - Vera Maria Dantas
- Departamento de Pediatria, Universidade Federal Do Rio Grande Do Norte, Natal, RN, Brazil
| | | | | | - Hans Dietrich Ochs
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Research Institute, Seattle, USA
| | - Jacinta Bustamante
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France
- Imagine Institute, University of Paris, Paris, France
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children, AP-HP, Paris, France
| | - Jolan Eszter Walter
- University of South Florida at Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
- Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Antonio Condino-Neto
- Laboratory of Human Immunology, Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, 1730, Av. Professor Lineu Prestes, Sao Paulo, SP, 05508-000, Brazil.
- Immunogenic Laboratories Inc, Sao Paulo, SP, Brazil.
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21
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Abstract
PURPOSE OF REVIEW The aim is to review recent reports on childhood polyarteritis nodosa, including recent reports on treatment and outcome. Recently deficiency of adenosine deaminase-2 (ADA2), which may present as a polyarteritis nodosa-mimic, is becoming an important part of our practice. We also aim to highlight differences of childhood polyarteritis nodosa with deficiency of ADA2 as well as adult-onset disease. RECENT FINDINGS The few recent childhood series confirm the systemic nature of this vasculitis with predominantly medium-vessel involvement. American College of Rheumatology Vasculitis foundation has suggested recommendations for the management of this vasculitis. Unfortunately, we lack large patient numbers to provide us high evidence for the treatment of these patients. However, for induction mycophenolate mofetil or shorter courses of cyclophosphamide can be considered.Deficiency of ADA2 is now in the differential diagnosis of polyarteritis nodosa patients presenting with a family history and/or stroke with hematological and/or immunological abnormalities. SUMMARY We need collaborative work to define management and treatment strategies for childhood polyarteritis nodosa. Distinguishing deficiency of ADA2 is important because the treatment is different.
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Affiliation(s)
- Yelda Bilginer
- Department of Pediatrics, division of Pediatric Rheumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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22
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Escherich C, Bötticher B, Harmsen S, Hömberg M, Schaper J, Lorenz MR, Schwarz K, Borkhardt A, Oommen PT. The Growing Spectrum of DADA2 Manifestations-Diagnostic and Therapeutic Challenges Revisited. Front Pediatr 2022; 10:885893. [PMID: 35774100 PMCID: PMC9237362 DOI: 10.3389/fped.2022.885893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/20/2022] [Indexed: 12/23/2022] Open
Abstract
Deficiency of Adenosine Deaminase Type 2 (DADA2) is a rare autosomal recessive inherited disorder with a variable phenotype including generalized or cerebral vasculitis and bone marrow failure. It is caused by variations in the adenosine deaminase 2 gene (ADA2), which leads to decreased adenosine deaminase 2 enzyme activity. Here we present three instructive scenarios that demonstrate DADA2 spectrum characteristics and provide a clear and thorough diagnostic and therapeutic workflow for effective patient care. Patient 1 illustrates cerebral vasculitis in DADA2. Genetic analysis reveals a compound heterozygosity including the novel ADA2 variant, p.V325Tfs*7. In patient 2, different vasculitis phenotypes of the DADA2 spectrum are presented, all resulting from the homozygous ADA2 mutation p.Y453C. In this family, the potential risk for siblings is particularly evident. Patient 3 represents pure red cell aplasia with bone marrow failure in DADA2. Here, ultimately, stem cell transplantation is considered the curative treatment option. The diversity of the DADA2 spectrum often delays diagnosis and treatment of this vulnerable patient cohort. We therefore recommend early ADA2 enzyme activity measurement as a screening tool for patients and siblings at risk, and we expect early steroid-based remission induction will help avoid fatal outcomes.
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Affiliation(s)
- Carolin Escherich
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Benedikt Bötticher
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Stefani Harmsen
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Marc Hömberg
- Department of Pediatric Hematology and Oncology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Jörg Schaper
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Myriam Ricarda Lorenz
- Institute for Transfusion Medicine, University Hospital, Medical Faculty, Ulm University, Ulm, Germany
| | - Klaus Schwarz
- Institute for Transfusion Medicine, University Hospital, Medical Faculty, Ulm University, Ulm, Germany.,Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service Baden-Württemberg - Hessen, Ulm, Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Prasad Thomas Oommen
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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23
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Abstract
Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that preferentially affects medium-sized vessels. The idiopathic form has become rare. Its treatment relies on corticosteroid therapy and is combined with cyclophosphamide infusions for severe forms. Secondary PANs were mainly associated with hepatitis B virus infection; they were treated with plasma exchange and antivirals in combination with short-term corticosteroid therapy. Other secondary forms of PAN are now becoming more common, such as those due to blood disorders. More recently, a monogenic form linked to adenosine deaminase-2 mutations has been identified. It requires treatment with TNF inhibitors to decrease the occurrence of ischemic central nervous system complications, which make it serious. Once remission is obtained, relapses are typically rare during PAN and affect 28% of idiopathic PANs, within an average of 26 months from the diagnosis. The prognosis has improved considerably, with 5- and 10-year survival rates of 83% and 74%.
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Affiliation(s)
- Xavier Puéchal
- Centre de Référence des Maladies Systémiques Auto-immunes rares d'Île de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; Institut Cochin, Inserm U1016, CNRS UMR 8104, Paris, France.
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24
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Abinun M, Slatter MA. Haematopoietic stem cell transplantation in paediatric rheumatic disease. Curr Opin Rheumatol 2021; 33:387-397. [PMID: 34261117 DOI: 10.1097/bor.0000000000000823] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW A small proportion of children affected by rheumatic diseases suffer from severe, progressive disease, resistant to conventional antirheumatic therapies and to biologic agents interfering with inflammatory cytokines, costimulatory molecules expressed on immune system cells and intracellular signalling pathways. Adding to the poor prognosis is a high risk from significant morbidity and mortality associated with long-term treatment with multiple, often combined anti-inflammatory and immunosuppressive agents. Carefully selected patients from this unfortunate group may benefit from treatment with haematopoietic stem cell transplantation. RECENT FINDINGS The majority of patients with severe paediatric rheumatic and autoinflammatory diseases treated with autologous and/or allogeneic haematopoietic stem cell transplantation achieved long-term remission. However, the incidence of disease relapse and transplant related morbidity and mortality is still significant. SUMMARY Careful patient and donor selection, timing of the transplant earlier in the course of disease rather than the 'last resort' and choosing the most suitable conditioning regimen for each individual patient are the major factors favouring successful outcome. Close co-operation between the patients, their family, and involved medical teams is essential.
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Affiliation(s)
- Mario Abinun
- Department of Paediatric Immunology, Great North Children's Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University
| | - Mary A Slatter
- Haematopoietic Stem Cell Transplantation Unit, Great North Children's Hospital, Newcastle upon Tyne Hospitals, National Health Service Foundation Trust, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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25
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Garcia-Gil M, Camici M, Allegrini S, Pesi R, Tozzi MG. Metabolic Aspects of Adenosine Functions in the Brain. Front Pharmacol 2021; 12:672182. [PMID: 34054547 PMCID: PMC8160517 DOI: 10.3389/fphar.2021.672182] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022] Open
Abstract
Adenosine, acting both through G-protein coupled adenosine receptors and intracellularly, plays a complex role in multiple physiological and pathophysiological processes by modulating neuronal plasticity, astrocytic activity, learning and memory, motor function, feeding, control of sleep and aging. Adenosine is involved in stroke, epilepsy and neurodegenerative pathologies. Extracellular concentration of adenosine in the brain is tightly regulated. Adenosine may be generated intracellularly in the central nervous system from degradation of AMP or from the hydrolysis of S-adenosyl homocysteine, and then exit via bi-directional nucleoside transporters, or extracellularly by the metabolism of released nucleotides. Inactivation of extracellular adenosine occurs by transport into neurons or neighboring cells, followed by either phosphorylation to AMP by adenosine kinase or deamination to inosine by adenosine deaminase. Modulation of the nucleoside transporters or of the enzymatic activities involved in the metabolism of adenosine, by affecting the levels of this nucleoside and the activity of adenosine receptors, could have a role in the onset or the development of central nervous system disorders, and can also be target of drugs for their treatment. In this review, we focus on the contribution of 5'-nucleotidases, adenosine kinase, adenosine deaminase, AMP deaminase, AMP-activated protein kinase and nucleoside transporters in epilepsy, cognition, and neurodegenerative diseases with a particular attention on amyotrophic lateral sclerosis and Huntington's disease. We include several examples of the involvement of components of the adenosine metabolism in learning and of the possible use of modulators of enzymes involved in adenosine metabolism or nucleoside transporters in the amelioration of cognition deficits.
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Affiliation(s)
- Mercedes Garcia-Gil
- Department of Biology, Unit of Physiology, University of Pisa, Pisa, Italy.,Interdepartmental Research Center "Nutraceuticals and Food for Health", University of Pisa, Pisa, Italy
| | - Marcella Camici
- Department of Biology, Unit of Biochemistry, University of Pisa, Pisa, Italy
| | - Simone Allegrini
- Department of Biology, Unit of Biochemistry, University of Pisa, Pisa, Italy
| | - Rossana Pesi
- Department of Biology, Unit of Biochemistry, University of Pisa, Pisa, Italy
| | - Maria Grazia Tozzi
- Department of Biology, Unit of Biochemistry, University of Pisa, Pisa, Italy
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26
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Xu Y, Shan Y, Hu Y, Cao J, Wang Y, Lou L, Ye P. Case Report: An Adult Patient With Deficiency of Adenosine Deaminase 2 Resembled Unilateral Frosted Branch Angiitis. Front Med (Lausanne) 2021; 8:642454. [PMID: 33996853 PMCID: PMC8116590 DOI: 10.3389/fmed.2021.642454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Deficiency of adenosine deaminase 2 (DADA2) is a rare autosomal recessive systemic autoinflammatory disorder. We describe a rare case of an adult patient with DADA2 who presented with unilateral frosted branch angiitis (FBA) combined with branch retinal vein occlusion and panuveitis. Method: This paper is a clinical case report. Results: A 31-year-old male patient complained of blurred vision in his right eye for 2 days. His fundus examination showed FBA combined with branch retinal vein occlusion and panuveitis. He had a medical history of intermittent and recurrent fever, skin rash and aphthous ulcer for 5 years, and lacunar infarction for 1 month. Laboratory examinations showed hypogammaglobulinemia and mild prolonged activated partial thromboplastin time (APTT). Brain magnetic resonance imaging (MRI) revealed old lacunar infarction in the right basal ganglia and the lateral ventricle and fresh lacunar infarction in the right pons, respectively. The perivascular sheathing of FBA and macular edema were resolved after steroid administration and treatment of intravitreal anti-VEGF injection. During the period of follow-up, the patient subsequently suffered from recurrence of strokes, abnormality of coagulation function, sudden hearing loss of the left ear, and diplopia. His gene sequencing results demonstrated several deletion mutations in ADA2, and the diagnosis of DADA2 was eventually confirmed. Conclusions: FBA represents a very rare ocular feature of DADA2 and may in some cases be the presenting manifestation. Therefore, ophthalmologists need to be aware of this rare autoinflammatory disease.
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Affiliation(s)
- Yufeng Xu
- Eye Center, College of Medicine, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Yi Shan
- Eye Center, College of Medicine, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Yin Hu
- Department of Neurology, College of Medicine, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Jing Cao
- Eye Center, College of Medicine, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Yijie Wang
- Eye Center, College of Medicine, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Lixia Lou
- Eye Center, College of Medicine, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
| | - Panpan Ye
- Eye Center, College of Medicine, The Second Affiliated Hospital of Zhejiang University, Zhejiang, China
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27
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Kasap Cuceoglu M, Sener S, Batu ED, Kaya Akca U, Demir S, Sag E, Atalay E, Balık Z, Basaran O, Bilginer Y, Ozen S. Systematic review of childhood-onset polyarteritis nodosa and DADA2. Semin Arthritis Rheum 2021; 51:559-564. [PMID: 33901990 DOI: 10.1016/j.semarthrit.2021.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Diagnosis of childhood polyarteritis nodosa (PAN) has become challenging after the definition of deficiency of adenosine deaminase 2 (DADA2). We aimed to define the differential features of pediatric PAN and DADA2 patients in our center and in the literature. METHODS The charts of pediatric PAN and DADA2 patients followed at the Pediatric Rheumatology Unit of Hacettepe University between 2010-2020 were analyzed. A systematic literature review was conducted for articles regarding pediatric PAN or DADA2. RESULTS Thirty-four pediatric PAN and 18 pediatric DADA2 patients were included. The age at onset was younger, parental consanguinity, livedo reticularis, neurologic involvement (especially strokes), lymphopenia, and hypogammaglobulinemia were more frequent, while thrombocytosis and panniculitis were less frequent in DADA2 patients. The primary treatment was anti-tumor necrosis factor (anti-TNF) in DADA2. For induction treatment, all systemic PAN patients received corticosteroids, and cyclophosphamide (n=11) or mycophenolate mofetil (MMF) (n = 3). Cyclophosphamide was replaced with MMF in nine once remission was confirmed with PVAS. In the literature, 28 articles describing 613 pediatric PAN patients and 26 articles describing 207 pediatric DADA2 patients were identified. Neurologic, gastrointestinal, and cardiac involvements were more frequent in DADA2, while constitutional symptoms and testis involvement were more common in PAN. CONCLUSION In a child with PAN-like phenotype, DADA2 should be considered in the presence of young age at disease onset, parental consanguinity, strokes, lymphopenia, and lack of thrombocytosis during active disease. Anti-TNF treatment is indicated for vasculitic DADA2. Cyclophosphamide could be switched to MMF when remission is confirmed with PVAS in severe PAN.
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Affiliation(s)
- Muserref Kasap Cuceoglu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Seher Sener
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ummusen Kaya Akca
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Selcan Demir
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Erdal Sag
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Erdal Atalay
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Zeynep Balık
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ozge Basaran
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey.
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28
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Pinto B, Deo P, Sharma S, Syal A, Sharma A. Expanding spectrum of DADA2: a review of phenotypes, genetics, pathogenesis and treatment. Clin Rheumatol 2021; 40:3883-3896. [PMID: 33791889 DOI: 10.1007/s10067-021-05711-w] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/16/2021] [Accepted: 03/21/2021] [Indexed: 01/02/2023]
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is a monogenic disease caused by biallelic mutations in ADA2 gene (previously CECR1). The aim of this review was to describe the clinical phenotypes, genetics, pathogenesis and treatment of DADA2. ADA2 is highly expressed on myeloid cells and deficiency leads to polarisation of macrophages to an M1 inflammatory type and activation of neutrophils. The pathogenesis of immunological and haematological manifestations is less clear. The spectrum of clinical presentations varies widely from asymptomatic individual to severe vasculitis, several autoinflammatory, immunological and haematological manifestations. Initially considered a childhood disease, the first presentation is now being reported well into adulthood. Vasculitis closely resembles polyarteritis nodosa. Livedoid reticularis/racemosa like skin rash and central nervous system involvement in the form of ischemic or haemorrhagic stroke are dominant manifestations. Immunological manifestations include hypogammaglobulinemia and recurrent infections. Lymphopenia is the most common haematological manifestation; pure red cell aplasia and bone marrow failure has been reported in severe cases. The disease is extremely heterogeneous with variable severity noted in patients with the same mutation and even within family members. Tumour necrosis factor inhibitors are currently the treatment of choice for vasculitic and inflammatory manifestations and also prevent strokes. Haematopoietic stem cell transplantation is a curative option for severe haematological manifestations like pure red cell aplasia, bone marrow failure and immunodeficiency. Further research is required to understand pathogenesis and all clinical aspects of this disease to enable early diagnosis and prompt treatment. Key Points • Deficiency of adenosine deaminase 2 (DADA2) is a monogenic disease caused by biallelic mutations in ADA2 gene. • The clinical features include vasculitis resembling polyarteritis nodosa, autoinflammation, haematological manifestations and immunodeficiency. • The severity varies widely from mild to fatal even in patients within a family and with the same mutation. • The treatment of choice for inflammatory and vasculitic disease is tumour necrosis factor α blockers. Bone marrow transplant may be considered for severe haematological disease.
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Affiliation(s)
- Benzeeta Pinto
- Department of Clinical Immunology and Rheumatology, St. John's National Academy of Health Sciences, Bangalore, India
| | - Prateek Deo
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Susmita Sharma
- Department of Obstetrics and Gynaecology, Adesh Medical College and Hospital, Mohri, Ambala, India
| | - Arshi Syal
- Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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29
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Wang W, Zhang T, Zheng W, Zhong L, Wang L, Li J, Liu Q, Dong Y, Song H. Diagnosis and management of adenosine deaminase 2 deficiency children: the experience from China. Pediatr Rheumatol Online J 2021; 19:44. [PMID: 33757531 PMCID: PMC7986504 DOI: 10.1186/s12969-021-00535-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) is a rare autoinflammatory disease caused by mutations in the ADA2 gene. Few Chinese cases have been reported. We describe and compare the clinical features, genotypes, and treatments of Chinese DADA2 patients and non-Chinese patients. METHODS Primary immunodeficiency disease panel or whole-exome sequencing was performed for suspected cases, and assays for adenosine deaminase 2 (ADA2) enzyme activity were also carried out for the patients and their parents. Case reports of Chinese and non-Chinese patients with DADA2 were searched in PubMed and Chinese national databases. RESULTS Seven unrelated children from China with DADA2 were included in our study. Five were identified at Peking Union Medical College Hospital, and two had been reported previously (1 on PubMed and 1 in Chinese literature). Fourteen mutations in ADA2 were identified, 7 of which have not previously been reported in non-Chinese patients. Four children who underwent enzymatic analysis had lower ADA2 activity compared with their parents. Phenotypic manifestations included fever, skin symptoms, vasculitis, and neurologic involvement. Treatments varying from steroids, immunosuppressants, and tocilizumab, anti-TNF therapy and hematopoietic stem cell transplantation (HSCT) were effective depending on phenotype and severity. CONCLUSION This study includes the largest number of Chinese DADA2 patients to date. We recommend the combination of enzymatic analysis with gene screening to confirm the diagnosis. Different genotypes were observed among Chinese DADA2 patients; most phenotypes were similar to those of non-Chinese DADA2 patients, except for growth retardation. Disease remission might not be achieved with anti-IL-6 therapy.
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Affiliation(s)
- Wei Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Tiannan Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenjie Zheng
- grid.417384.d0000 0004 1764 2632Department of Rheumatology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province China
| | - Linqing Zhong
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lin Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ji Li
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qian Liu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanqing Dong
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongmei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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Schnappauf O, Moura NS, Aksentijevich I, Stoffels M, Ombrello AK, Hoffmann P, Barron K, Remmers EF, Hershfield M, Kelly SJ, Cuthbertson D, Carette S, Chung SA, Forbess L, Khalidi NA, Koening CL, Langford CA, McAlear CA, Monach PA, Moreland L, Pagnoux C, Seo P, Springer JM, Sreih AG, Warrington KJ, Ytterberg SR, Kastner DL, Grayson PC, Merkel PA. Sequence-Based Screening of Patients With Idiopathic Polyarteritis Nodosa, Granulomatosis With Polyangiitis, and Microscopic Polyangiitis for Deleterious Genetic Variants in ADA2. Arthritis Rheumatol 2021; 73:512-519. [PMID: 33021335 PMCID: PMC9945880 DOI: 10.1002/art.41549] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/06/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Deficiency of adenosine deaminase 2 (DADA2) is a monogenic form of vasculitis that can resemble polyarteritis nodosa (PAN). This study was undertaken to identify potential disease-causing sequence variants in ADA2 in patients with idiopathic PAN, granulomatosis with polyangiitis (GPA), or microscopic polyangiitis (MPA). METHODS Patients with idiopathic PAN (n = 118) and patients with GPA or MPA (n = 1,107) were screened for rare nonsynonymous variants in ADA2 using DNA sequencing methods. ADA-2 enzyme activity was assessed in selected serum samples. RESULTS Nine of 118 patients with PAN (7.6%) were identified as having rare nonsynonymous variants in ADA2. Four patients (3.4%) were biallelic for pathogenic or likely pathogenic variants, and 5 patients (4.2%) were monoallelic carriers for 3 variants of uncertain significance and 2 likely pathogenic variants. Serum samples from 2 patients with PAN with biallelic variants were available and showed markedly reduced ADA-2 enzyme activity. ADA-2 enzyme testing of 86 additional patients revealed 1 individual with strongly reduced ADA-2 activity without detectable pathogenic variants. Patients with PAN and biallelic variants in ADA2 were younger at diagnosis than patients with 1 or no variant in ADA2, with no other clinical differences noted. None of the patients with GPA or MPA carried biallelic variants in ADA2. CONCLUSION A subset of patients with idiopathic PAN meet genetic criteria for DADA2. Given that tumor necrosis factor inhibition is efficacious in DADA2 but is not conventional therapy for PAN, these findings suggest that ADA-2 testing should strongly be considered in patients with hepatitis B virus-negative idiopathic PAN.
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Affiliation(s)
- Oskar Schnappauf
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Natalia Sampaio Moura
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Ivona Aksentijevich
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Monique Stoffels
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Amanda K. Ombrello
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Patrycja Hoffmann
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Karyl Barron
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | - Elaine F. Remmers
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | | | | | | - Paul A. Monach
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Daniel L. Kastner
- NIH Intramural Sequencing Center (NISC) Comparative Sequencing Program, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Peter C. Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
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Zhang B, Sun Y, Xu N, Wang W, Huang X, Chen J, Shen M, Wang R, Zeng X, Zhang X. Adult-onset deficiency of adenosine deaminase 2-a case report and literature review. Clin Rheumatol 2021; 40:4325-4339. [PMID: 33638065 DOI: 10.1007/s10067-021-05587-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive disease caused by ADA2 gene mutation that is characterized by three phenotype domains: vasculopathy and inflammation, hematological abnormality, and immunodeficiency. Most patients are pediatric patients; adult-onset patients are only occasionally reported. To describe a Chinese case of adult-onset DADA2 in a Chinese patient and explore the genotype and phenotype characteristics of adult-onset DADA2. We examined the clinical, serological, and genetic features of a Chinese adult-onset DADA2 patient. English literature on DADA2 was reviewed. The clinical and genetic characteristics of different age and mutation subgroups were compared. A Chinese Han male presented with recurrent fever, rash, immunodeficiency, and significant vascular events since the age of 25 years. Serum ADA2 activity was diminished, and genotyping revealed a unique compound heterozygous mutation of exon2-10del/exon7del in the ADA2 gene leading to complete exon 7 deletion. Treatment with a TNFα inhibitor achieved disease control. A total of 269 cases carrying 102 mutations were analyzed through a literature review. Adult-onset patients had few symptoms in all three clinical domains; vasculopathy and inflammation were the major symptoms. Patients with null mutations had early disease onset and more frequent hematological abnormalities and immunodeficiency. Patients in all subgroups responded well to TNFα inhibitors. We reported the first Chinese adult-onset DADA2 patient, with a unique mutation. Screening for and differentiation of DADA2 are recommended for patients of all ages, as they might become symptomatic later in life and treatment strategies differ from those of traditional vasculitis. Key Points • We report a novel compound heterozygous deletion mutations of exons 2-10 and exon 7, leading to complete loss of exon 7 in the ADA2 gene. • Adult-onset DADA2 patients had high similarity to systemic vasculitis. • Null mutations contribute to earlier disease onset and more aggressive disease. • We suggest screening for DADA2 in patients with significant central vasculitis, hematological abnormality and immunodeficiency.
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Affiliation(s)
- Bingqing Zhang
- Department of General Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, NO. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yang Sun
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Na Xu
- Department of General Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, NO. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Wei Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xiaoming Huang
- Department of General Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, NO. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jialin Chen
- Department of General Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, NO. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, NO. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Rongrong Wang
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China.
| | - Xuejun Zeng
- Department of General Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, NO. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Xue Zhang
- McKusick-Zhang Center for Genetic Medicine, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
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32
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Sharma A, Naidu GSRSNK, Sharma V, Jha S, Dhooria A, Dhir V, Bhatia P, Sharma V, Bhattad S, KG C, Gupta V, Misra DP, Chavan PP, Malaviya S, Dudam R, Sharma B, Kumar S, Bhojwani R, Gupta P, Agarwal V, Sharma K, Singhal M, Rathi M, Nada R, Minz RW, Chaturvedi V, Aggarwal A, Handa R, Grossi A, Gattorno M, Huang Z, Wang J, Jois R, Negi VS, Khubchandani R, Jain S, Arostegui JI, Chambers EP, Hershfield MS, Aksentijevich I, Zhou Q, Lee PY. Deficiency of Adenosine Deaminase 2 in Adults and Children: Experience From India. Arthritis Rheumatol 2021; 73:276-285. [PMID: 32892503 PMCID: PMC7902299 DOI: 10.1002/art.41500] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/17/2020] [Accepted: 08/20/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Deficiency of adenosine deaminase 2 (DADA2) is a potentially fatal monogenic syndrome characterized by variable manifestations of systemic vasculitis, bone marrow failure, and immunodeficiency. Most cases are diagnosed by pediatric care providers, given the typical early age of disease onset. This study was undertaken to describe the clinical phenotypes and treatment response both in adults and in children with DADA2 in India. METHODS A retrospective analysis of pediatric and adult patients with DADA2 diagnosed at various rheumatology centers across India was conducted. Clinical characteristics, diagnostic findings, and treatment responses were analyzed in all subjects. RESULTS In total, 33 cases of DADA2 were confirmed in this cohort between April 2017 and March 2020. Unlike previous studies, nearly one-half of the confirmed cases presented during adulthood. All symptomatic patients exhibited features of vasculitis, whereas constitutional symptoms and anemia were more common in pediatric patients. Cutaneous and neurologic involvement were common, and 18 subjects had experienced at least one stroke. In addition, the clinical spectrum of DADA2 was expanded by recognition of novel features in these patients, including pancreatic infarction, focal myocarditis, and diffuse alveolar hemorrhage. Treatment with tumor necrosis factor inhibitors (TNFi) was initiated in 25 patients. All of the identified disease manifestations showed marked improvement after initiation of TNFi, and disease remission was achieved in 19 patients. Two cases were complicated by tuberculosis infection, and 2 deaths were reported. CONCLUSION This report presents the first case series of patients with DADA2 from India, diagnosed by adult and pediatric care providers. The findings raise awareness of this syndrome, particularly with regard to its presentation in adults.
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Affiliation(s)
- Aman Sharma
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - GSRSNK Naidu
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Vikas Sharma
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Saket Jha
- Clinical Immunology and Rheumatology, Om Hospital and
Research Center, Kathmandu, Nepal
| | - Aaadhar Dhooria
- Department of Rheumatology Santokba Durlabhji Memorial
Hospital, Jaipur, India
| | - Varun Dhir
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Prateek Bhatia
- Department of Paediatrics, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Sagar Bhattad
- Department of Pediatrics ASTER CMI Hospitals, Bengaluru,
India
| | - Chengappa KG
- Department of Clinical Immunology, JIPMER, Puducherry,
India
| | - Vikas Gupta
- Department of Rheumatology, DMC, Ludhiana, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | | | | | | | - Rajesh Bhojwani
- Santokba Institute of Digestive Surgical Sciences,
Santokba Durlabhji Memorial Hospital, Jaipur, India
| | - Pankaj Gupta
- Department of Gastroenterology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kusum Sharma
- Department of Medical Microbiology, Postgraduate
Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis and Imaging, Postgraduate
Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Ranjana W Minz
- Department of Immunopathology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Ved Chaturvedi
- Department of Rheumatology and Clinical Immunology, Sir
Ganga Ram Hospital, New Delhi, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rohini Handa
- Department of Rheumatology, Indraprastha Apollo
Hospitals, New Delhi, India
| | - Alice Grossi
- IRCCS Istituto Giannina Gaslini, UOSD Genetics and
Genomics of Rare Diseases, Genoa, Italy
| | - Marco Gattorno
- Centro Malattie Autoinfiammatorie e Immunodeficienze,
IRCCS G. Gaslini, Genoa, Italy
| | - Zhengping Huang
- Department of Rheumatology and Immunology, Guangdong
Second Provincial General Hospital, Guangzhou, China
| | - Jun Wang
- Life Sciences Institute, Zhejiang University, Zhejiang,
China
| | | | - VS Negi
- Department of Clinical Immunology, JIPMER, Puducherry,
India
| | - Raju Khubchandani
- Department of Paediatric Rheumatology, SRCC
Children’s Hospital, Mumbai, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Juan I Arostegui
- Department of Immunology, Hospital Clinic, Barcelona,
Spain
- Institut d’Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Eugene P. Chambers
- Department of Surgery, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
- DADA2 Foundation, Nashville, Tennessee, USA
| | - Michael S. Hershfield
- Department of Medicine and Biochemistry, Duke University
School of Medicine, Durham, North Caroline, USA
| | - Ivona Aksentijevich
- Inflammatory Disease Section, National Human Genome
Research Institute, Bethesda, Maryland, USA
| | - Qing Zhou
- Life Sciences Institute, Zhejiang University, Zhejiang,
China
| | - Pui Y. Lee
- Division of Immunology, Boston Children’s
Hospital, Boston, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW We aim to describe the pathophysiology, clinical findings, diagnosis, and treatment of deficiency of adenosine deaminase 2 (DADA2). RECENT FINDINGS DADA2 is a multi-organ disease of children and less often adults, which can present with wide-ranging manifestations including strokes, medium vessel vasculitis, hematologic disease, and immunodeficiency. Diagnosis is through detection of reduced activity level of the adenosine deaminase 2 (ADA2) enzyme and/or identification of bi-allelic mutations in the ADA2 gene. Outside of high-dose glucocorticoids, conventional immunosuppression has been largely ineffective in treating this relapsing and remitting disease. Vasculitic-predominant manifestations respond extremely well to tumor necrosis factor-α inhibition. Hematopoietic stem cell transplantation can lead to normalization of enzyme activity, as well as resolution of vasculitic, hematologic, and immunologic manifestations, although treatment-related adverse effects are not uncommon. Early detection of this disease across multiple disciplines could prevent devastating clinical outcomes, especially in genetically pre-disposed populations.
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Affiliation(s)
- Jennifer Lee Kendall
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Medicine University of Kansas Medical Center, 3901 Rainbow Blvd MS 2026, Kansas City, KS 66160 USA
| | - Jason Michael Springer
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Medicine University of Kansas Medical Center, 3901 Rainbow Blvd MS 2026, Kansas City, KS 66160 USA
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Schnappauf O, Zhou Q, Moura NS, Ombrello AK, Michael DG, Deuitch N, Barron K, Stone DL, Hoffmann P, Hershfield M, Applegate C, Bjornsson HT, Beck DB, Witmer PD, Sobreira N, Wohler E, Chiorini JA, Center TAG, Dalgard CL, Center NIS, Kastner DL, Aksentijevich I. Deficiency of Adenosine Deaminase 2 (DADA2): Hidden Variants, Reduced Penetrance, and Unusual Inheritance. J Clin Immunol 2020; 40:917-926. [PMID: 32638197 PMCID: PMC7416912 DOI: 10.1007/s10875-020-00817-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/29/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive disorder that manifests with fever, early-onset vasculitis, strokes, and hematologic dysfunction. This study aimed to identify disease-causing variants by conventional Sanger and whole exome sequencing in two families suspected to have DADA2 and non-confirmatory genotypes. ADA2 enzymatic assay confirmed the clinical diagnosis of DADA2. Molecular diagnosis was important to accurately identify other family members at risk. METHODS We used a variety of sequencing technologies, ADA2 enzymatic testing, and molecular methods including qRT-PCR and MLPA. RESULTS Exome sequencing identified heterozygosity for the known pathogenic variant ADA2: c.1358A>G, p.Tyr453Cys in a 14-year-old female with a history of ischemic strokes, livedo, and vasculitis. No second pathogenic variant could be identified. ADA2 enzymatic testing in combination with quantitative RT-PCR suggested a loss-of-function allele. Subsequent genome sequencing identified a canonical splice site variant, c.-47+2T>C, within the 5'UTR of ADA2. Two of her unaffected siblings were found to carry the same two pathogenic variants. A homozygous 800-bp duplication comprising exon 7 of ADA2 was identified in a 5-year-old female with features consistent with Diamond-Blackfan anemia (DBA). The duplication was missed by Sanger sequencing of ADA2, chromosomal microarray, and exome sequencing but was detected by MLPA in combination with long-read PCR sequencing. The exon 7 duplication was also identified in her non-symptomatic father and younger sister. CONCLUSIONS ADA2 pathogenic variants may not be detected by conventional sequencing and genetic testing and may require the incorporation of additional diagnostic methods. A definitive molecular diagnosis is crucial for all family members to make informed treatment decisions.
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Affiliation(s)
- Oskar Schnappauf
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA.
| | - Qing Zhou
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Natalia Sampaio Moura
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Amanda K Ombrello
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Drew G Michael
- Department of Laboratory Medicine, Center for Genetic Medicine Research, Children's National, Washington, DC, USA
| | - Natalie Deuitch
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Karyl Barron
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Deborah L Stone
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Patrycja Hoffmann
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University School of Medicine, Durham, NC, USA
| | - Carolyn Applegate
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hans T Bjornsson
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Landspitali University Hospital, Reykjavik, Iceland
| | - David B Beck
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - P Dane Witmer
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nara Sobreira
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Wohler
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John A Chiorini
- Molecular Physiology and Therapeutics Branch, National Institute of Dental and Craniofacial Research (NIDCR), Bethesda, MD, USA
| | | | - Clifton L Dalgard
- Department of Anatomy, Physiology & Genetics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nih Intramural Sequencing Center
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Daniel L Kastner
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Ivona Aksentijevich
- Metabolic, Cardiovascular and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
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Bowers SM, Gibson KM, Cabral DA, Brown KL. Adenosine deaminase 2 activity negatively correlates with age during childhood. Pediatr Rheumatol Online J 2020; 18:54. [PMID: 32650798 PMCID: PMC7350767 DOI: 10.1186/s12969-020-00446-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/30/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Human adenosine deaminase 2 (ADA2) is an extracellular enzyme that negatively regulates adenosine-mediated cell signaling by converting adenosine to inosine. Altered ADA2 enzyme activity has been associated with some viral infections and rheumatic diseases. The potential utility of ADA2 as a biomarker is, however, limited by the absence of established ranges of ADA2 concentration and enzyme activity in the healthy population. It is known that ADA2 enzyme activity is lower in adults, but when (and why) this decline happens is not known. The purpose of this study was to establish normative ranges of ADA2 enzyme activity and protein concentration in the healthy pediatric population. METHODS We modified a commercially available ADA2 enzyme activity assay to enable higher throughput analysis of fresh, frozen and hemolyzed blood samples. With this assay and ADA2 protein immunoblotting, we analyzed ADA2 enzyme activity and protein concentration in blood plasma from a cohort of children and adolescents (n = 94) aged 5 months to 18 years. One-way ANOVA with subsequent Tukey multiple comparison test was used to analyze group differences. Reference intervals were generated using the central 95% of the population (2-97.5 percentiles). RESULTS ADA2 enzyme activity was consistent in fresh, frozen, and hemolyzed sera and plasma as measured by our modified assay. Analysis of plasma samples from the healthy pediatric cohort revealed that ADA2 enzyme activity is significantly lower in older children than in younger children (p < 0.0001). In contrast, there was no significant correlation between ADA2 protein concentration and either age or ADA2 enzyme activity. CONCLUSION We observed that ADA2 enzyme activity, but not ADA2 protein concentration, negatively correlates with age in a cohort of children and adolescents. Our findings stress the importance of appropriate age-matched controls for assessing ADA2 enzyme activity in the clinical setting.
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Affiliation(s)
- Sarah M Bowers
- British Columbia Children's Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC, V5Z 4H4, Canada
- Centre for Blood Research, The University of British Columbia, Vancouver, BC, Canada
| | - Kristen M Gibson
- British Columbia Children's Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC, V5Z 4H4, Canada
- Centre for Blood Research, The University of British Columbia, Vancouver, BC, Canada
- Department of Medical Genetics, The University of British Columbia, Vancouver, BC, Canada
| | - David A Cabral
- Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada
- Division of Rheumatology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Kelly L Brown
- British Columbia Children's Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC, V5Z 4H4, Canada.
- Centre for Blood Research, The University of British Columbia, Vancouver, BC, Canada.
- Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada.
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Huang Z, Li T, Nigrovic PA, Lee PY. Polyarteritis nodosa and deficiency of adenosine deaminase 2 - Shared genealogy, generations apart. Clin Immunol 2020; 215:108411. [PMID: 32276138 PMCID: PMC7387119 DOI: 10.1016/j.clim.2020.108411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/27/2019] [Accepted: 04/05/2020] [Indexed: 12/24/2022]
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that predominantly affects medium-sized arteries. With the establishment and refinement of vasculitis nomenclature and diagnostic criteria, clinical findings of PAN and distinguishing features from other vasculitides are now well characterized. Although PAN typically manifests in adulthood, cohort studies in paediatric patients have shaped our understanding of childhood-onset PAN. The paradigm of childhood-onset PAN changed considerably with the landmark discovery of deficiency of ADA2 (DADA2), a monogenic cause of vasculitis that is often indistinguishable from PAN. Testing for DADA2 has provided an explanation to numerous challenging cases of familial PAN and early-onset PAN around the world. The ability to distinguish DADA2 from classic PAN have important therapeutic implications as tumor necrosis factor inhibitors have demonstrated remarkable efficacy in the treatment of DADA2. In this review, we will discuss our current understanding of PAN and DADA2 and highlight similarities and differences between these vasculitides.
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Affiliation(s)
- Zhengping Huang
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Tianwang Li
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Peter A Nigrovic
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Pui Y Lee
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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Lee PY, Kellner ES, Huang Y, Furutani E, Huang Z, Bainter W, Alosaimi MF, Stafstrom K, Platt CD, Stauber T, Raz S, Tirosh I, Weiss A, Jordan MB, Krupski C, Eleftheriou D, Brogan P, Sobh A, Baz Z, Lefranc G, Irani C, Kilic SS, El-Owaidy R, Lokeshwar MR, Pimpale P, Khubchandani R, Chambers EP, Chou J, Geha RS, Nigrovic PA, Zhou Q. Genotype and functional correlates of disease phenotype in deficiency of adenosine deaminase 2 (DADA2). J Allergy Clin Immunol 2020; 145:1664-1672.e10. [PMID: 31945408 DOI: 10.1016/j.jaci.2019.12.908] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/07/2019] [Accepted: 12/27/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Deficiency of adenosine deaminase 2 (DADA2) is a syndrome with pleiotropic manifestations including vasculitis and hematologic compromise. A systematic definition of the relationship between adenosine deaminase 2 (ADA2) mutations and clinical phenotype remains unavailable. OBJECTIVE We sought to test whether the impact of ADA2 mutations on enzyme function correlates with clinical presentation. METHODS Patients with DADA2 with severe hematologic manifestations were compared with vasculitis-predominant patients. Enzymatic activity was assessed using expression constructs reflecting all 53 missense, nonsense, insertion, and deletion genotypes from 152 patients across the DADA2 spectrum. RESULTS We identified patients with DADA2 presenting with pure red cell aplasia (n = 5) or bone marrow failure (BMF, n = 10) syndrome. Most patients did not exhibit features of vasculitis. Recurrent infection, hepatosplenomegaly, and gingivitis were common in patients with BMF, of whom half died from infection. Unlike patients with DADA2 with vasculitis, patients with pure red cell aplasia and BMF proved largely refractory to TNF inhibitors. ADA2 variants associated with vasculitis predominantly reflected missense mutations with at least 3% residual enzymatic activity. In contrast, pure red cell aplasia and BMF were associated with missense mutations with minimal residual enzyme activity, nonsense variants, and insertions/deletions resulting in complete loss of function. CONCLUSIONS Functional interrogation of ADA2 mutations reveals an association of subtotal function loss with vasculitis, typically responsive to TNF blockade, whereas more extensive loss is observed in hematologic disease, which may be refractory to treatment. These findings establish a genotype-phenotype spectrum in DADA2.
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Affiliation(s)
- Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Erinn S Kellner
- Division of Allergy/Immunology, Cincinnati Children's Hospital and University of Cincinnati, Cincinnati, Ohio
| | - Yuelong Huang
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Elissa Furutani
- Dana Farber and Boston Children's Cancer and Blood Disorders Center, Boston, Mass
| | - Zhengping Huang
- Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Wayne Bainter
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Mohammed F Alosaimi
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Department of Pediatrics, King Saud University, Riyadh, Saudi Arabia
| | - Kelsey Stafstrom
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Tali Stauber
- Primary Immunodeficiency Clinic, Sheba Medical Center, Jeffrey Modell Foundation, Tel Hashomer, Israel
| | - Somech Raz
- Primary Immunodeficiency Clinic, Sheba Medical Center, Jeffrey Modell Foundation, Tel Hashomer, Israel
| | - Irit Tirosh
- Pediatric Rheumatology Service, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Aaron Weiss
- Department of Pediatrics, Maine Medical Center, Portland, Me
| | - Michael B Jordan
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio; Division of Immunobiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Christa Krupski
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Despina Eleftheriou
- University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Paul Brogan
- University College London, Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ali Sobh
- Department of Pediatrics, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Zeina Baz
- Department of Pediatrics, St George Hospital University Medical Center, Beirut, Lebanon
| | - Gerard Lefranc
- Institut de Génétique Humaine, UMR 9002 CNRS-Université de Montpellier, Montpellier, France
| | - Carla Irani
- Internal Medicine & Clinical Immunology Department, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Sara S Kilic
- Department of Pediatric Immunology and Rheumatology, Uludag University Medical Faculty, Bursa, Turkey
| | - Rasha El-Owaidy
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - M R Lokeshwar
- Department of Pediatrics, Lilavati Hospital and Research Centre, Mumbai, India
| | | | | | - Eugene P Chambers
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn; DADA2 Foundation, Nashville, Tenn
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Raif S Geha
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Qing Zhou
- Life Sciences Institute, Zhejiang University, Zhejiang, China
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Zervou MI, Goulielmos GN, Matalliotakis M, Matalliotaki C, Spandidos DA, Eliopoulos E. Role of adenosine deaminase 2 gene variants in pediatric deficiency of adenosine deaminase 2: A structural biological approach. Mol Med Rep 2019; 21:876-882. [PMID: 31974608 PMCID: PMC6947897 DOI: 10.3892/mmr.2019.10862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/04/2019] [Indexed: 01/06/2023] Open
Abstract
Adenosine deaminase 2 (ADA2) belongs to the novel family of adenosine deaminase growth factors (ADGFs), which play an important role in tissue development. The deficiency of adenosine deaminase 2 (DADA2) is a recently recognized autosomal recessive autoinflammatory disease, characterized by various systemic vascular and inflammatory manifestations, which is associated with ADA2 mutations. Considering that a recent screening of an international registry of children with systemic primary vasculitis revealed novel and already known variants in ADA2, this study aimed to further investigate the functional significance of the rare variants detected, namely p.Gly47Arg, p.Gly47Ala, p.Arg8Trp, p.Leu351Gln and p.Ala357Thr, by using a structural biological approach. Three-dimensional models of the mutants were developed and their three-dimensional (3D) structures were subjected to detailed interaction and conformational analyses. This led to suggestions that the novel mutations found may affect the formation/stability of the homodimer or may influence the activity of the enzyme. It was thus concluded that the Arg8Trp and Gly47Arg mutations affect the position and interaction of the dimer-associated HN1 helical structure and therefore, dimer formation and stabilization, while Leu351Gln and Ala357Thr influence the metal coordination in the active site. These findings shed further light onto the structural consequences of the mutations under investigation.
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Affiliation(s)
- Maria I Zervou
- Section of Molecular Pathology and Human Genetics, Department of Internal Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - George N Goulielmos
- Section of Molecular Pathology and Human Genetics, Department of Internal Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Michail Matalliotakis
- Section of Molecular Pathology and Human Genetics, Department of Internal Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Charoula Matalliotaki
- Section of Molecular Pathology and Human Genetics, Department of Internal Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Demetrios A Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Elias Eliopoulos
- Laboratory of Genetics, Department of Biotechnology, Agricultural University of Athens, 11855 Athens, Greece
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