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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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Muacevic A, Adler JR, Alqurashi SS, Alsaeedi EE, Alsulami H. A Unique Case of Deficiency of Adenosine Deaminase 2 Single in a Young Adult Patient. Cureus 2023; 15:e33273. [PMID: 36606112 PMCID: PMC9808879 DOI: 10.7759/cureus.33273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/04/2023] Open
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is a rare monogenic disease caused by mutations in the adenosine deaminase 2 gene (ADA2). It is characterized by a wide range of manifestations, including systemic inflammation and vasculopathy, early onset stroke (ischemic or hemorrhagic), immunodeficiency, and bone marrow failure. The diagnosis of DADA2 is confirmed by pathogenic mutations in ADA2 or low ADA2 enzymatic activity in the patient. In this study, we present a case of a 24-year-old Saudi male who was admitted with symptomatic anemia, lightheadedness, exertional symptoms, and a history of fever (38.1 C) for one week. Laboratory tests revealed normocytic normochromic anemia, leucopenia, lymphopenia, and neutropenia-autoimmune profile: low C3 and positive anti-ds DNA. The genetic testing revealed two Pathogenic variants, which were identified in ADA2. The diagnosis of DADA2 was made, and the patient received subcutaneous adalimumab 40 mg every two weeks. At the follow-up after one month, he showed improvement in fever, rash, and C-reactive protein (CRP) from (6 to 0.65). In conclusion, we present one of the first cases in Saudi Arabia of an adult patient diagnosed with DADA2 with a unique gene mutation. Adult-onset patients with DADA2 usually have a vague presentation and a relatively narrower phenotype range of symptoms which produce additional challenges for the physician to add DADA2 to the list of differentials. We suggest further studies investigate the genotype-phenotype association, possible clinical presentation, and the development of curative treatments for those cases.
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Barzaghi F, Cicalese MP, Zoccolillo M, Brigida I, Barcella M, Merelli I, Sartirana C, Zanussi M, Calbi V, Bernardo ME, Tucci F, Migliavacca M, Giglio F, Doglio M, Canarutto D, Ferrua F, Consiglieri G, Prunotto G, Saettini F, Bonanomi S, Rovere-Querini P, Di Colo G, Jofra T, Fousteri G, Penco F, Gattorno M, Hershfield MS, Bongiovanni L, Ponzoni M, Marktel S, Milani R, Peccatori J, Ciceri F, Mortellaro A, Aiuti A. Case Report: Consistent disease manifestations with a staggered time course in two identical twins affected by adenosine deaminase 2 deficiency. Front Immunol 2022; 13:910021. [PMID: 36248833 PMCID: PMC9557171 DOI: 10.3389/fimmu.2022.910021] [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: 03/31/2022] [Accepted: 09/05/2022] [Indexed: 12/03/2022] Open
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive disease associated with a highly variable clinical presentation, including vasculitis, immunodeficiency, and hematologic manifestations, potentially progressing over time. The present study describes the long-term evolution of the immuno-hematological features and therapeutic challenge of two identical adult twin sisters affected by DADA2. The absence of plasmatic adenosine deaminase 2 (ADA2) activity in both twins suggested the diagnosis of DADA2, then confirmed by genetic analysis. Exon sequencing revealed a missense (p.Leu188Pro) mutation on the paternal ADA2 allele. While, whole genome sequencing identified an unreported deletion (IVS6_IVS7del*) on the maternal allele predicted to produce a transcript missing exon 7. The patients experienced the disease onset during childhood with early strokes (Patient 1 at two years, Patient 2 at eight years of age), subsequently followed by other shared DADA2-associated features, including neutropenia, hypogammaglobulinemia, reduced switched memory B cells, inverted CD4:CD8 ratio, increased naïve T cells, reduced follicular regulatory T cells, the almost complete absence of NK cells, T-large granular cell leukemia, and osteoporosis. Disease evolution differed: clinical manifestations presented several years earlier and were more pronounced in Patient 1 than in Patient 2. Due to G-CSF refractory life-threatening neutropenia, Patient 1 successfully underwent an urgent hematopoietic stem cell transplantation (HSCT) from a 9/10 matched unrelated donor. Patient 2 experienced a similar, although delayed, disease evolution and is currently on anti-TNF therapy and anti-infectious prophylaxis. The unique cases confirmed that heterozygous patients with null ADA2 activity deserve deep investigation for possible structural variants on a single allele. Moreover, this report emphasizes the importance of timely recognizing DADA2 at the onset to allow adequate follow-up and detection of disease progression. Finally, the therapeutic management in these identical twins raises significant concerns as they share a similar phenotype, with a delayed but almost predictable disease evolution in one of them, who could benefit from a prompt definitive treatment like elective allogeneic HSCT. Additional data are required to assess whether the absence of enzymatic activity at diagnosis is associated with hematological involvement and is also predictive of bone marrow dysfunction, encouraging early HSCT to improve functional outcomes.
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Affiliation(s)
- Federica Barzaghi
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Pia Cicalese
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Matteo Zoccolillo
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Immacolata Brigida
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Barcella
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Institute for Biomedical Technologies, National Research Council, Segrate, Italy
| | - Ivan Merelli
- Institute for Biomedical Technologies, National Research Council, Segrate, Italy
| | - Claudia Sartirana
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Monica Zanussi
- Clinical Genomics-Molecular Genetics Service, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Raffaele Hospital, Milan, Italy
| | - Valeria Calbi
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Ester Bernardo
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Tucci
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maddalena Migliavacca
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Matteo Doglio
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniele Canarutto
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Ferrua
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Consiglieri
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Prunotto
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Bone Marrow Transplantation Unit, Pediatric Department of Milano-Bicocca University, Monza e Brianza per il Bambino e la sua Mamma Foundation, Monza, Italy
| | - Francesco Saettini
- Bone Marrow Transplantation Unit, Pediatric Department of Milano-Bicocca University, Monza e Brianza per il Bambino e la sua Mamma Foundation, Monza, Italy
| | - Sonia Bonanomi
- Bone Marrow Transplantation Unit, Pediatric Department of Milano-Bicocca University, Monza e Brianza per il Bambino e la sua Mamma Foundation, Monza, Italy
| | - Patrizia Rovere-Querini
- Vita-Salute San Raffaele University, Milan, Italy
- Internal Medicine, Diabetes, and Endocrinology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Di Colo
- Vita-Salute San Raffaele University, Milan, Italy
- Immunology, Rheumatology, Allergy and Rare Disease Unit, IRCCS San Rafaelle Hospital, Milan, Italy
| | - Tatiana Jofra
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Georgia Fousteri
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Penco
- Clinica Pediatrica – Reumatologia e Centro Malattie Autoinfiammatorie, IRCCS Giannina Gaslini, Genova, Italy
| | - Marco Gattorno
- Clinica Pediatrica – Reumatologia e Centro Malattie Autoinfiammatorie, IRCCS Giannina Gaslini, Genova, Italy
| | - Michael S. Hershfield
- Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, United States
| | - Lucia Bongiovanni
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maurilio Ponzoni
- Vita-Salute San Raffaele University, Milan, Italy
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Raffaella Milani
- Immunohematology and Transfusion Medicine Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Fabio Ciceri
- Vita-Salute San Raffaele University, Milan, Italy
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Alessandra Mortellaro
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- *Correspondence: Alessandra Mortellaro,
| | - Alessandro Aiuti
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Abbasi A, Batllori M, Gil-Sáez FJ, Rodríguez-Pintó I, Antón López J, Iglesias Jímenez E. Importance of the determination of enzymatic activity in the diagnosis of deficiency of adenosine deaminase 2 (DADA2). Med Clin (Barc) 2022; 159:283-286. [PMID: 35241284 DOI: 10.1016/j.medcli.2021.12.020] [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: 07/31/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe the usefulness of determining the enzymatic activity of adenosine deaminase 2 (ADA2) in patients with suspected ADA2 deficiency (DADA2). METHOD Retrospective multicenter study. Review with analysis of the clinical, biochemical and genetic data of the patients in whom the enzymatic activity of ADA2 has been determined by spectrophotometric method. RESULT In 3 of the 20 patients, the diagnosis of DADA2 was confirmed by the combination of reduced enzyme activity and biallelic pathogenic variants in the CECR1 gene. In 2 patients with variants of uncertain significance in CECR1, the study of enzymatic activity allowed to rule out the disease. CONCLUSIONS The reduced enzymatic detection of ADA2 confirms the diagnosis of DADA2, particularly important in carriers of variants of uncertain significance in CECR1.
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Affiliation(s)
- Adrián Abbasi
- Servicio de Enfermedades del Sistema Inmune-Reumatología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - Marta Batllori
- Servicio de Laboratorio, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | | | - Ignasi Rodríguez-Pintó
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Mútua de Terrassa, Barcelona, España
| | - Jordi Antón López
- Sección de Reumatología Pediátrica, Servicio de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - Estíbaliz Iglesias Jímenez
- Sección de Reumatología Pediátrica, Servicio de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
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5
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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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Krusche M, Kallinich T. [Autoinflammation-differences between children and adults]. Z Rheumatol 2021; 81:45-54. [PMID: 34762171 DOI: 10.1007/s00393-021-01115-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2021] [Indexed: 10/19/2022]
Abstract
Autoinflammatory diseases present as multisystemic inflammation and often manifest in early childhood. In contrast, in a few diseases, e.g., the recently described VEXAS (vacuoles, E1 enzyme, X‑linked, autoinflammatory, somatic) syndrome, the first symptoms occur exclusively in adulthood. This article describes how the phenotypic expression and severity of individual autoinflammatory diseases differ depending on age. Furthermore, differences in the development of organ damage in children and adults are pointed out. In addition to the hereditary periodic fever syndromes, the clinical picture of deficiency of adenosine deaminase 2, the interferonopathies, periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome as well as VEXAS and Schnitzler syndromes are highlighted.
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Affiliation(s)
- Martin Krusche
- Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Tilmann Kallinich
- Klinik für Pädiatrie mit Schwerpunkt Pneumologie, Immunologie und Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland. .,SozialpädiatischesZentrum, Charité - Universitätsmedizin Berlin, Berlin, Deutschland. .,Berlin Institute of Health, Berlin, Deutschland. .,Deutsches Rheuma-Forschungszentrum Berlin, ein Institut der Leibniz-Gemeinschaft, Berlin, Deutschland.
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