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Costagliola G, D’Elios S, Cappelli S, Massei F, Maestrini G, Beni A, Peroni D, Consolini R. Case Report: Efficacy, safety, and favorable long-term outcome of early treatment with IL-1 inhibitors in a patient with chronic infantile neurological cutaneous articular (CINCA) syndrome caused by NLRP3 mosaicism. Front Pediatr 2024; 12:1379616. [PMID: 38720945 PMCID: PMC11076766 DOI: 10.3389/fped.2024.1379616] [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: 01/31/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Chronic infantile neurological cutaneous articular (CINCA) syndrome is an autoinflammatory disease encompassed in the group of cryopyrin-associated periodic syndromes (CAPS). Patients suffering from CINCA have an elevated risk of developing chronic sequelae, including deforming arthropathy, chronic meningitis, neurodevelopmental delay, and neurosensorial hearing loss. The diagnosis of CINCA presents several difficulties, as the clinical phenotype could be difficult to recognize, and almost half of the patients have negative genetic testing. In this paper, we describe the case of a patient presenting with the typical phenotype of neonatal-onset CINCA who resulted negative for NLRP3 mutations. Based on the clinical judgment, the patient underwent treatment with anti-interleukin-1 (IL-1) agents (anakinra and, later, canakinumab) resulting in a complete clinical and laboratory response that allowed confirmation of the diagnosis. Additional genetic investigations performed after the introduction of anti-IL-1 therapy revealed a pathogenic mosaicism in the NLRP3 gene. After a 12-year follow-up, the patient has not experienced chronic complications. Although genetics is rapidly progressing, this case highlights the importance of early diagnosis of CINCA patients when the clinical and laboratory picture is highly suggestive in order to start the appropriate anti-cytokine treatment even in the absence of a genetic confirmation.
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Affiliation(s)
- Giorgio Costagliola
- Section of Pediatric Hematology and Oncology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Sofia D’Elios
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Susanna Cappelli
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Massei
- Section of Pediatric Hematology and Oncology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giulia Maestrini
- Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandra Beni
- Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diego Peroni
- Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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2
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The Clinical Chameleon of Autoinflammatory Diseases in Children. Cells 2022; 11:cells11142231. [PMID: 35883675 PMCID: PMC9318468 DOI: 10.3390/cells11142231] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/12/2022] [Accepted: 07/17/2022] [Indexed: 01/27/2023] Open
Abstract
The very first line of defense in humans is innate immunity, serving as a critical strongpoint in the regulation of inflammation. Abnormalities of the innate immunity machinery make up a motley group of rare diseases, named ‘autoinflammatory’, which are caused by mutations in genes involved in different immune pathways. Self-limited inflammatory bouts involving skin, serosal membranes, joints, gut and other districts of the human body burst and recur with variable periodicity in most autoinflammatory diseases (ADs), often leading to secondary amyloidosis as a long-term complication. Dysregulated inflammasome activity, overproduction of interleukin (IL)-1 or other IL-1-related cytokines and delayed shutdown of inflammation are pivotal keys in the majority of ADs. The recent progress of cellular biology has clarified many molecular mechanisms behind monogenic ADs, such as familial Mediterranean fever, tumor necrosis factor receptor-associated periodic syndrome (or ‘autosomal dominant familial periodic fever’), cryopyrin-associated periodic syndrome, mevalonate kinase deficiency, hereditary pyogenic diseases, idiopathic granulomatous diseases and defects of the ubiquitin-proteasome pathway. A long-lasting history of recurrent fevers should require the ruling out of chronic infections and malignancies before considering ADs in children. Little is known about the potential origin of polygenic ADs, in which sterile cytokine-mediated inflammation results from the activation of the innate immunity network, without familial recurrency, such as periodic fever/aphthous stomatitis/pharyngitis/cervical adenopathy (PFAPA) syndrome. The puzzle of febrile attacks recurring over time with chameleonic multi-inflammatory symptoms in children demands the inspection of the mixture of clinical data, inflammation parameters in the different disease phases, assessment of therapeutic efficacy of a handful of drugs such as corticosteroids, colchicine or IL-1 antagonists, and genotype analysis to exclude or confirm a monogenic origin.
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3
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Matsuda T, Kambe N, Takimoto-Ito R, Ueki Y, Nakamizo S, Saito MK, Takei S, Kanazawa N. Potential Benefits of TNF Targeting Therapy in Blau Syndrome, a NOD2-Associated Systemic Autoinflammatory Granulomatosis. Front Immunol 2022; 13:895765. [PMID: 35711422 PMCID: PMC9195515 DOI: 10.3389/fimmu.2022.895765] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
Blau syndrome is a systemic autoinflammatory granulomatous disease caused by mutations in the nucleotide-binding oligomerization domain 2 (NOD2) gene. NOD2 is an intracellular pathogen recognition receptor. Upon binding to muramyl dipeptide (MDP), NOD2 activates the NF-κB pathway, leading to the upregulation of proinflammatory cytokines. Clinical manifestations of Blau syndrome appear in patients before the age of four. Skin manifestations resolve spontaneously in some cases; however, joint and eye manifestations are progressive, and lead to serious complications, such as joint contracture and blindness. Currently, there is no specific curative treatment for the disease. Administration of high-dose oral steroids can improve clinical manifestations; however, treatments is difficult to maintain due to the severity of the side effects, especially in children. While several new therapies have been reported, including JAK inhibitors, anti-IL-6 and anti-IL-1 therapies, anti-TNF therapy plays a central role in the treatment of Blau syndrome. We recently performed an ex vivo study, using peripheral blood and induced pluripotent stem cells from patients. This study demonstrated that abnormal cytokine expression in macrophages from untreated patients requires IFNγ stimulation, and that anti-TNF treatment corrects the abnormalities associated with Blau syndrome, even in the presence of IFNγ. Therefore, although the molecular mechanisms by which the genetic mutations in NOD2 lead to granuloma formation remain unclear, it is possible that prior exposure to TNFα combined with IFNγ stimulation may provide the impetus for the clinical manifestations of Blau syndrome.
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Affiliation(s)
- Tomoko Matsuda
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Naotomo Kambe
- Department of Dermatology, Kansai Medical University, Hirakata, Japan.,Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Riko Takimoto-Ito
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Ueki
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Satoshi Nakamizo
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumu K Saito
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Syuji Takei
- Department of Pediatrics, Kagoshima University, Kagoshima, Japan
| | - Nobuo Kanazawa
- Department of Dermatology, Hyogo Medical University, Nishinomiya, Japan
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4
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Multisystem Inflammatory Syndrome in Neonates Born to Mothers with SARS-CoV-2 Infection (MIS-N) and in Neonates and Infants Younger Than 6 Months with Acquired COVID-19 (MIS-C): A Systematic Review. Viruses 2022; 14:v14040750. [PMID: 35458480 PMCID: PMC9024762 DOI: 10.3390/v14040750] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 12/25/2022] Open
Abstract
(1) Introduction: There is an increasing literature describing neonates born to mothers with SARS-CoV-2 infection (MIS-N) and infants infected with SARS-CoV-2 who presented with a severe disease (MIS-C). (2) Methods: To investigate clinical features of multisystem inflammatory syndrome in neonates and infants under six months of age, we used a systematic search to retrieve all relevant publications in the field. We screened in PubMed, EMBASE and Scopus for data published until 10 October 2021. (3) Results: Forty-eight articles were considered, including 29 case reports, six case series and 13 cohort studies. Regarding clinical features, only 18.2% of MIS-N neonates presented with fever; differently from older children with MIS-C, in which gastrointestinal symptoms were the most common manifestation, we displayed that cardiovascular dysfunction and respiratory distress are the prevalent findings both in neonates with MIS-N and in neonates/infants with MIS-C. (4) Conclusions: We suggest that all infants with suspected inflammatory disease should undergo echocardiography, due to the possibility of myocardial dysfunction and damage to the coronary arteries observed both in neonates with MIS-N and in neonates/infants with MIS-C. Moreover, we also summarize how they were treated and provide a therapeutic algorithm to suggest best management of these fragile infants.
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Abstract
The innate immunity works as a defence bullwark that safeguards healthy tissues with the power of detecting infectious agents in the human body: errors in the context of innate immunity identify autoinflammatory disorders (AIDs), which arise as bouts of aberrant inflammation with little or no involvement of T and B cells and neither recognized infections, nor associated autoimmune phenomena. Hereditary AIDs tend to have a pediatric-onset heralded by stereotyped inflammatory symptoms and fever, while AIDs without an ascertained cause, such as systemic juvenile idiopathic arthritis, derive from the interaction of genetic factors with environmental noxae and are unevenly defined. A dysregulated inflammasome activation promotes the best-known family of AIDs, as well as several degenerative and metabolic disorders, but also nuclear factor κB- and interferon-mediated conditions have been framed as AIDs: the zenith of inflammatory flares marks different phenotypes, but diagnosis may go unnoticed until adulthood due to downplayed symptoms and complex kaleidoscopic presentations. This review summarizes the main AIDs encountered in childhood with special emphasis on the clinical stigmata that may help establish a correct framework and blueprints to empower young scientists in the recognition of AIDs. The description focuses inflammasomopathies as paradigms of interleukinopathies, nuclear factor-κB -related disorders and interferonopathies. The challenges in the management of AIDs during childhood have been recently boosted by numerous therapeutic options derived from genomically-based approaches, which have led to identify targeted biologic agents as rationalized treatments and achieve more tangible perspectives of disease control.
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Affiliation(s)
- Raffaele Manna
- Department of Internal Medicine, Fondazione Policlinico A. Gemelli IRCCS, Rare Diseases and Periodic Fevers Research Centre, Università Cattolica Sacro Cuore, Largo A. Gemelli no. 8, 00168, Rome, Italy.
- Rare Diseases and Periodic Fevers Research Centre, Università Cattolica Sacro Cuore, Rome, Italy.
| | - Donato Rigante
- Rare Diseases and Periodic Fevers Research Centre, Università Cattolica Sacro Cuore, Rome, Italy
- Department of Life Sciences and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
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De Rose DU, Auriti C, Lozzi S, Coltella L, Piccioni L, Rossi S, Novelli A, Iannotta R, Pianini T, Picone S, Paolillo P, Savignoni F, Capolupo I, Digilio MC, Cutrera R, Dotta A. Severe herpes virus 6 interstitial pneumonia in an infant with three variants in genes predisposing to lung disease. J Med Virol 2021; 93:5182-5187. [PMID: 33851733 DOI: 10.1002/jmv.27016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/21/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023]
Abstract
Infections due to human herpesvirus 6 (HHV-6) are frequent during early childhood. Usually, they have a favorable clinical course. Conversely, HHV-6 congenital infections occur in about 1% of neonates and may present with more severe clinical pictures. HHV-6 can be found in lung tissues and bronchoalveolar lavage (BAL) samples from patients with pneumonia and in immunocompromised patients can cause mild to severe pneumonia. In neonates, the role of HHV-6 in the genesis of severe pneumonia is poorly defined still now. We describe a healthy infant with a late-onset (15 days of life) severe interstitial pneumonia and heavy HHV-6 genome load, persistently detected in its BAL fluid. The baby underwent high-frequency oscillatory ventilation, hydroxychloroquine, steroids, and ganciclovir for 6 weeks and at 9 months she died. Next-generation sequencing of genes known to cause neonatal respiratory insufficiency revealed the presence of a "probably pathogenetic" heterozygous variant in the autosomal recessive DRC1 gene, a heterozygous variant of unknown significance (VUS) in the autosomal recessive RSPH9 gene, and a heterozygous VUS in the autosomal recessive MUC5B gene. HHV-6 infection should be considered in the differential diagnosis of late-onset severe respiratory distress in neonates and the co-occurrence of genetic predisposing factors or modifiers should be tested by specific molecular techniques. The intensity of HHV-6 genome load in BAL fluid could be an indicator of the response to antiviral therapy.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Simona Lozzi
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Luana Coltella
- Microbiology Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Livia Piccioni
- Microbiology Unit, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Sabrina Rossi
- Department of Pathology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Antonio Novelli
- Medical Genetics Laboratory, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Rossella Iannotta
- Neonatal Intensive Care Unit, "Policlinico Casilino" General Hospital, Rome, Italy
| | - Teresa Pianini
- Neonatal Intensive Care Unit, "Policlinico Casilino" General Hospital, Rome, Italy
| | - Simonetta Picone
- Neonatal Intensive Care Unit, "Policlinico Casilino" General Hospital, Rome, Italy
| | - Piermichele Paolillo
- Neonatal Intensive Care Unit, "Policlinico Casilino" General Hospital, Rome, Italy
| | - Ferdinando Savignoni
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Maria Cristina Digilio
- Genetics and Rare Diseases Research Division, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Department of Pediatrics, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy
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7
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Marchesi A, Rigante D, Cimaz R, Ravelli A, Tarissi de Jacobis I, Rimini A, Cardinale F, Cattalini M, De Zorzi A, Dellepiane RM, Salice P, Secinaro A, Taddio A, Palma P, El Hachem M, Cortis E, Maggio MC, Corsello G, Villani A. Revised recommendations of the Italian Society of Pediatrics about the general management of Kawasaki disease. Ital J Pediatr 2021; 47:16. [PMID: 33494789 PMCID: PMC7830049 DOI: 10.1186/s13052-021-00962-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/04/2021] [Indexed: 12/19/2022] Open
Abstract
Aim of these revised recommendations for the general management of Kawasaki disease is to encourage its prompter recognition and warrant the most appropriate therapy, based on ascertained scientific data, raising awareness of the complications related to misdiagnosis or delayed treatment. A set of 20 synthetic operative statements is herein provided, including the definition of Kawasaki disease, its protean presentations, clinical course and seminal treatment modalities of all disease phases. The application of these recommendations should improve prognosis of Kawasaki disease and prevent the progression to permanent vascular abnormalities, thereby diminishing morbidity and mortality.
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Affiliation(s)
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Università Cattolica Sacro Cuore, Rome, Italy
| | - Rolando Cimaz
- Pediatric Rheumatology, ASST Gaetano Pini-CTO, Milan, Italy. .,University of Milan, Milan, Italy.
| | - Angelo Ravelli
- Pediatrics and Rheumatology Unit, IRCCS Istituto Giannina Gaslini, University of Genoa, Genoa, Italy
| | | | | | - Fabio Cardinale
- Department of Pediatrics, AOU Policlinico Giovanni XXIII, Bari, Italy
| | - Marco Cattalini
- Pediatrics Clinic, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Rosa Maria Dellepiane
- UOC of Pediatrics, UOS of Pediatric Immunology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrizia Salice
- Section of Pediatric Cardiovascular Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Andrea Taddio
- University of Trieste, Trieste, Italy.,Institute of Child and Maternal Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Paolo Palma
- Bambino Gesù Children's Hospital, Rome, Italy
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