5
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López-Nevado M, González-Granado LI, Ruiz-García R, Pleguezuelo D, Cabrera-Marante O, Salmón N, Blanco-Lobo P, Domínguez-Pinilla N, Rodríguez-Pena R, Sebastián E, Cruz-Rojo J, Olbrich P, Ruiz-Contreras J, Paz-Artal E, Neth O, Allende LM. Primary Immune Regulatory Disorders With an Autoimmune Lymphoproliferative Syndrome-Like Phenotype: Immunologic Evaluation, Early Diagnosis and Management. Front Immunol 2021; 12:671755. [PMID: 34447369 PMCID: PMC8382720 DOI: 10.3389/fimmu.2021.671755] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/16/2021] [Indexed: 12/26/2022] Open
Abstract
Primary immune regulatory disorders (PIRD) are associated with autoimmunity, autoinflammation and/or dysregulation of lymphocyte homeostasis. Autoimmune lymphoproliferative syndrome (ALPS) is a PIRD due to an apoptotic defect in Fas-FasL pathway and characterized by benign and chronic lymphoproliferation, autoimmunity and increased risk of lymphoma. Clinical manifestations and typical laboratory biomarkers of ALPS have also been found in patients with a gene defect out of the Fas-FasL pathway (ALPS-like disorders). Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), we identified more than 600 patients suffering from 24 distinct genetic defects described in the literature with an autoimmune lymphoproliferative phenotype (ALPS-like syndromes) corresponding to phenocopies of primary immunodeficiency (PID) (NRAS, KRAS), susceptibility to EBV (MAGT1, PRKCD, XIAP, SH2D1A, RASGRP1, TNFRSF9), antibody deficiency (PIK3CD gain of function (GOF), PIK3R1 loss of function (LOF), CARD11 GOF), regulatory T-cells defects (CTLA4, LRBA, STAT3 GOF, IL2RA, IL2RB, DEF6), combined immunodeficiencies (ITK, STK4), defects in intrinsic and innate immunity and predisposition to infection (STAT1 GOF, IL12RB1) and autoimmunity/autoinflammation (ADA2, TNFAIP3,TPP2, TET2). CTLA4 and LRBA patients correspond around to 50% of total ALPS-like cases. However, only 100% of CTLA4, PRKCD, TET2 and NRAS/KRAS reported patients had an ALPS-like presentation, while the autoimmunity and lymphoproliferation combination resulted rare in other genetic defects. Recurrent infections, skin lesions, enteropathy and malignancy are the most common clinical manifestations. Some approaches available for the immunological study and identification of ALPS-like patients through flow cytometry and ALPS biomarkers are provided in this work. Protein expression assays for NKG2D, XIAP, SAP, CTLA4 and LRBA deficiencies and functional studies of AKT, STAT1 and STAT3 phosphorylation, are showed as useful tests. Patients suspected to suffer from one of these disorders require rapid and correct diagnosis allowing initiation of tailored specific therapeutic strategies and monitoring thereby improving the prognosis and their quality of life.
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Affiliation(s)
- Marta López-Nevado
- Immunology Department, University Hospital 12 de Octubre, Madrid, Spain.,Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Luis I González-Granado
- Research Institute Hospital 12 Octubre (imas12), Madrid, Spain.,Immunodeficiency Unit, Department of Pediatrics, University Hospital 12 de Octubre, Madrid, Spain
| | - Raquel Ruiz-García
- Immunology Department, Centre Diagnòstic Biomèdic, Hospital Clínic, Barcelona, Spain
| | - Daniel Pleguezuelo
- Immunology Department, University Hospital 12 de Octubre, Madrid, Spain.,Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Oscar Cabrera-Marante
- Immunology Department, University Hospital 12 de Octubre, Madrid, Spain.,Research Institute Hospital 12 Octubre (imas12), Madrid, Spain
| | - Nerea Salmón
- Research Institute Hospital 12 Octubre (imas12), Madrid, Spain.,Immunodeficiency Unit, Department of Pediatrics, University Hospital 12 de Octubre, Madrid, Spain
| | - Pilar Blanco-Lobo
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, University Hospital Virgen del Rocío, Institute of Biomedicine, Biomedicine Institute (IBiS)/University of Seville/Superior Council of Scientific Investigations (CSIC), Seville, Spain
| | - Nerea Domínguez-Pinilla
- Research Institute Hospital 12 Octubre (imas12), Madrid, Spain.,Pediatric Hematology and Oncology Unit, Toledo Hospital Complex, Toledo, Spain and University Hospital 12 de Octubre, Madrid, Spain
| | | | - Elena Sebastián
- Hematology and Hemotherapy Unit, University Children's Hospital Niño Jesús, Madrid, Spain
| | - Jaime Cruz-Rojo
- Endocrine Unit, Department of Pediatrics, University Hospital 12 de Octubre, Madrid, Spain
| | - Peter Olbrich
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, University Hospital Virgen del Rocío, Institute of Biomedicine, Biomedicine Institute (IBiS)/University of Seville/Superior Council of Scientific Investigations (CSIC), Seville, Spain
| | - Jesús Ruiz-Contreras
- Research Institute Hospital 12 Octubre (imas12), Madrid, Spain.,Immunodeficiency Unit, Department of Pediatrics, University Hospital 12 de Octubre, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Estela Paz-Artal
- Immunology Department, University Hospital 12 de Octubre, Madrid, Spain.,Research Institute Hospital 12 Octubre (imas12), Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Olaf Neth
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, University Hospital Virgen del Rocío, Institute of Biomedicine, Biomedicine Institute (IBiS)/University of Seville/Superior Council of Scientific Investigations (CSIC), Seville, Spain
| | - Luis M Allende
- Immunology Department, University Hospital 12 de Octubre, Madrid, Spain.,Research Institute Hospital 12 Octubre (imas12), Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
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9
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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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11
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Özen S, Batu ED, Taşkıran EZ, Özkara HA, Ünal Ş, Güleray N, Erden A, Karadağ Ö, Gümrük F, Çetin M, Sönmez HE, Bilginer Y, Ayvaz DÇ, Tezcan I. A Monogenic Disease with a Variety of Phenotypes: Deficiency of Adenosine Deaminase 2. J Rheumatol 2019; 47:117-125. [PMID: 31043544 DOI: 10.3899/jrheum.181384] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive autoinflammatory disorder associated with ADA2 mutations. We aimed to investigate the characteristics and ADA2 enzyme activities of patients with DADA2 compared to non-DADA2 patients. METHODS This is a descriptive study of 24 patients with DADA2 who were admitted to the Adult and Pediatric Rheumatology, Pediatric Haematology, and Pediatric Immunology Departments of Hacettepe University. All ADA2 exons were screened by Sanger sequencing. Serum ADA2 enzyme activity was measured by modified spectrophotometric method. RESULTS Twenty-four patients with DADA2 were included: 14 with polyarteritis nodosa (PAN)-like phenotype (Group 1); 9 with Diamond-Blackfan anemia (DBA)-like features, and 1 with immunodeficiency (Group 2). Fourteen PAN-like DADA2 patients did not have the typical thrombocytosis seen in classic PAN. Inflammatory attacks were evident only in Group 1 patients. Serum ADA2 activity was low in all patients with DADA2 except one, who was tested after hematopoietic stem cell transplantation. There was no significant difference in ADA2 activities between PAN-like and DBA-like patients. In DADA2 patients with one ADA2 mutation, serum ADA2 activities were as low as those of patients with homozygote DADA2. ADA2 activities were normal in non-DADA2 patients. ADA2 mutations were affecting the dimerization domain in Group 1 patients and the catalytic domain in Group 2 patients. CONCLUSION We suggest assessing ADA2 activity along with genetic analysis because there are patients with one ADA2 mutation and absent enzyme activity. Our data suggest a possible genotype-phenotype correlation in which dimerization domain mutations are associated with PAN-like phenotype, and catalytic domain mutations are associated with hematological manifestations.
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Affiliation(s)
- Seza Özen
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey. .,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study.
| | - Ezgi Deniz Batu
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Ekim Z Taşkıran
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Hatice Asuman Özkara
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Şule Ünal
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Naz Güleray
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Abdulsamet Erden
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Ömer Karadağ
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Fatma Gümrük
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Mualla Çetin
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Hafize Emine Sönmez
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Yelda Bilginer
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Deniz Çağdaş Ayvaz
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
| | - Ilhan Tezcan
- From the Division of Rheumatology, Department of Pediatrics, Division of Immunology, Department of Internal Medicine, Department of Medical Genetics, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Ankara, Turkey.,S. Özen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; Y. Bilginer, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.D. Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; E.Z. Taşkıran, PhD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; H.A. Özkara, MD, PhD, Department of Medical Biochemistry, Hacettepe University Faculty of Medicine; Ş. Ünal, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; N. Güleray, MD, Department of Medical Genetics, Hacettepe University Faculty of Medicine; A. Erden, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; Ö. Karadağ, MD, Division of Rheumatology, Department of Internal Medicine, Hacettepe University Faculty of Medicine; F. Gümrük, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes; M. Çetin, MD, Hacettepe University Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes (retired); H.E. Sönmez, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine; D.Ç. Ayvaz, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine; I. Tezcan, MD, Division of Immunology, Department of Pediatrics, Hacettepe University Faculty of Medicine. E.D. Batu and E.Z. Taşkıran contributed equally to this study
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