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Braud A, Lipsker D. Schnitzler Syndrome: Insights into Its Pathogenesis, Clinical Manifestations, and Current Management. Biomolecules 2024; 14:646. [PMID: 38927050 PMCID: PMC11202231 DOI: 10.3390/biom14060646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
Schnitzler syndrome is a rare disorder characterized by a chronic urticarial rash associated with immunoglobulin M (IgM) monoclonal gammopathy. Schnitzler syndrome shares strong clinicopathologic similarities with monogenic IL-1-mediated autoinflammatory disorders and is now considered an acquired adult-onset autoinflammatory disease. The spectacular effect of interleukin-1 inhibitors demonstrates the key role of this cytokine in the pathogenesis of the disease. However, the physiopathology of Schnitzler syndrome remains elusive, and the main question regarding the relationship between autoinflammatory features and monoclonal gammopathy is still unanswered. The purpose of this narrative review is to describe what is currently known about the pathogenesis of this peculiar disease, as well as to address its diagnosis and management.
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Affiliation(s)
- Antoine Braud
- Dermatologic Clinic, University Hospital of Strasbourg, 67091 Strasbourg, France;
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2
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Lin CH, Huston DP. Collecting Puzzle Pieces. N Engl J Med 2023; 389:2189-2195. [PMID: 38055256 DOI: 10.1056/nejmcps2308355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Chen-Hsing Lin
- From the Division of Allergy and Immunology, Houston Methodist Immunology Center, Houston Methodist Hospital, and Texas A&M School of Medicine - both in Houston
| | - David P Huston
- From the Division of Allergy and Immunology, Houston Methodist Immunology Center, Houston Methodist Hospital, and Texas A&M School of Medicine - both in Houston
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Woo S, Gandhi S, Ghincea A, Saber T, Lee CJ, Ryu C. Targeting the NLRP3 inflammasome and associated cytokines in scleroderma associated interstitial lung disease. Front Cell Dev Biol 2023; 11:1254904. [PMID: 37849737 PMCID: PMC10577231 DOI: 10.3389/fcell.2023.1254904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/19/2023] [Indexed: 10/19/2023] Open
Abstract
SSc-ILD (scleroderma associated interstitial lung disease) is a complex rheumatic disease characterized in part by immune dysregulation leading to the progressive fibrotic replacement of normal lung architecture. Because improved treatment options are sorely needed, additional study of the fibroproliferative mechanisms mediating this disease has the potential to accelerate development of novel therapies. The contribution of innate immunity is an emerging area of investigation in SSc-ILD as recent work has demonstrated the mechanistic and clinical significance of the NLRP3 inflammasome and its associated cytokines of TNFα (tumor necrosis factor alpha), IL-1β (interleukin-1 beta), and IL-18 in this disease. In this review, we will highlight novel pathophysiologic insights afforded by these studies and the potential of leveraging this complex biology for clinical benefit.
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Affiliation(s)
| | | | | | | | | | - Changwan Ryu
- Department of Internal Medicine, Yale School of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, New Haven, CT, United States
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Bonnekoh H, Krusche M, Feist E, Wagner AD, Pankow A. [Autoinflammatory syndromes]. Z Rheumatol 2023; 82:678-687. [PMID: 37672064 DOI: 10.1007/s00393-023-01428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
The concept of autoinflammation includes a heterogeneous group of monogenic and polygenic diseases. These are characterized by excessive activation of the innate immune system without antigen-specific T cells or autoantibodies. The diseases are characterized by periodic episodes of fever and increased inflammation parameters. Monogenic diseases include familial Mediterranean fever (FMF) and the newly described VEXAS (vacuoles, E1 enzyme, X‑linked, autoinflammatory, somatic) syndrome. Heterogeneous diseases include adult-onset Still's disease and Schnitzler syndrome. Treatment is aimed at preventing the excessive inflammatory reaction in order to avoid long-term damage, such as amyloid A (AA) amyloidosis.
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Affiliation(s)
- Hanna Bonnekoh
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Hindenburgdamm 27, 12203, Berlin, Deutschland
- Allergologie und Immunologie, Fraunhofer-Institut für Translationale Medizin und Pharmakologie (ITMP), Berlin, Deutschland
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik für Nephrologie, Rheumatologie und Endokrinologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Eugen Feist
- Klinik für Rheumatologie, Helios Fachklinik Vogelsang-Gommern, Sophie-von-Boetticher-Straße 1, 39245, Vogelsang, Deutschland
| | - Annette Doris Wagner
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - Anne Pankow
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
- Medizinische Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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Puxkandl V, Currie A, Hoetzenecker W, Altrichter S. Therapy resistant urticaria as a long-term symptom of an incomplete Schnitzler syndrome. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:64. [PMID: 37496089 PMCID: PMC10373319 DOI: 10.1186/s13223-023-00819-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 07/03/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Recurring therapy resistant hives, accompanied by IgM-gammopathy, fever and joint pain can indicate Schnitzler syndrome, a rare autoimmune disorder. There is currently no approved treatment, but complete remission of symptoms can be induced with IL-1 antagonists. CASE PRESENTATION A patient with a history of chronic urticaria presented frequently at the outpatient clinic with severe hives and was treated unsuccessfully with antihistamines and omalizumab. After several years, additional symptoms such as joint pain, recurrent fever, and IgM-gammopathy developed. After the diagnostic criteria for Schnitzler syndrome were met, treatment with anakinra was initiated and resulted in an improvement of the symptoms. Shortly after the first injection, the patient developed large and painful erythematous lesions at the injection sites, leading to discontinuation of treatment and a rapid recurrence of symptoms. Subsequently, treatment with a longer-acting IL-1 antagonist (canakinumab) was initiated, resulting in a complete remission of symptoms. CONCLUSION This case report demonstrates that patients with urticarial symptoms that are not relieved by typical treatments should prompt repeated reassessments of the diagnosis, even years later, because gammopathy and other diagnostic criteria for Schnitzler syndrome can occur with a delay.
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Affiliation(s)
- Viktoria Puxkandl
- Department of Dermatology, Comprehensive Allergy Center, Kepler University Hospital Linz & Johannes Kepler University, Krankenhausstrasse 9, 4020, Linz, Austria
| | - Antonia Currie
- Department of Dermatology, Comprehensive Allergy Center, Kepler University Hospital Linz & Johannes Kepler University, Krankenhausstrasse 9, 4020, Linz, Austria
| | - Wolfram Hoetzenecker
- Department of Dermatology, Comprehensive Allergy Center, Kepler University Hospital Linz & Johannes Kepler University, Krankenhausstrasse 9, 4020, Linz, Austria.
| | - Sabine Altrichter
- Department of Dermatology, Comprehensive Allergy Center, Kepler University Hospital Linz & Johannes Kepler University, Krankenhausstrasse 9, 4020, Linz, Austria
- Departement of Dermatology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
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Bonnekoh H, Krusche M, Feist E, Wagner AD, Pankow A. [Autoinflammatory syndromes]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:442-451. [PMID: 37115240 PMCID: PMC10140729 DOI: 10.1007/s00108-023-01505-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/29/2023]
Abstract
The concept of autoinflammation includes a heterogeneous group of monogenic and polygenic diseases. These are characterized by excessive activation of the innate immune system without antigen-specific T cells or autoantibodies. The diseases are characterized by periodic episodes of fever and increased inflammation parameters. Monogenic diseases include familial Mediterranean fever (FMF) and the newly described VEXAS (vacuoles, E1 enzyme, X‑linked, autoinflammatory, somatic) syndrome. Heterogeneous diseases include adult-onset Still's disease and Schnitzler syndrome. Treatment is aimed at preventing the excessive inflammatory reaction in order to avoid long-term damage, such as amyloid A (AA) amyloidosis.
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Affiliation(s)
- Hanna Bonnekoh
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Hindenburgdamm 27, 12203, Berlin, Deutschland
- Allergologie und Immunologie, Fraunhofer-Institut für Translationale Medizin und Pharmakologie (ITMP), Berlin, Deutschland
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik für Nephrologie, Rheumatologie und Endokrinologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Eugen Feist
- Klinik für Rheumatologie, Helios Fachklinik Vogelsang-Gommern, Sophie-von-Boetticher-Straße 1, 39245, Vogelsang, Deutschland
| | - Annette Doris Wagner
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - Anne Pankow
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
- Medizinische Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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Matsuda T, Takimoto-Ito R, Lipsker D, Kambe N. Similarities and differences in autoinflammatory diseases with urticarial rash, cryopyrin-associated periodic syndrome and Schnitzler syndrome. Allergol Int 2023:S1323-8930(23)00009-6. [PMID: 36906447 DOI: 10.1016/j.alit.2023.02.005] [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: 01/19/2023] [Indexed: 03/12/2023] Open
Abstract
Cryopyrin-associated periodic syndromes (CAPS) and Schnitzler syndrome (SchS) are autoinflammatory diseases that present with urticaria-like rashes. CAPS is characterized by periodic or persistent systemic inflammation caused by the dysfunction of the NLRP3 gene. With the advent of IL-1-targeted therapies, the prognosis of CAPS has improved remarkably. SchS is considered an acquired form of autoinflammatory syndrome. Patients with SchS are adults of relatively older age. The pathogenesis of SchS remains unknown and is not associated with the NLRP3 gene. Previously, the p.L265P mutation in the MYD88 gene, which is frequently detected in Waldenström macroglobulinemia (WM) with IgM gammopathy, was identified in several cases of SchS. However, because persistent fever and fatigue are symptoms of WM that require therapeutic intervention, it is a challenge to determine whether these patients truly had SchS or whether advanced WM was misidentified as SchS. There are no established treatments for SchS. The treatment algorithm proposed with the diagnostic criteria is to use colchicine as first-line treatment, and systemic administration of steroids is not recommended due to concerns about side effects. In difficult-to-treat cases, treatment targeting IL-1 is recommended. If targeted IL-1 treatment does not improve symptoms, the diagnosis should be reconsidered. We hope that the efficacy of IL-1 therapy in clinical practice will serve as a stepping stone to elucidate the pathogenesis of SchS, focusing on its similarities and differences from CAPS.
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Affiliation(s)
- Tomoko Matsuda
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Riko Takimoto-Ito
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Dan Lipsker
- Dermatology Department, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Naotomo Kambe
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Patel V, Balasubramaniam D, Cavero-Chavez V, Cuervo-Pardo L, Sanchez-Alvarez C. Clinical Presentation of Schnitzler's Syndrome: A Rare Autoimmune Disease. J Investig Med High Impact Case Rep 2023; 11:23247096231220480. [PMID: 38130124 DOI: 10.1177/23247096231220480] [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: 12/23/2023] Open
Abstract
Schnitzler's Syndrome (SS) is a rare late-onset acquired autoinflammatory disorder which consists of chronic urticaria associated with a monoclonal IgM-kappa gammopathy, arthralgias, skeletal hyperostosis, lymphadenopathy, and recurrent constitutional symptoms. The average age of diagnosis is 51 years with a slight male predominance with a male to female ratio of 1.6. Diagnosis of SS requires the presence of 2 major criteria including chronic urticaria and monoclonal IgM along with at least two of the following minor criteria: recurrent intermittent fevers, bone pain, arthralgias, elevated erythrocyte sedimentation rate (ESR), neutrophilic dermal infiltrate on skin biopsy, and leukocytosis or elevated C-reactive protein (CRP). Early diagnosis and clinical awareness are paramount in SS as it is associated with a 15-20% risk of lymphoproliferative malignancy. The median overall survival is 12.8 years. We present a case of a 39-year-old female with new onset urticaria associated with recurrent fevers and joint pain. Symptoms were refractory to steroids, and high dose antihistamines. Multi-disciplinary evaluation resulted in the ultimate diagnosis of Schnitzler's Syndrome. The patient was ultimately treated with canakinumab (Il-1 inhibitor), with near resolution of symptoms. This case demonstrates the importance of a broad differential diagnosis and maintaining a high clinical suspicion for rare diseases when presented with a complex form of an otherwise common condition.
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Asero R, Ferrucci S, Tedeschi A, Cugno M. Biologics for chronic spontaneous urticaria: toward a personalized treatment. Expert Rev Clin Immunol 2022; 18:1297-1305. [PMID: 36264653 DOI: 10.1080/1744666x.2022.2138347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Chronic spontaneous urticaria (CSU) is characterized by the recurrent occurrence of short-lived wheals with or without angioedema for more than 6 weeks. Although its pathogenesis is not completely defined, several mechanisms seem involved, including autoimmunity and autoallergy with complement and coagulation activation. Various biologics are currently available or under investigation to counteract different CSU pathomechanisms. AREAS COVERED The recent literature dealing with biologics in the treatment of CSU was screened and analyzed; the different treatments were divided into anti-IgE and other than anti-IgE biologics. The latter were subdivided according to their target mechanisms. EXPERT OPINION Biologic drugs exert their effects in a very precise and specific manner. A majority of patients (arguably those with type I disease) respond to anti-IgE treatment. Others, possibly with type IIa disease, show a slow response to anti-IgE drugs. Things are much more complicated in anti-IgE-refractory patients. Some respond well to nonspecific immune suppressors, such as corticosteroids and cyclosporin suggesting that an immune-mediated pathogenic mechanism, not involving the high-affinity IgE receptor, is probably active. Several ongoing studies are evaluating biologics and small molecules counteracting other pathomechanisms, including anti-receptor biologics, Bruton tyrosine kinase (BTK) inhibitors, mast cell targets, and specific cytokines.
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Affiliation(s)
- Riccardo Asero
- Clinica San Carlo, Ambulatorio di Allergologia, Paderno Dugnano, Italy
| | - Silvia Ferrucci
- Dermatologia, Fondazione, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Alberto Tedeschi
- Unità Operativa di Medicina Generale, Ospedale Bolognini, ASST Bergamo Est, Seriate, Bergamo, Italy
| | - Massimo Cugno
- Medicina Interna, Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano; IRCCS Fondazione Ca' Granda, Milano, Italy
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Paerewijck O, Lamkanfi M. The human inflammasomes. Mol Aspects Med 2022; 88:101100. [PMID: 35696786 DOI: 10.1016/j.mam.2022.101100] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/25/2022] [Accepted: 06/01/2022] [Indexed: 12/14/2022]
Abstract
Two decades of inflammasome research has led to a vast body of knowledge on the complex regulatory mechanisms and pathological roles of canonical and non-canonical inflammasome activation in a plethora of research models of primarily rodent origin. More recently, the field has made notable progress in characterizing human-specific inflammasomes and their regulation mechanisms, including an expansion of inflammasome biology to adaptive immune cells. These exciting developments in basic research have been accompanied by potentially transformative results from large clinical trials and translational efforts to develop inflammasome-targeted small molecule inhibitors for therapeutic use. Here, we will discuss recent findings in the field with a specific emphasis on activation mechanisms of human inflammasomes and their potential role in auto-inflammatory, metabolic and neoplastic diseases.
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Affiliation(s)
- Oonagh Paerewijck
- Laboratory of Medical Immunology, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, B-9000, Belgium
| | - Mohamed Lamkanfi
- Laboratory of Medical Immunology, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, B-9000, Belgium.
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Takimoto-Ito R, Kambe N, Kogame T, Nomura T, Izawa K, Jo T, Kazuma Y, Yoshifuji H, Tabuchi Y, Abe H, Yamamoto M, Nakajima K, Tomita O, Yagi Y, Katagiri K, Matsuzaka Y, Takeuchi Y, Hatanaka M, Kanekura T, Takeuchi S, Kadono T, Fujita Y, Migita K, Fujino T, Akagi T, Mukai T, Nagano T, Kawano M, Kimura H, Okubo Y, Morita A, Hide M, Satoh T, Asahina A, Kanazawa N, Kabashima K. Summary of the current status of clinically diagnosed cases of Schnitzler syndrome in Japan. Allergol Int 2022; 72:297-305. [PMID: 36470790 DOI: 10.1016/j.alit.2022.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/16/2022] [Accepted: 10/31/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Schnitzler syndrome is a rare disorder with chronic urticaria, and there is no report summarizing the current status in Japan. METHODS A nationwide survey of major dermatology departments in Japan was conducted in 2019. We further performed a systematic search of PubMed and Ichushi-Web, using the keywords "Schnitzler syndrome" and "Japan" then contacted the corresponding authors or physicians for further information. RESULTS Excluding duplicates, a total of 36 clinically diagnosed cases were identified from 1994 through the spring of 2022, with a male to female ratio of 1:1. The median age of onset was 56.5 years. It took 3.3 years from the first symptom, mostly urticaria, to reach the final diagnosis. The current status of 30 cases was ascertained; two patients developed B-cell lymphoma. SchS treatment was generally effective with high doses of corticosteroids, but symptoms sometimes recurred after tapering. Colchicine was administered in 17 cases and was effective in 8, but showed no effect in the others. Tocilizumab, used in six cases, improved laboratory abnormalities and symptoms, but lost its efficacy after several years. Rituximab, used in five cases, was effective in reducing serum IgM levels or lymphoma mass, but not in inflammatory symptoms. Four cases were treated with IL-1 targeting therapy, either anakinra or canakinumab, and achieved complete remission, except one case with diffuse large B-cell lymphoma. CONCLUSIONS Since Schnitzler syndrome is a rare disease, the continuous collection and long-term follow-up of clinical information is essential for its appropriate treatment and further understanding of its pathophysiology.
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Oganesyan A, Gregory A, Malard F, Ghahramanyan N, Mohty M, Kazandjian D, Mekinian A, Hakobyan Y. Monoclonal gammopathies of clinical significance (MGCS): In pursuit of optimal treatment. Front Immunol 2022; 13:1045002. [PMID: 36505449 PMCID: PMC9728929 DOI: 10.3389/fimmu.2022.1045002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of clinical significance (MGCS) represents a new clinical entity referring to a myriad of pathological conditions associated with the monoclonal gammopathy of undetermined significance (MGUS). The establishment of MGCS expands our current understanding of the pathophysiology of a range of diseases, in which the M protein is often found. Aside from the kidney, the three main organ systems most affected by monoclonal gammopathy include the peripheral nervous system, skin, and eye. The optimal management of these MGUS-related conditions is not known yet due to the paucity of clinical data, the rarity of some syndromes, and limited awareness among healthcare professionals. Currently, two main treatment approaches exist. The first one resembles the now-established therapeutic strategy for monoclonal gammopathy of renal significance (MGRS), in which chemotherapy with anti-myeloma agents is used to target clonal lesion that is thought to be the culprit of the complex clinical presentation. The second approach includes various systemic immunomodulatory or immunosuppressive options, including intravenous immunoglobulins, corticosteroids, or biological agents. Although some conditions of the MGCS spectrum can be effectively managed with therapies aiming at the etiology or pathogenesis of the disease, evidence regarding other pathologies is severely limited to individual patient data from case reports or series. Future research should pursue filling the gap in knowledge and finding the optimal treatment for this novel clinical category.
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Affiliation(s)
- Artem Oganesyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia,*Correspondence: Artem Oganesyan,
| | - Andrew Gregory
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Nerses Ghahramanyan
- Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Arsène Mekinian
- Department of Internal Medicine (DMU i3), Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France,French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
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Efthimiou P, Petryna O, Nakasato P, Kontzias A. New insights on multigenic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2022; 14:1759720X221117880. [PMID: 36081748 PMCID: PMC9445512 DOI: 10.1177/1759720x221117880] [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: 12/22/2021] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
Autoinflammatory diseases are disorders of the innate immune system, which can be either monogenic due to a specific genetic mutation or complex multigenic due to the involvement of multiple genes. The aim of this review is to explore and summarize the recent advances in pathogenesis, diagnosis, and management of genetically complex autoinflammatory diseases, such as Schnitzler's syndrome; adult-onset Still's disease; synovitis, acne, pustulosis, hyperostosis, osteitis syndrome/chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis; Adamantiades-Behçet's disease; Yao syndrome; and periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. The PubMed database was screened for relevant articles using free text words and specific search strings. The search was limited to English-language articles, reporting the results of studies in humans, published through March 2021. Evidence from literature suggest that these rare multigenic autoinflammatory diseases can present with different clinical features and the diagnosis of these diseases can be challenging due to a combination of nonspecific manifestations that can be seen in a variety of other conditions. Diagnostic delays and disease complications may occur due to low disease awareness and the lack of pathognomonic markers. The pathogeneses of these diseases are complex and in some cases precise pathogenesis is not clearly understood. Conventional treatments are commonly used for the management of these conditions, but biologics have shown promising results. Biologics targeting proinflammatory cytokines including IL-1, IL-6, TNF-α, IL-17A and IL-18 have been shown to ameliorate signs and symptoms of different multigenic autoinflammatory diseases.
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Affiliation(s)
- Petros Efthimiou
- New York Rheumatology Care, Ross University School of Medicine, New York, USA
| | - Olga Petryna
- NYU Grossman School of Medicine, New York, NY, USA
| | | | - Apostolos Kontzias
- Department of Rheumatology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Arnold DD, Yalamanoglu A, Boyman O. Systematic Review of Safety and Efficacy of IL-1-Targeted Biologics in Treating Immune-Mediated Disorders. Front Immunol 2022; 13:888392. [PMID: 35874710 PMCID: PMC9296857 DOI: 10.3389/fimmu.2022.888392] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background The cytokine interleukin (IL)-1 plays a pivotal role in immune-mediated disorders, particularly in autoinflammatory diseases. Targeting this cytokine proved to be efficacious in treating numerous IL-1-mediated pathologies. Currently, three IL-1 blockers are approved, namely anakinra, canakinumab and rilonacept, and two additional ones are expected to receive approval, namely gevokizumab and bermekimab. However, there is no systematic review on the safety and efficacy of these biologics in treating immune-mediated diseases. Objective To evaluate safety and efficacy of anakinra, canakinumab, rilonacept, gevokizumab, and bermekimab for the treatment of immune-mediated disorders compared to placebo, standard-of-care treatment or other biologics. Methods The PRISMA checklist guided the reporting of the data. We searched the PubMed database between 1 January 1984 and 31 December 2020 focusing on immune-mediated disorders. Our PubMed literature search identified 7363 articles. After screening titles and abstracts for the inclusion and exclusion criteria and assessing full texts, 75 articles were included in a narrative synthesis. Results Anakinra was both efficacious and safe in treating cryopyrin-associated periodic syndromes (CAPS), familial Mediterranean fever (FMF), gout, macrophage activation syndrome, recurrent pericarditis, rheumatoid arthritis (RA), and systemic juvenile idiopathic arthritis (sJIA). Conversely, anakinra failed to show efficacy in graft-versus-host disease, Sjögren’s syndrome, and type 1 diabetes mellitus (T1DM). Canakinumab showed efficacy in treating CAPS, FMF, gout, hyper-IgD syndrome, RA, Schnitzler’s syndrome, sJIA, and TNF receptor-associated periodic syndrome. However, use of canakinumab in the treatment of adult-onset Still’s disease and T1DM revealed negative results. Rilonacept was efficacious and safe for the treatment of CAPS, FMF, recurrent pericarditis, and sJIA. Contrarily, Rilonacept did not reach superiority compared to placebo in the treatment of T1DM. Gevokizumab showed mixed results in treating Behçet’s disease-associated uveitis and no benefit when assessed in T1DM. Bermekimab achieved promising results in the treatment of hidradenitis suppurativa. Conclusions This systematic review of IL-1-targeting biologics summarizes the current state of research, safety, and clinical efficacy of anakinra, bermekimab, canakinumab, gevokizumab, and rilonacept in treating immune-mediated disorders. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021228547.
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Affiliation(s)
- Dennis D. Arnold
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Ayla Yalamanoglu
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Onur Boyman
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- *Correspondence: Onur Boyman,
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15
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Cho H. Diagnosis and management of monoclonal gammopathy of clinical significance. Blood Res 2022; 57:20-26. [PMID: 35483921 PMCID: PMC9057659 DOI: 10.5045/br.2022.2022035] [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: 02/05/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022] Open
Abstract
The term "monoclonal gammopathy of clinical significance" (MGCS) refers to any plasma cell or B-cell clonal disorder that does not meet the current criteria for malignant disorders but produces a monoclonal protein that directly or indirectly results in organ damage. The most commonly affected organs are the kidneys, nerves, and skin. This review summarizes the current classification of MGCS and its diagnostic and treatment approaches.
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Affiliation(s)
- Hyungwoo Cho
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Cutaneous manifestations of monoclonal gammopathy. Blood Cancer J 2022; 12:58. [PMID: 35411042 PMCID: PMC9001632 DOI: 10.1038/s41408-022-00661-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 12/29/2022] Open
Abstract
Monoclonal gammopathy associated with dermatological manifestations are a well-recognized complication. These skin disorders can be associated with infiltration and proliferation of a malignant plasma cells or by a deposition of the monoclonal immunoglobulin in a nonmalignant monoclonal gammopathy. These disorders include POEMS syndrome, light chain amyloidosis, Schnitzler syndrome, scleromyxedema and TEMPI syndrome. This article provides a review of clinical manifestations, diagnostics criteria, natural evolution, pathogenesis, and treatment of these cutaneous manifestations.
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17
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Kecelj Žgank B, Benko M. A patient with urticarial lesions, recurrent fever, and IgM-type monoclonal gammopathy. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2022. [DOI: 10.15570/actaapa.2022.s9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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18
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Jiang Q, Wang X, Huang E, Wang Q, Wen C, Yang G, Lu L, Cui D. Inflammasome and Its Therapeutic Targeting in Rheumatoid Arthritis. Front Immunol 2022; 12:816839. [PMID: 35095918 PMCID: PMC8794704 DOI: 10.3389/fimmu.2021.816839] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/21/2021] [Indexed: 12/30/2022] Open
Abstract
Inflammasome is a cytoplasmic multiprotein complex that facilitates the clearance of exogenous microorganisms or the recognition of endogenous danger signals, which is critically involved in innate inflammatory response. Excessive or abnormal activation of inflammasomes has been shown to contribute to the development of various diseases including autoimmune diseases, neurodegenerative changes, and cancers. Rheumatoid arthritis (RA) is a chronic and complex autoimmune disease, in which inflammasome activation plays a pivotal role in immune dysregulation and joint inflammation. This review summarizes recent findings on inflammasome activation and its effector mechanisms in the pathogenesis of RA and potential development of therapeutic targeting of inflammasome for the immunotherapy of RA.
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Affiliation(s)
- Qi Jiang
- Department of Blood Transfusion, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Xin Wang
- Department of Rheumatology and Immunology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Enyu Huang
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, Hong Kong SAR, China.,Chongqing International Institute for Immunology, Chongqing, China
| | - Qiao Wang
- School of Basic Medical Science, Zhejiang Chinese Medical University, Hangzhou, China
| | - Chengping Wen
- School of Basic Medical Science, Zhejiang Chinese Medical University, Hangzhou, China
| | - Guocan Yang
- Department of Blood Transfusion, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Liwei Lu
- Department of Pathology and Shenzhen Institute of Research and Innovation, The University of Hong Kong, Hong Kong, Hong Kong SAR, China.,Chongqing International Institute for Immunology, Chongqing, China
| | - Dawei Cui
- Department of Blood Transfusion, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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19
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Abstract
Schnitzler syndrome is a rare disease of adult-onset with main features including chronic urticarial rash, recurrent fever, arthralgia or arthritis, monoclonal gammopathy of undetermined significance (MGUS), and marked systemic inflammation. Schnitzler syndrome is often underdiagnosed. Patients with Schnitzler syndrome may present to dermatologists and allergists for urticaria, hematologists for MGUS, or rheumatologists for arthritis. It is important to recognize Schnitzler syndrome for its remarkable response to interleukin (IL)-1 blockade. Besides, many cases of Schnitzler-like syndromes do not meet the diagnostic criteria of classical Schnitzler syndrome but display excellent response to IL-1 inhibitors. The overly produced IL-1 is the result of a somatic mosaic gain of function mutation of NLRP3 (nucleotide-binding oligomerization domain [NOD]-like receptor [NLR] family pyrin domain containing 3) gene in some patients with Schnitzler-like syndromes. Inflammasome activation is evident in patients with classical Schnitzler syndrome although no NLRP3 gene mutation is identified. Collectively, Schnitzler syndrome and Schnitzler-like syndromes represent a spectrum of IL-1 mediated adult-onset autoinflammatory diseases.
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20
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Calabrese L, Fiocco Z, Satoh TK, Peris K, French LE. Therapeutic potential of targeting IL-1 family cytokines in chronic inflammatory skin diseases. Br J Dermatol 2022; 186:925-941. [PMID: 34990008 DOI: 10.1111/bjd.20975] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/15/2021] [Accepted: 12/30/2021] [Indexed: 11/27/2022]
Abstract
The interleukin-1 (IL-1) family of cytokines is a central regulator of a myriad of immunological responses. It comprises several cytokines, including those belonging to the IL-1, IL-36 and IL-18 subfamilies, as well as IL-33. The IL-1 family primarily plays a role in orchestrating innate immune responses but also in adaptive immunity. Increased interest in the IL-1 family occurred following the discovery that dysregulation of IL-1 signalling underlies the pathogenesis of several monogenic auto-inflammatory diseases, characterized by sterile inflammation involving the skin and other organs. This also provided increased understanding of the role of innate immunity and the IL-1 family in polygenic auto-inflammatory skin conditions, such as neutrophilic dermatoses, as well as in some of the most common chronic inflammatory skin diseases, such as psoriasis or hidradenitis suppurativa. Several therapeutic agents have been developed to inhibit the IL-1 family members and their signalling pathways. These have shown therapeutic efficacy in several chronic inflammatory skin disorders. The aim of this review is to thoroughly describe the consequences of pathological dysregulation of IL-1, IL-33, IL-36, IL-18 pathways in dermatological conditions and to provide a forward-looking update on therapeutic strategies targeting signalling by IL-1 family cytokines.
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Affiliation(s)
- Laura Calabrese
- Institute of Dermatology, Catholic University of the Sacred Heart, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Zeno Fiocco
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Takashi K Satoh
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
| | - Ketty Peris
- Institute of Dermatology, Catholic University of the Sacred Heart, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany.,Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida
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21
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Navetta-Modrov B, Yao Q. Macroglobulinemia and Autoinflammatory Disease. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2021; 2:227-232. [PMID: 36467983 PMCID: PMC9524799 DOI: 10.2478/rir-2021-0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/19/2021] [Indexed: 06/17/2023]
Abstract
Macroglobulinemia is associated with Schnitzler syndrome (SchS) and Waldenstrom macroglobulinemia (WM). The aim of this article was to review the above-mentioned two diseases from clinical aspects and their potential genetic links. We performed a PubMed search using the following keywords: "SchS," "WM," "autoinflammatory disease," "periodic fever syndrome," and "nucleotide-binding oligomerization domain containing protein 2 (NOD2)." A case is exemplified. Both SchS and WM share some clinical phenotypes, and SchS can evolve into WM. Though no genetic link to SchS has been established, myeloid differentiation primary response gene 88 (MyD88) mutations are detected in one-third of SchS patients and 86% WM patients. Genetic analysis of periodic fever syndrome genes has detected NOD2 mutations in 18% SchS patients and rarely NLRP3 mutations. The literature data suggest that both MyD88 and NOD2 mutations may contribute to SchS. Both MyD88 and NOD2 are known to play important roles in innate immune response, and they may be cooperative in certain autoinflammatory diseases. Molecular analysis of NOD2 mutations may be incorporated into genetic testing for patients with suspected SchS or SchS/WM.
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Affiliation(s)
- Brianne Navetta-Modrov
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Qingping Yao
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
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22
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Takimoto-Ito R, Kambe N, Kogame T, Otsuka A, Nomura T, Izawa K, Tabuchi Y, Yoshifuji H, Takeuchi Y, Kabashima K. Refractory serum immunoglobulin M elevation during anti-interleukin (IL)-1- or IL-6-targeted treatment in four patients with Schnitzler syndrome. J Dermatol 2021; 48:1789-1792. [PMID: 34435697 DOI: 10.1111/1346-8138.16124] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/26/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022]
Abstract
Schnitzler syndrome is characterized by chronic urticarial rash, neutrophilic dermal infiltrate, recurrent fever, bone pain, elevated C-reactive protein, and neutrophilic leukocytosis. The pathophysiology of Schnitzler syndrome is unknown, but it is considered to be an acquired form of an autoinflammatory disease because of the resemblance to clinical phenotypes of cryopyrin-associated periodic syndrome, in which a gain-of-function mutation in NLRP3 causes overexpression of interleukin (IL)-1β. Schnitzler syndrome is generally accompanied by a monoclonal immunoglobulin (Ig)M gammopathy with a long-term risk of lymphoproliferation that is possibly associated with an MYD88 mutation. Herein, we present the following four patients with Schnitzler syndrome: a 63-year-old woman; a 65-year-old man; a 43-year-old woman; and a 63-year-old woman. Each patient fulfilled the Strasbourg diagnostic criteria, but none of the patients had any mutation in NLRP3 or MYD88 detected in their peripheral blood. Although approved treatment options for Schnitzler syndrome are lacking, our patients were treated with IL-1-targeted therapy (anakinra or canakinumab) or anti-IL-6 (tocilizumab). The acute inflammatory clinical manifestations improved completely with canakinumab and partially with anakinra and tocilizumab, but the serum IgM levels were gradually increased in all patients, even during treatment. To determine whether treatment with anti-IL-1β or IL-6 prevents conversion to a hematopoietic disorder, further collection of cases and long-term follow-up will be needed.
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Affiliation(s)
- Riko Takimoto-Ito
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Naotomo Kambe
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshiaki Kogame
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Atsushi Otsuka
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Nomura
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuya Tabuchi
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yohei Takeuchi
- Department of Internal Medicine, Sanuki Municipal Hospital, Sanuki, Japan
| | - Kenji Kabashima
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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23
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Tocilizumab treatment in patients with Schnitzler syndrome: An open-label study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2486-2489.e4. [PMID: 33545397 DOI: 10.1016/j.jaip.2021.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/20/2022]
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24
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Malcova H, Milota T, Strizova Z, Cebecauerova D, Striz I, Sediva A, Horvath R. Interleukin-1 Blockade in Polygenic Autoinflammatory Disorders: Where Are We now? Front Pharmacol 2021; 11:619273. [PMID: 33708123 PMCID: PMC7941751 DOI: 10.3389/fphar.2020.619273] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Polygenic autoinflammatory diseases (AIDs), such as systemic juvenile idiopathic arthritis (sJIA), adult-onset Still's disease, Kawasaki disease, idiopathic recurrent pericarditis (IRP), Behçet’s Syndrome, Crystal-induced arthropatihes such as gout or Calcium pyrophosphate deposition disease are characterized by the overexpression of inflammasome-associated genes, leading to a dysregulation of the innate immune response. The IL-1 cytokine family (IL-1α, IL-1β, IL-1Ra, IL-18, IL-36Ra, IL-36α, IL-37, IL-36β, IL-36g, IL-38, IL-33) was defined to be principally responsible for the inflammatory nature of polygenic AIDs. Several clinical trials were initiated, and IL-1 blockade has been proven to cause a rapid reduction of clinical symptoms and normalization of laboratory parameters in the majority of cases. Randomized, placebo-controlled, clinical trials, together with registry-based clinical trials and open-label, retrospective and prospective observational studies, supported the efficacy and safety of IL-1 inhibitors in the treatment of polygenic AIDs. Most of the current data are focused on the therapeutic use of anakinra, an IL-1 receptor antagonist, canakinumab, an anti-IL-1β monoclonal antibody, and rilonacept, a soluble decoy receptor. However, other promising agents, such as gevokizumab, IL-1β blocking monoclonal antibody, tadekinig alfa, a human recombinant IL-18-binding protein, and tranilast, an analog of a tryptophan metabolite, are currently being tested. Anakinra, canakinumab and rilonacept caused impressive improvements in both systemic and musculoskeletal symptoms. Furthermore, the anti-IL-1 therapy allowed corticosteroid tapering and, in some cases, even withdrawal. This article reviews the current IL-1 inhibitors and the results of all clinical trials in which they have been tested for the management of broad spectrum of polygenic AIDs.
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Affiliation(s)
- Hana Malcova
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
| | - Tomas Milota
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia.,Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Zuzana Strizova
- Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Dita Cebecauerova
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
| | - Ilja Striz
- Department of Clinical Immunology and Allergology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Rudolf Horvath
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
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25
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Gusdorf L, Lipsker D. Schnitzler Syndrome: the paradigm of an acquired adult-onset auto-inflammatory disease. GIORN ITAL DERMAT V 2020; 155:567-573. [PMID: 33295738 DOI: 10.23736/s0392-0488.20.06692-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Schnitzler Syndrome is a rare acquired auto-inflammatory syndrome defined by an urticarial eruption and a monoclonal gammopathy, mainly of the IgM kappa isotype. It shares many clinical and biological features with other autoinflammatory disorders such as NLRP3-auto-inflammatory disorders (NLRP3-AID, formerly cryopyrin associated periodic syndromes or CAPS) or adult-onset Still disease (AOSD). Hence, recurrent fever, urticarial rash with a neutrophilic infiltrate on skin biopsy (i.e. neutrophilic urticarial dermatosis or NUD) and a significant elevation of blood inflammation markers are commonly found in Schnitzler Syndrome as well as in NLRP3-AID or AOSD. IL-1ß plays a crucial role in the pathogenesis and explains the clinical symptoms of Schnitzler Syndrome. This is emphasized by the spectacular effectiveness of IL-1 blocking therapies, especially anakinra. IL-1 blocking therapies are efficient on the inflammation-linked symptoms but not on the monoclonal component. The evolution is chronic and about 15-20% of patients may develop lymphoproliferative disease, in particular Waldenström disease, a proportion similar to patients with IgM monoclonal gammopathy of undetermined significance, and more rarely AA-amyloidosis.
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Affiliation(s)
- Laurence Gusdorf
- Department of Dermatology and Venereology, CHU de Reims, Reims, France -
| | - Dan Lipsker
- Department of Dermatology, University Hospital of Strasbourg, Strasbourg, France
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26
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Darrieutort-Laffite C, Ansquer C, Aubert H, Kraeber-Bodéré F, Masseau A, Agard C, Hamidou M, Bernier C, Berthelot JM, Le Goff B, Barbarot S, Néel A. Rheumatic involvement and bone scan features in Schnitzler syndrome: initial and follow-up data from a single-center cohort of 25 patients. Arthritis Res Ther 2020; 22:272. [PMID: 33208192 PMCID: PMC7677784 DOI: 10.1186/s13075-020-02318-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/11/2020] [Indexed: 11/26/2022] Open
Abstract
Objective To report on the characteristics and long-term course of rheumatic manifestations in Schnitzler syndrome (SchS). Methods A retrospective cohort study of patients with SchS followed between 2000 and 2020. Inclusion criteria included a diagnosis of SchS (Strasbourg criteria). All available bone scans were reviewed and scored according to the intensity and number of pathological sites. The scintigraphic score was compared with the clinical activity score, CRP level, and treatments. Results Twenty-five patients were included. Median age at diagnosis was 68 years. Eighty patients (72%) had SchS-related rheumatic pain. Most patients had a long-standing isolated rash before constitutional and/or rheumatic symptoms appeared. The monoclonal component level was usually very low (IgMκ in 22/25). Rheumatic pain predominated around the knees. Bone scans revealed abnormal tracer uptake in 15/18 (85%). The scintigraphic score correlated with clinical activity (r = 0.4, p < 0.02) and CRP level (r = 0.47, p < 0.01). The scintigraphic score was lower in patients receiving corticosteroids or IL1Ra (interleukin 1 receptor antagonist) than in untreated patients (median scores:2, 0, and 13, respectively; p < 0.05). Two patients developed Waldenström macroglobulinemia. Of the 22 surviving patients, median age at follow-up was 76 years. IL1Ra was used in 13 patients, with dramatic efficacy on both symptoms and bone scan features. Conclusions Rheumatic manifestations are very prevalent in SchS. However, bone pain can be misleading and contribute to misdiagnosis. Bone scan abnormalities are very prevalent and correlate with disease activity and treatments. IL1-Ra has a dramatic and durable efficacy but may not be required in every patient early on.
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Affiliation(s)
| | | | - Hélène Aubert
- Department of Dermatology, CHU Nantes, Nantes, France
| | | | - Agathe Masseau
- Department of Internal Medicine Interne, CHU Nantes, Nantes, France
| | - Christian Agard
- Department of Internal Medicine Interne, CHU Nantes, Nantes, France
| | - Mohamed Hamidou
- Department of Internal Medicine Interne, CHU Nantes, Nantes, France
| | | | - Jean-Marie Berthelot
- Department of Rheumatology, CHU Nantes, 1 place Alexis Ricordeau, 44000, Nantes, France
| | - Benoit Le Goff
- Department of Rheumatology, CHU Nantes, 1 place Alexis Ricordeau, 44000, Nantes, France
| | | | - Antoine Néel
- Department of Internal Medicine Interne, CHU Nantes, Nantes, France
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27
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Oldham J, Lachmann HJ. The systemic autoinflammatory disorders for dermatologists. Part 2: disease examples. Clin Exp Dermatol 2020; 45:967-973. [PMID: 32882069 DOI: 10.1111/ced.14251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/21/2022]
Abstract
The systemic autoinflammatory disorders (SAIDS) or periodic fever syndromes are disorders of innate immunity, which can be inherited or acquired. They are almost all very rare and easily overlooked; typically, patients will have seen multiple specialities prior to diagnosis, so a high level of clinical suspicion is key. It is important to note that these are 'high-value' diagnoses as the majority of these syndromes can be very effectively controlled, dramatically improving quality of life and providing protection against the development of irreversible complications such as AA amyloidosis. In Part 1 of this review, we took an overview of SAIDS and described the common features; in this article, we take a more in-depth look at the better recognized or more dermatologically relevant conditions.
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Affiliation(s)
- J Oldham
- Portsmouth Hospitals NHS Trust, National Amyloidosis Centre, UCL Division of Medicine and Royal Free London NHS Foundation Trust, Portsmouth, Hampshire, UK
| | - H J Lachmann
- Portsmouth Hospitals NHS Trust, National Amyloidosis Centre, UCL Division of Medicine and Royal Free London NHS Foundation Trust, Portsmouth, Hampshire, UK
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28
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Chauhan D, Vande Walle L, Lamkanfi M. Therapeutic modulation of inflammasome pathways. Immunol Rev 2020; 297:123-138. [PMID: 32770571 PMCID: PMC7497261 DOI: 10.1111/imr.12908] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 12/23/2022]
Abstract
Inflammasomes are macromolecular complexes formed in response to pathogen‐associated molecular patterns (PAMPs) and danger‐associated molecular patterns (DAMPs) that drive maturation of the pro‐inflammatory cytokines interleukin (IL)‐1β and IL‐18, and cleave gasdermin D (GSDMD) for induction of pyroptosis. Inflammasomes are highly important in protecting the host from various microbial pathogens and sterile insults. Inflammasome pathways are strictly regulated at both transcriptional and post‐translational checkpoints. When these checkpoints are not properly imposed, undue inflammasome activation may promote inflammatory, metabolic and oncogenic processes that give rise to autoinflammatory, autoimmune, metabolic and malignant diseases. In addition to clinically approved IL‐1‐targeted biologics, upstream targeting of inflammasome pathways recently gained interest as a novel pharmacological strategy for selectively modulating inflammasome activation in pathological conditions.
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Affiliation(s)
- Dhruv Chauhan
- Janssen Immunosciences, World Without Disease Accelerator, Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium
| | - Lieselotte Vande Walle
- Laboratory of Medical Innate Immunity, Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Mohamed Lamkanfi
- Laboratory of Medical Innate Immunity, Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
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29
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Abstract
Autoinflammatory syndromes are characterized by an exaggerated activation of the innate immune system and frequently present with skin symptoms. In contrast to autoimmune disorders no specific autoantibodies or autoreactive immune cells are detected. Thus, the diagnosis is usually difficult and can only be made by a careful interpretation of anamnestic, clinical and laboratory parameters. In some hereditary autoimmune syndromes specific genetic mutations are described and can be helpful for the diagnosis. For treatment of these disorders both classic immunomodulatory drugs and specific cytokine inhibitors are used, mainly directed against interleukin‑1. Long-term therapy is generally required.
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Kacar M, Pathak S, Savic S. Hereditary systemic autoinflammatory diseases and Schnitzler's syndrome. Rheumatology (Oxford) 2020; 58:vi31-vi43. [PMID: 31769858 PMCID: PMC6878846 DOI: 10.1093/rheumatology/kez448] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/09/2019] [Indexed: 12/18/2022] Open
Abstract
The systemic autoinflammatory diseases are disorders of the innate immune system distinguished by severe inflammation resulting from dysregulation of the innate immune system. Hereditary fever syndromes, such as FMF, TNF receptor-associated periodic syndrome, cryopyrin-associated periodic syndromes and mevalonate kinase deficiency, were the first group of systemic autoinflammatory diseases for which a genetic basis was established, between 1999 and 2001. Currently according to the latest report of the international union of immunological societies, 37 separate monogenic disorders were classified as autoinflammatory. In addition to the abovementioned monogenic conditions, we describe Schnitzler's syndrome, a well-defined, acquired autoinflammatory condition without a clear genetic basis. For the purposes of this review, we discuss several conditions defined by the latest consensus process as systemic autoinflammatory diseases. We focus on those disorders where recent studies have contributed to further phenotypic characterization or had an impact on clinical management.
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Affiliation(s)
- Mark Kacar
- National Institute for Health Research-Leeds Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK.,Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
| | - Shelly Pathak
- National Institute for Health Research-Leeds Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
| | - Sinisa Savic
- National Institute for Health Research-Leeds Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK.,Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
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Aslam F, Wiedmeier JE, DiCaudo DJ. A Man With Recurrent Fever, Episodic Rash, and Pain. Arthritis Care Res (Hoboken) 2020; 73:1106-1113. [PMID: 31961498 DOI: 10.1002/acr.24142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
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Krause K, Bonnekoh H, Ellrich A, Tsianakas A, Wagner N, Fischer J, Maurer M. Long-term efficacy of canakinumab in the treatment of Schnitzler syndrome. J Allergy Clin Immunol 2020; 145:1681-1686.e5. [PMID: 31940469 DOI: 10.1016/j.jaci.2019.12.909] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Karoline Krause
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Hanna Bonnekoh
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - André Ellrich
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Athanasios Tsianakas
- Department of Dermatology, Universitätsklinikum Münster, Germany; Department of Dermatology, Fachklinik Bad Bentheim, Bentheim, Germany
| | - Nicola Wagner
- Department of Dermatology, Klinikum Erlangen, Erlangen, Germany
| | - Jörg Fischer
- Department of Dermatology and Allergy, Universitätsklinik Tübingen, Tübingen, Germany
| | - Marcus Maurer
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Caffarelli C, Paravati F, El Hachem M, Duse M, Bergamini M, Simeone G, Barbagallo M, Bernardini R, Bottau P, Bugliaro F, Caimmi S, Chiera F, Crisafulli G, De Ranieri C, Di Mauro D, Diociaiuti A, Franceschini F, Gola M, Licari A, Liotti L, Mastrorilli C, Minasi D, Mori F, Neri I, Pantaleo A, Saretta F, Tesi CF, Corsello G, Marseglia GL, Villani A, Cardinale F. Management of chronic urticaria in children: a clinical guideline. Ital J Pediatr 2019; 45:101. [PMID: 31416456 PMCID: PMC6694633 DOI: 10.1186/s13052-019-0695-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/01/2019] [Indexed: 12/12/2022] Open
Abstract
The aim of this guidance is to provide recommendations to clinicians and other interested parties on chronic urticaria in children. The Italian Society for Pediatrics (SIP), the Italian Society for Allergy and Immunology (SIAIP), the Italian Society for Pediatric dermatology (SIDerP) convened a multidisciplinary panel that prepared clinical guidelines for diagnosis and management of chronic urticaria in childhood. Key questions on epidemiology, natural history, diagnosis, and management were developed. The literature was systematically searched and evaluated, recommendations were rated and algorithms for diagnosis and treatment were developed. The recommendations focus on identification of diseases and comorbidities, strategies to recognize triggering factors, improvement of treatment by individualized care.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Dipartimento Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Francesco Paravati
- Pediatric Unit, Maternal Infant Department, Azienda Sanitaria Provinciale Crotone, Crotone, Italy
| | - Maya El Hachem
- Dermatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marzia Duse
- Department of Pediatrics, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | | | - Giovanni Simeone
- Primary care Pediatrician, Local Health Unit of Brindisi, Brindisi, Italy
| | - Massimo Barbagallo
- Pediatric Unit, Azienda di rilievo nazionale ARNAS "GARIBALDI", Catania, Italy
| | | | - Paolo Bottau
- Pediatric and Neonatology Unit, Imola Hospital, Imola, BO, Italy
| | - Filomena Bugliaro
- FEDERASMA e Allergie Onlus - Federazione Italiana Pazienti, Prato, Italy
| | - Silvia Caimmi
- Pediatric Clinic, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Fernanda Chiera
- Pediatric Unit, Maternal Infant Department, Azienda Sanitaria Provinciale Crotone, Crotone, Italy
| | - Giuseppe Crisafulli
- UO Allergologia, Dipartimento di Pediatria, Università di Messina, Messina, Italy
| | | | - Dora Di Mauro
- Clinica Pediatrica, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Diociaiuti
- Dermatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Massimo Gola
- Allergological and Pediatric Dermatology Unit, AUTC and University of Florence, Florence, Italy
| | - Amelia Licari
- Pediatric Clinic, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Lucia Liotti
- Department of Pediatrics, Senigallia Hospital, Senigallia, Italy
| | - Carla Mastrorilli
- Department of Pediatrics and Emergency, Pediatric Allergy and Pulmunology Unit, Azienda Ospedaliera-Universitaria "Consorziale-Policlinico", Ospedale Pediatrico Giovanni XXIII, Bari, Italy
| | - Domenico Minasi
- UOC di Pediatria Azienda Ospedaliera "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Iria Neri
- Dermatology Unit, University of Bologna, Bologna, Italy
| | - Aurelia Pantaleo
- Clinica Pediatrica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Francesca Saretta
- Pediatric Department, AAS2 Bassa Friulana-Isontina, Palmanova-Latisana, Italy.,Pediatric Allergy Unit, Department of Medicine, Udine, Italy
| | - Carlo Filippo Tesi
- FEDERASMA e Allergie Onlus - Federazione Italiana Pazienti, Prato, Italy
| | - Giovanni Corsello
- Clinica Pediatrica Università degli Studi di Palermo, Palermo, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alberto Villani
- UOC di Pediatria Generale e Malattie Infettive, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Fabio Cardinale
- Department of Pediatrics and Emergency, Pediatric Allergy and Pulmunology Unit, Azienda Ospedaliera-Universitaria "Consorziale-Policlinico", Ospedale Pediatrico Giovanni XXIII, Bari, Italy.
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Abstract
The autoinflammatory diseases comprise a broad spectrum of disorders characterized by unchecked activation of the innate immune system. Whereas aberrations in adaptive immunity have long been identified in 'autoimmune' disorders, the concept of 'autoinflammation' emerged relatively recently, first describing a group of clinical disorders characterized by spontaneous episodes of systemic inflammation without manifestations typical of autoimmune disorders. Improved knowledge of innate immune mechanisms, coupled with remarkable progress in genomics and an expanding number of clinical cases, has since led to an increasing number of disorders classified as autoinflammatory or containing an autoinflammatory component. Biologic therapies targeting specific components of the innate immune system have provided immense clinical benefit, and have further elucidated the role of innate immunity in autoinflammatory disorders. This article reviews the basic mechanisms of autoinflammation, followed by an update on the pathophysiology and treatment of the monogenic and multifactorial autoinflammatory diseases, and the common dermatologic conditions in which autoinflammation plays a major role.
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Abstract
Schnitzler syndrome is a very rare acquired systemic disease with many similarities to hereditary autoinflammatory syndromes. The main characteristics are generalized exanthema and IgM monoclonal gammopathy. Other clinical features include fever, muscle, bone, and/or joint pain, and lymphadenopathy. About 15-20% of patients with Schnitzler syndrome develop lymphoproliferative diseases and, in rare cases, amyloid A (AA) amyloidosis can occur if the disease is not treated. Activation of the innate immune system, especially interleukin (IL)-1β, is central to the pathogenesis of disease. Consequently, complete control of disease symptoms can be achieved in 80% of patients by treatment with the IL-1 receptor antagonist anakinra.
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Affiliation(s)
- F F Gellrich
- Department of Dermatology, University Hospital Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - C Günther
- Department of Dermatology, University Hospital Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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36
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Abstract
Schnitzler syndrome is a very rare acquired systemic disease with many similarities to hereditary autoinflammatory syndromes. The main characteristics are generalized exanthema and a monoclonal gammopathy with IgM. Other clinical features include fever, muscle, bone and/or joint pain, and lymphadenopathy. About 15-20% of patients with Schnitzler syndrome develop lymphoproliferative diseases and, in rare cases, amyloid A (AA) amyloidosis can occur if the disease is not treated. Activation of the innate immune system, especially interleukin(IL)-1β, is central in the pathogenesis of the disease. Consequently, complete control of disease symptoms can be achieved in 80% of patients by treatment with the IL-1 receptor antagonist anakinra.
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Affiliation(s)
- F F Gellrich
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Anstalt des öffentlichen Rechts des Freistaates Sachsen, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - C Günther
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Anstalt des öffentlichen Rechts des Freistaates Sachsen, Fetscherstr. 74, 01307, Dresden, Deutschland
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Sánchez-Manubens J, Iglesias E, Anton J. Canakinumab for the treatment of hyperimmunoglobulin D syndrome. Expert Rev Clin Immunol 2019; 15:215-220. [PMID: 30652926 DOI: 10.1080/1744666x.2019.1571410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Mevalonate Kinase Deficiency (MKD) is a rare monogenic autoinflammatory disorder (AID) with autosomal recessive inheritance caused by mutations in the MVK gene. It includes hyperimmunoglobulinemia D syndrome (HIDS) and mevalonic aciduria (a severe form). Patients have recurrent inflammatory attacks with high fever, gastrointestinal symptoms, lymphadenopathy, splenomegaly, arthralgia, rash, pharyngitis, aphtosis and constitutional complaints. Heightened understanding of molecular mechanisms in monogenic autoinflammatory disorders has provided tools for targeted treatment. HIDS is an extrinsic inflammasomopathy and is responsive to anti-IL-1 therapies, such as the recombinant IL-1-receptor antagonist anakinra, the monoclonal antibody against IL-1b canakinumab (CAN), and the recombinant IL-1R fusion protein rilonacept. Areas covered: CAN is a human monoclonal anti-IL-1β antibody that binds with high affinity and neutralizes the activity of IL-1 β. Both observational registries and some case reports have seemed promising in the efficacy of CAN in the HIDS treatment. Two clinical trials have corroborated CAN as an effective and safe drug. Expert commentary: CAN is effective and safe for the treatment of HIDS patients. Some data suggest these patients may need higher dosage or shorter dosing interval than other AIDs, to achieve and maintain complete clinical and laboratory response. Reported adverse events were mild, most often non-complicated infections.
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Affiliation(s)
- Judith Sánchez-Manubens
- a Pediatric Rheumatology Unit, Pediatrics Department, Hospital Universitari Parc Taulí , Universitat Autònoma de Barcelona , Sabadell (Barcelona) , Spain.,b Pediatric Rheumatology Unit, Pediatrics Department, Hospital Sant Joan de Déu , Universitat de Barcelona , Barcelona , Spain
| | - Estibaliz Iglesias
- b Pediatric Rheumatology Unit, Pediatrics Department, Hospital Sant Joan de Déu , Universitat de Barcelona , Barcelona , Spain
| | - Jordi Anton
- b Pediatric Rheumatology Unit, Pediatrics Department, Hospital Sant Joan de Déu , Universitat de Barcelona , Barcelona , Spain
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A New Case of Schnitzler Syndrome in Bulgaria. ACTA MEDICA BULGARICA 2018. [DOI: 10.2478/amb-2018-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
We describe the case of a 74-year-old Bulgarian woman with a long history of chronic urticaria with severe burning sensation, arthralgia and fever. Additional symptoms of Schnitzler such as monoclonal immunoglobulin – kappa component, elevated erythrocyte sedimentation rate and enlarged lymph nodes were detected six years after the onset of the symptoms. The first diagnoses hypersensitive vasculitis and dermatitis were established in 2009. Schnitzler syndrome was recognized and the diagnosis was established 2 years later after some examination tests. The time course of the values of IgM, C-reactive protein, erythrocyte sedimentation rate and neutrophils were presented. The mean value of IgM is 13.8 ± 2.19 g/l, the mean value of erythrocyte sedimentation rate is 48.6 ± 14.46 mm/h and the mean value of C-reactive protein – 29.8 ± 7.34 mg/l. The use of nonsteroid anti-inflammatory drugs throughout the period and corticosteroids prescribed parenterally and orally resulted in the relief of arthralgia and fever.
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Zhang XR, Jia SX, Fang MY. [Diagnosis and treatment of Schnitzler syndrome]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:1052-1056. [PMID: 30612413 PMCID: PMC7348231 DOI: 10.3760/cma.j.issn.0253-2727.2018.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - M Y Fang
- Department of Hematology, Affiliated Zhongshan Hospital of Dalian University, Dalian 116000, China
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Krause K, Sabat R, Witte-Händel E, Schulze A, Puhl V, Maurer M, Wolk K. Association of CCL2 with systemic inflammation in Schnitzler syndrome. Br J Dermatol 2018; 180:859-868. [PMID: 30339714 DOI: 10.1111/bjd.17334] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Schnitzler syndrome (SchS) is a rare autoinflammatory disease characterized by urticarial exanthema, bone and joint alterations, fever and monoclonal gammopathy, which manifest mostly in the second half of life. It involves overactivation of the interleukin (IL)-1 system, but the exact pathophysiological pathways remain largely unknown. OBJECTIVES To identify and characterize the pathogenetic players in SchS. METHODS Blood parameters were quantified in patients with SchS compared with healthy controls and patients with psoriasis and hidradenitis suppurativa using enzyme-linked immunosorbent assay (ELISA). CCL2 expression in cultured primary cells was analysed by quantitative reverse-transcriptase polymerase chain reaction and ELISA. RESULTS CCL2, a chemoattractant for monocytic and further mononuclear immune cells, was found to be significantly elevated in patients with SchS. CCL2 levels showed a positive association with global disease activity, especially with bone pain, but not disease duration, gammopathy, neutrophilia or skin disease. In vitro stimulation assays demonstrated a strong CCL2 production capacity of mononuclear immune cells and fibroblasts, but not epithelial or endothelial cells. Among a range of inflammatory mediators, only IL-1β (immune cells, fibroblasts) and tumour necrosis factor (TNF)-α (fibroblasts) were important CCL2 inducers. TNF-α, but not IL-17, strengthened the CCL2-inducing effect of IL-1β in fibroblasts. Accordingly, CCL2 levels positively correlated with both TNF-α and IL-1β serum levels in patients with SchS. Therapeutic IL-1β blockade decreased CCL2 blood levels in these patients as early as 1 week after the initiation of treatment. CONCLUSIONS CCL2 may be an important component of the pathogenetic cascade leading to bone alterations, and a suitable marker of disease activity in patients with SchS.
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Affiliation(s)
- K Krause
- Dermatological Allergology, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Autoinflammation Reference Centre Charité, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - R Sabat
- Interdisciplinary Group of Molecular Immunopathology, Dermatology/Medical Immunology and, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Psoriasis Research and Treatment Centre, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - E Witte-Händel
- Interdisciplinary Group of Molecular Immunopathology, Dermatology/Medical Immunology and, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Psoriasis Research and Treatment Centre, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - A Schulze
- Interdisciplinary Group of Molecular Immunopathology, Dermatology/Medical Immunology and, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Psoriasis Research and Treatment Centre, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - V Puhl
- Dermatological Allergology, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Autoinflammation Reference Centre Charité, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - M Maurer
- Dermatological Allergology, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Autoinflammation Reference Centre Charité, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - K Wolk
- Interdisciplinary Group of Molecular Immunopathology, Dermatology/Medical Immunology and, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Psoriasis Research and Treatment Centre, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin-Brandenburg Centre for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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41
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[Schnitzler syndrome]. Hautarzt 2018; 69:761-772. [PMID: 30167710 DOI: 10.1007/s00105-018-4250-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Schnitzler syndrome is a very rare acquired systemic disease with many similarities to hereditary autoinflammatory syndromes. The main characteristics are generalized exanthema and a monoclonal gammopathy with IgM. Other clinical features include fever, muscle, bone and/or joint pain, and lymphadenopathy. About 15-20% of patients with Schnitzler syndrome develop lymphoproliferative diseases and, in rare cases, amyloid A (AA) amyloidosis can occur if the disease is not treated. Activation of the innate immune system, especially interleukin(IL)-1β, is central in the pathogenesis of the disease. Consequently, complete control of disease symptoms can be achieved in 80% of patients by treatment with the IL-1 receptor antagonist anakinra.
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42
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Urticaria, Urticarial Vasculitis, Angioedema, and Related Diseases. CURRENT DERMATOLOGY REPORTS 2018. [DOI: 10.1007/s13671-018-0223-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
PURPOSE OF REVIEW We focus on recent advances in diagnosis and therapeutic strategies, as well as on pathogenesis of Schnitzler syndrome. RECENT FINDINGS New diagnostic criteria were established, and their external validity was assessed in a retrospective cohort study. The cytokine interleukin-1 (IL-1) plays a crucial role in the pathogenesis of the Schnitzler syndrome, and this explains the spectacular efficiency of IL-1 blocking therapies. The Schnitzler syndrome is now considered as a late-onset acquired autoinflammatory syndrome in which the cytokine IL-1 plays a crucial role. IL-1 blocking therapies are efficient on the inflammation-linked symptoms but not on the monoclonal component. Therefore, they probably don't reduce the risk of the development of lymphoproliferative disorders that remains the main prognostic issue. The link between autoinflammation and the monoclonal component needs to be further elucidated.
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A Rare but Fascinating Disorder: Case Collection of Patients with Schnitzler Syndrome. Case Rep Rheumatol 2018; 2018:7041576. [PMID: 29707401 PMCID: PMC5863343 DOI: 10.1155/2018/7041576] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/16/2018] [Accepted: 02/08/2018] [Indexed: 12/03/2022] Open
Abstract
Background Schnitzler syndrome is a rare disorder characterized by a chronic urticarial rash and monoclonal gammopathy (IgM in more than 90% of the cases). It is difficult to distinguish from other neutrophilic urticarial dermatoses, and diagnosis is based on the Strasbourg criteria. Interleukin-1 is considered the key mediator, and interleukin-1 inhibitors are considered first line treatment. Here, we present two cases of Schnitzler syndrome, both successfully treated with anakinra. Objectives To increase awareness regarding clinical presentation, diagnosis, and treatment of this rare disorder. Cases We describe the clinical features and disease course of two patients with Schnitzler syndrome, diagnosed using the Strasbourg criteria. Both were treated with anakinra with remarkable response to therapy. Conclusion Schnitzler syndrome is a rare and underdiagnosed disorder. High suspicion should be maintained in patients with chronic urticaria-like dermatoses, intermittent fevers, and arthralgias. A serum protein electrophoresis and immunofixation should be performed in these patients. The diagnosis is important to recognize as Schnitzler syndrome is associated with malignancy. A lymphoproliferative disorder develops in about 20% of patients at an average of 7.6 years after onset of symptoms. Thus, patients warrant long-term follow-up. IL-1 inhibitors are extremely effective in relieving symptoms and are considered first line therapy.
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Bonnekoh H, Scheffel J, Kambe N, Krause K. The role of mast cells in autoinflammation. Immunol Rev 2018; 282:265-275. [DOI: 10.1111/imr.12633] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hanna Bonnekoh
- Department of Dermatology and Allergy; Allergie-Centrum-Charité; Charité - Universitätsmedizin Berlin; Berlin Germany
- Autoinflammation Reference Center Charité (ARC2); Charité - Universitätsmedizin Berlin; Berlin Germany
| | - Jörg Scheffel
- Department of Dermatology and Allergy; Allergie-Centrum-Charité; Charité - Universitätsmedizin Berlin; Berlin Germany
- Autoinflammation Reference Center Charité (ARC2); Charité - Universitätsmedizin Berlin; Berlin Germany
| | - Naotomo Kambe
- Department of Dermatology; Kansai Medical University; Hirakata Japan
- Allergy Center; Kansai Medical University; Hirakata Japan
| | - Karoline Krause
- Department of Dermatology and Allergy; Allergie-Centrum-Charité; Charité - Universitätsmedizin Berlin; Berlin Germany
- Autoinflammation Reference Center Charité (ARC2); Charité - Universitätsmedizin Berlin; Berlin Germany
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Molecular genetic investigation, clinical features, and response to treatment in 21 patients with Schnitzler syndrome. Blood 2017; 131:974-981. [PMID: 29284595 DOI: 10.1182/blood-2017-10-810366] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/08/2017] [Indexed: 12/15/2022] Open
Abstract
To date, the pathogenic mechanisms underlying Schnitzler syndrome remain obscure, in particular, the interplay between the monoclonal protein and increased interleukin-1β (IL-1β) production, although interest in the contribution of genetic factors has been fueled by detection of somatic NLRP3 mosaicism in 2 patients with the variant-type Schnitzler syndrome. At 2 specialist UK centers, we have identified 21 patients who fulfilled diagnostic criteria for Schnitzler syndrome with urticarial rash, fever, arthralgia, and bone pain; 47% reported weight loss, 40% fatigue, and 21% lymphadenopathy. An immunoglobulin M (IgM) κ paraprotein was detected in 86%; the remainder had IgM λ or IgG κ. Patients underwent searches for germ line and somatic mutations using next-generation sequencing technology. Moreover, we designed a panel consisting of 32 autoinflammatory genes to explore genetic susceptibility factor(s) to Schnitzler syndrome. Genetic analysis revealed neither germ line nor somatic NLRP3, TNFRSF1A, NLRC4, or NOD2 mutations, apart from 1 patient with a germ line NLRP3 p.V198M substitution. The proinflammatory cytokines and extracellular apoptosis-associated speck-like protein with caspase recruitment domain (ASC) measured in the serum of Schnitzler syndrome patients during active disease were significantly higher than healthy controls. Ninety-five percent of our cohort achieved a complete response to recombinant IL-1 receptor antagonist (anakinra). Our findings do not support a role for somatic NLRP3 mosaicism in disease pathogenesis; although elevated levels of ASC, IL-6, and IL-18 in patients' serum, and the response to anakinra, suggest that Schnitzler syndrome is associated with upregulated inflammasome activation. Despite its rarity, Schnitzler syndrome is an important diagnosis as treatment with IL-1 antagonists dramatically improves quality of life for patients.
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Salugina SO, Gorodetsky VR, Fedorov ES, Lopatina NE, Evsikova MD. [Schnitzler syndrome: A review of literature, the authors' observation, and experience with the interleukin-1 inhibitor canakinumab]. TERAPEVT ARKH 2017; 89:111-115. [PMID: 29260755 DOI: 10.17116/terarkh20178911111-115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The paper reviews the publications dealing with Schnitzler syndrome, a rare autoinflammatory disease, and describes the authors' own clinical observation. It describes the first Russian experience in successfully using the interleukin-1 inhibitor canakinumab to treat this disease.
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Affiliation(s)
- S O Salugina
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - V R Gorodetsky
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - E S Fedorov
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - N E Lopatina
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - M D Evsikova
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russia
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Radiotherapy for a breast cancer patient with Schnitzler syndrome: Report of acute toxicity and early follow-up. Rep Pract Oncol Radiother 2017; 22:463-469. [PMID: 28932175 DOI: 10.1016/j.rpor.2017.08.006] [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: 06/19/2017] [Accepted: 08/21/2017] [Indexed: 11/20/2022] Open
Abstract
This article provides description about acute toxicity and early follow-up of one patient treated for breast cancer and Schnitzler syndrome. There are no previously reported cases exploring this interaction on medical literature. The expected radiodermitis to occur in the region treated with radiotherapy along with urticarial-like lesions might be challenging in view of the interaction between symptoms and therapeutic measures.
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Faggioli P, Tamburello A, Roncoroni L, Mazzone A. Schnitzler syndrome, a rare autoinflammatory disease. Complete response to IL-1 blockade. Clin Pract 2017; 7:1018. [PMID: 29291047 PMCID: PMC5736995 DOI: 10.4081/cp.2017.1018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/15/2017] [Indexed: 11/23/2022] Open
Abstract
The Schnitzler syndrome (SCS) is a rare, late-onset acquired autoinflammatory syndrome often underdiagnosed. The diagnosis is based on the Lipsker and recently on validated Strasbourg diagnostic criteria (chronic urticarial rash, monoclonal gammopathy, intermittent fever, arthritis, arthralgia, bone involvement, hepatomegaly, splenomegaly, lymphadenopathy, dermal infiltration of neutrophils and laboratory markers of inflammation). Conventional therapies including anti-histamines, anti-inflammatory drugs, corticosteroids and immunosuppressive drugs that are usually ineffective. Recently the gold standard therapy of SCS are considered IL-1 blocking agents as anakinra, canakinumab, rilonacept that led to a significant control of clinical symptoms, even if a relapse could appear at suspension of the treatment. We report a case of a 63-year-old man with a recent diagnosis of SCS - after 6 years of symptoms of disease - refractory to several conventional immunosuppressive therapies and treated with anakinra, with sustained remission of clinic manifestations during treatment at 24 months of follow up.
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Affiliation(s)
| | | | - Lucia Roncoroni
- Pathology Unit, Legnano Hospital, ASST Ovest Milanese, Legnano (MI), Italy
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Cytokines of the IL-1 family: recognized targets in chronic inflammation underrated in organ transplantations. Clin Sci (Lond) 2017; 131:2241-2256. [DOI: 10.1042/cs20170098] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 02/06/2023]
Abstract
Interleukin 1 (IL-1) family is a group of cytokines with multiple local and systemic effects, which regulates both innate and adaptive immune responses. Generally, most IL-1 family cytokines express prevailing pro-inflammatory activities (IL-1α, IL-1β, IL-18, IL-33, IL-36 α, β, γ), whereas others are anti-inflammatory (IL-1Ra (IL-1 receptor antagonist), IL-36Ra, IL-38, IL-37). In addition to their immunomodulatory roles, some of them are also involved in the physiological modulation of homeostatic processes and directly affect mRNA transcription. IL-1 family cytokines bind to specific receptors composed of a ligand-binding chain and an accessory chain. The pro-inflammatory effects of IL-1 family cytokines are regulated on the level of transcription, enzymatic processing of precursors, release of soluble antagonists, and expression of decoy receptors. Members of the IL-1 family regulate the recruitment and activation of effector cells involved in innate and adaptive immunity, but they are also involved in the pathogenesis of chronic disorders, including inflammatory bowel disease, rheumatoid arthritis, and various autoimmune and autoinflammatory diseases. There are only limited data regarding the role of IL-1 cytokines in transplantation. In recent years, targeted therapeutics affecting IL-1 have been used in multiple clinical studies. In addition to the recombinant IL-1Ra, anakinra (highly effective in autoinflammatory diseases and tested for other chronic diseases), the monoclonal antibodies canakinumab, gevokizumab, and rilonacept (a long-acting IL-1 receptor fusion protein) provide further options to block IL-1 activity. Furthermore, new inhibitors of IL-18 (GSK 1070806, ABT-325, rIL-18BP (IL-18 binding protein)) and IL-33 (CNTO-7160) are presently under clinical studies and other molecules are being developed to target IL-1 family cytokines.
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