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Tucker LB, Lamot L, Niemietz I, Chung BK, Cabral DA, Houghton K, Petty RE, Morishita KA, Rice GI, Turvey SE, Gibson WT, Brown KL. Complexity in unclassified auto-inflammatory disease: a case report illustrating the potential for disease arising from the allelic burden of multiple variants. Pediatr Rheumatol Online J 2019; 17:70. [PMID: 31660995 PMCID: PMC6819641 DOI: 10.1186/s12969-019-0374-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 10/14/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite recent advances in the diagnosis and understanding of many autoinflammatory diseases, there are still a great number of patients with phenotypes that do not fit any clinically- and/or genetically-defined disorders. CASE PRESENTATION We describe a fourteen-year-old boy who presented at two and a half years of age with recurrent febrile episodes. Over the course of the disease, the episodes increased in frequency and severity, with new signs and symptoms continuing to appear. Most importantly, these included skin changes, splenomegaly and transaminitis. Only partial control of the disease was achieved with anti-IL-1 therapy. Extensive investigation showed generalized inflammation without immune deficiency, with increased levels of serum amyloid A and several pro-inflammatory cytokines including interferon-γ, as well as an increased type I interferon score. Exome sequence analysis identified P369S and R408Q variants in the MEFV innate immunity regulator, pyrin (MEFV) gene and T260 M and T320 M variants in the NLR family pyrin domain containing 12 (NLRP12) gene. CONCLUSION Patients with unclassified and/or unexplained autoinflammatory syndromes present diagnostic and therapeutic challenges and collectively form a substantial part of every cohort of patients with autoinflammatory diseases. Therefore, it is important to acquire their full genomic profile through whole exome and/or genome sequencing and present their cases to a broader audience, to facilitate characterization of similar patients. A critical mass of well-characterized cases will lead to improved diagnosis and informed treatment.
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Affiliation(s)
- Lori B. Tucker
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4The Division of Rheumatology at British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Lovro Lamot
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4The Division of Rheumatology at British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Iwona Niemietz
- 0000 0001 2288 9830grid.17091.3eDepartment of Microbiology and Immunology, The University of British Columbia Faculty of Science, Health Sciences Mall, Vancouver, BC V6T 1Z3 Canada ,0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC V5Z 4H4 Canada
| | - Brian K. Chung
- 0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC V5Z 4H4 Canada ,0000 0001 2288 9830grid.17091.3eDepartment of Medical Genetics, The University of British Columbia Faculty of Medicine, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada ,0000 0004 0389 8485grid.55325.34Present Address: Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital Rikshospitalet, Postboks 4950, Nydalen, N-0424 Oslo, Norway
| | - David A. Cabral
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4The Division of Rheumatology at British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Kristin Houghton
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4The Division of Rheumatology at British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Ross E. Petty
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4The Division of Rheumatology at British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Kimberly A. Morishita
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4The Division of Rheumatology at British Columbia Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Gillian I. Rice
- 0000000121662407grid.5379.8Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Oxford Rd, Manchester, M13 9PL UK
| | - Stuart E. Turvey
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC V5Z 4H4 Canada
| | - William T. Gibson
- 0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC V5Z 4H4 Canada ,0000 0001 2288 9830grid.17091.3eDepartment of Medical Genetics, The University of British Columbia Faculty of Medicine, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Kelly L. Brown
- 0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, The University of British Columbia Faculty of Medicine, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada ,0000 0001 0684 7788grid.414137.4BC Children’s Hospital Research Institute, Rm A4-145, 950 West 28th Ave, Vancouver, BC V5Z 4H4 Canada
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Ozyilmaz B, Kirbiyik O, Koc A, Ozdemir TR, Kaya Ozer O, Kutbay YB, Erdogan KM, Saka Guvenc M, Ozturk C. Molecular genetic evaluation of NLRP3, MVK and TNFRSF1A associated periodic fever syndromes. Int J Immunogenet 2019; 46:232-240. [PMID: 31135083 DOI: 10.1111/iji.12431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 03/27/2019] [Accepted: 04/18/2019] [Indexed: 11/29/2022]
Abstract
Periodic fever syndromes (PFSs) are a family of clinical disorders, which are characterized by recurrent episodes of fever in the absence of microbial, autoimmune or malign conditions. Most common types of PFSs are associated with four genes: MEFV, MVK, TNFRSF1A and NLRP3. This paper aims to add new data to the genotype-phenotype association of MVK-, TNFRSF-1A- and NLRP3-associated PFSs. A total number of 211 patients were evaluated. Two different approaches were used for the molecular genetic evaluation of MVK-, TNFRSF-1A- and NLRP3-associated PFSs. For the first 147 patients, Sanger sequence analysis of selected exons of MVK, TNFRSF1A and NLRP3 genes was done. For subsequent 64 patients, targeted NGS panel analysis, covering all exons of MVK, TNFRSF1A and NLRP3 genes, was used. A total number of 48 variants were detected. The "variant detection rate in index patients" was higher in the NGS group than Sanger sequencing group (19% vs. 15,1%). For the variant positive patients, a detailed genotype-phenotype table was built. In PFSs, lack of correlation exists between genotype and phenotype in the general population and even within the families. In some cases, mutations behave differently and yield unexpected phenotypes. In this study, we discussed the clinical effects of eight different variants we have detected in the MVK, TNFRSF1A and NLRP3 genes. Four of them were previously identified in patients with PFS. The remaining four were not reported in patients with PFS. Thus, we had to interpret their clinical effects by analysing their frequencies and in silico analysis predictions. We suggest that new studies are needed to evaluate the effects of these variants more clearly. To be able to demonstrate a clearer genotype-phenotype relationship, all PFS-related genes should be analysed together and the possibility of polygenic inheritance should be considered.
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Affiliation(s)
- Berk Ozyilmaz
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Ozgur Kirbiyik
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Altug Koc
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Taha R Ozdemir
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Ozge Kaya Ozer
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Yasar B Kutbay
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Kadri M Erdogan
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Merve Saka Guvenc
- Tepecik Training and Research Hospital, Genetic Diagnosis Center, University of Health Sciences, Izmir, Turkey
| | - Can Ozturk
- Tepecik Training and Research Hospital, Pediatric Immunology, University of Health Sciences, Izmir, Turkey
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Cytokine signatures in hereditary fever syndromes (HFS). Cytokine Growth Factor Rev 2016; 33:19-34. [PMID: 27916611 DOI: 10.1016/j.cytogfr.2016.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/31/2016] [Accepted: 11/14/2016] [Indexed: 02/03/2023]
Abstract
Hereditary fever syndromes (HFS) include a group of disorders characterized by recurrent self-limited episodes of fever accompanied by inflammatory manifestations occurring in the absence of infection or autoimmune reaction. Advances in the genetics of HFS have led to the identification of new gene families and pathways involved in the regulation of inflammation and innate immunity. The key role of several cytokine networks in the pathogenesis of HFS has been underlined by several groups, and supported by the rapid response of patients to targeted cytokine blocking therapies. This can be due to the direct effect of cytokine overproduction or to an absence of receptor antagonist resulting in dysbalance of downstream pro- and anti-inflammatory cytokine networks. The aim of this study was to present an overview and to discuss the major concepts regarding the cellular and molecular immunology of HFS, with a particular focus on their specific cytokine signatures and physiopathological implications. Based on their molecular and cellular mechanisms, HFS have been classified into intrinsic and extrinsic IL-1β activation disorders or inflammasomopathies, and protein misfolding disorders. This review integrates all recent data in an updated classification of HFS.
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Ali NS, Sartori-Valinotti JC, Bruce AJ. Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. Clin Dermatol 2016; 34:482-6. [DOI: 10.1016/j.clindermatol.2016.02.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Pastore S, Vuch J, Bianco AM, Taddio A, Tommasini A. Fever tree revisited: From malaria to autoinflammatory diseases. World J Clin Pediatr 2015; 4:106-112. [PMID: 26566482 PMCID: PMC4637800 DOI: 10.5409/wjcp.v4.i4.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/20/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
Over the centuries the idea of recurrent fevers has mainly been associated with malaria, but many other fevers, such as typhoid and diphtheria were cause for concern. It is only in recent times, with the more severe forms of fever from infectious origin becoming less frequent or a cause for worry that we started noticing recurrent fevers without any clear infectious cause, being described as having a pathogenesis of autoinflammatory nature. The use of molecular examinations in many cases can allow a diagnosis where the cause is monogenic. In other cases, however the pathogenesis is likely to be multifactorial and the diagnostic-therapeutic approach is strictly clinical. The old fever tree paradigm developed to describe fevers caused by malaria has been revisited here to describe today’s periodic fevers from the periodic fever adenitis pharyngitis aphthae syndrome to the more rare autoinflammatory diseases. This model may allow us to place cases that are yet to be identified which are likely to be of multifactorial origin.
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Rusmini M, Federici S, Caroli F, Grossi A, Baldi M, Obici L, Insalaco A, Tommasini A, Caorsi R, Gallo E, Olivieri AN, Marzano A, Coviello D, Ravazzolo R, Martini A, Gattorno M, Ceccherini I. Next-generation sequencing and its initial applications for molecular diagnosis of systemic auto-inflammatory diseases. Ann Rheum Dis 2015; 75:1550-7. [PMID: 26386126 DOI: 10.1136/annrheumdis-2015-207701] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 08/28/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Systemic auto-inflammatory disorders (SAIDs) are a heterogeneous group of monogenic diseases sharing a primary dysfunction of the innate immune system. More than 50% of patients with SAID does not show any mutation at gene(s) tested because of lack of precise clinical classification criteria and/or incomplete gene screening. To improve the molecular diagnosis and genotype interpretation of SAIDs, we undertook the development of a next-generation sequencing (NGS)-based protocol designed to simultaneous screening of 10 genes. METHODS Fifty patients with SAID, already genotyped for the respective causative gene(s), were massively sequenced for the coding portions of MEFV, MVK, TNFRSF1A, NLRP3, NLRP12, NOD2, PSTPIP1, IL1RN, LPIN2 and PSMB8. Three different bioinformatic pipelines (Ion Reporter, CLC Bio Genomics Workbench, GATK-based in-house workflow) were compared. RESULTS Once resulting variants were compared with the expected mutation list, no workflow turned out to be able to detect all the 79 variants known in the 50 DNAs. Additional variants were also detected, validated by Sanger sequencing and compared to assess true and false positive detection rates of the three workflows. Finally, the overall clinical picture of 34 patients was re-evaluated in the light of the new mutations found. CONCLUSIONS The present gene panel has resulted suitable for molecular diagnosis of SAIDs. Moreover, genotype-phenotype correlation has confirmed that the interpretation of NGS data in patients with an undefined inflammatory phenotype is remarkably difficult, thus supporting the need of evidence-based and validated clinical criteria to be used concurrently with the genetic analysis for the final diagnosis and classification of patients with SAIDs.
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Affiliation(s)
- Marta Rusmini
- UOC Medical Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Silvia Federici
- UOC Pediatric Rheumatology, Lab Immunology Rheumatic Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesco Caroli
- UOC Medical Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Grossi
- UOC Medical Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizia Baldi
- Laboratory of Human Genetics, Ospedali Galliera, Genoa, Italy
| | - Laura Obici
- Amyloidosis Research and Treatment Centre, Biotechnology Research Laboratories, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Tommasini
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Roberta Caorsi
- UOC Pediatric Rheumatology, Lab Immunology Rheumatic Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Eleonora Gallo
- Dipartimento di Salute Pubblica e Pediatria, Universita' di Torino, Torino, Italy
| | - Alma Nunzia Olivieri
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda Universita' degli Studi di Napoli, Napoli, Italia
| | - AngeloValerio Marzano
- UO Dermatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico-Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | | | - Roberto Ravazzolo
- UOC Medical Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy Dipartimento Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genova, Italy
| | - Alberto Martini
- UOC Pediatric Rheumatology, Lab Immunology Rheumatic Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy Dipartimento Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genova, Italy
| | - Marco Gattorno
- UOC Pediatric Rheumatology, Lab Immunology Rheumatic Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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TRICARICO PAOLAMAURA, GIRARDELLI MARTINA, KLEINER GIULIO, KNOWLES ALESSANDRA, VALENCIC ERICA, CROVELLA SERGIO, MARCUZZI ANNALISA. Alendronate, a double-edged sword acting in the mevalonate pathway. Mol Med Rep 2015; 12:4238-4242. [PMID: 26096667 PMCID: PMC4526081 DOI: 10.3892/mmr.2015.3957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 04/30/2015] [Indexed: 01/29/2023] Open
Abstract
Aminobisphosphonate aledronate is a compound commonly used clinically for the treatment of osteoporosis and other bone diseases, as a result of it preventing bone resorption. However, in previous years it has also been used to obtain cellular and animal models of a rare genetic disorder termed Mevalonate Kinase Deficiency (MKD). MKD is caused by mutations affecting the mevalonate kinase enzyme, in the cholesterol pathway and alendronate can be used to biochemically mimic the genetic defect as it inhibits farnesyl pyrophosphate synthase in the same pathway. Despite evidence in favor of the inhibition exerted on the mevalonate pathway, there is at least one clinical case of MKD in which alendronate improved not only skeletal and bone fractures, as expected, but also MKD clinical features. Based on this finding, the present study assessed the anti‑inflammatory properties of this aminobisphosphonate in vitro. No anti‑inflammatory effects of alendronate were observed in the in vitro experiments. Since MKD lacks specific treatments, these results may assist scientists and physicians in making the decision as to the most suitable choice of therapeutic compounds for this neglected disease.
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Affiliation(s)
- PAOLA MAURA TRICARICO
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste I-34127, Italy
| | - MARTINA GIRARDELLI
- Department of Advanced Diagnostic and Clinical Trials, Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste I-34137, Italy
| | - GIULIO KLEINER
- Department of Advanced Diagnostic and Clinical Trials, Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste I-34137, Italy
| | - ALESSANDRA KNOWLES
- Department of Advanced Diagnostic and Clinical Trials, Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste I-34137, Italy
| | - ERICA VALENCIC
- Department of Advanced Diagnostic and Clinical Trials, Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste I-34137, Italy
| | - SERGIO CROVELLA
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste I-34127, Italy
- Department of Advanced Diagnostic and Clinical Trials, Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste I-34137, Italy
| | - ANNALISA MARCUZZI
- Department of Advanced Diagnostic and Clinical Trials, Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste I-34137, Italy
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Clinical features and genetic background of the periodic Fever syndrome with aphthous stomatitis, pharyngitis, and adenitis: a single center longitudinal study of 81 patients. Mediators Inflamm 2015; 2015:293417. [PMID: 25821352 PMCID: PMC4364074 DOI: 10.1155/2015/293417] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/22/2014] [Indexed: 12/15/2022] Open
Abstract
PFAPA syndrome is the most common autoinflammatory disorder in childhood with unknown etiology. The aim of our study was clinical evaluation of PFAPA patients from a single tertiary care center and to determine whether variations of AIM2, MEFV, NLRP3, and MVK genes are involved in PFAPA pathogenesis. Clinical and laboratory data of consecutive patients with PFAPA syndrome followed up at the University Children's Hospital, Ljubljana, were collected from 2008 to 2014. All four genes were PCR amplified and directly sequenced. Eighty-one patients fulfilled criteria for PFAPA syndrome, 50 (63%) boys and 31 (37%) girls, with mean age at disease onset of 2.1 ± 1.5 years. Adenitis, pharyngitis, and aphthae were present in 94%, 98%, and 56%, respectively. Family history of recurrent fevers in childhood was positive in 78%. Nineteen variants were found in 17/62 (27%) patients, 4 different variants in NLRP3 gene in 13 patients, and 6 different variants in MEFV gene in 5 patients, and 2 patients had 2 different variants. No variants of clinical significance were found in MVK and AIM2 genes. Our data suggest that PFAPA could be the result of multiple low-penetrant variants in different genes in combination with epigenetic and environmental factors leading to uniform clinical picture.
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