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Sathiyaseelan SL, Krishna K, Agarwal D, Oswal JS. Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome. BMJ Case Rep 2024; 17:e260146. [PMID: 38955384 DOI: 10.1136/bcr-2024-260146] [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: 07/04/2024] Open
Abstract
Camptodactyly-arthropathy-coxa vara-pericarditis syndrome (CACP) is a rare autosomal recessive disease caused by mutation in proteoglycan 4 (PRG4) gene on chromosome 1q25-q31. We faced a dilemma and delay in diagnosis in two sisters. The elder sister had pericardial effusion with constrictive pericarditis, underwent pericardiectomy and received empirical treatment for suspected tuberculosis. After 2 years, she developed bilateral knee swelling with restriction of movement. At the same time, her younger sister also presented with bilateral knee swelling which aroused the suspicion of genetic disease. The whole-genome sequencing revealed homozygous PRG4 mutation suggestive of CACP syndrome.
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MESH Headings
- Humans
- Female
- Coxa Vara/diagnosis
- Proteoglycans/genetics
- Hand Deformities, Congenital/genetics
- Hand Deformities, Congenital/diagnosis
- Arthropathy, Neurogenic/genetics
- Arthropathy, Neurogenic/diagnosis
- Pericardial Effusion/diagnosis
- Upper Extremity Deformities, Congenital/genetics
- Upper Extremity Deformities, Congenital/diagnosis
- Upper Extremity Deformities, Congenital/complications
- Pericarditis, Constrictive/diagnosis
- Pericarditis, Constrictive/complications
- Pericarditis, Constrictive/surgery
- Lower Extremity Deformities, Congenital/genetics
- Lower Extremity Deformities, Congenital/diagnosis
- Pericardiectomy
- Mutation
- Diagnosis, Differential
- Synovitis
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Affiliation(s)
- Sri Lakshmi Sathiyaseelan
- Clinical Immunology and Rheumatology, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Kavita Krishna
- Clinical Immunology and Rheumatology, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Deepti Agarwal
- Clinical Immunology and Rheumatology, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Jitendra Shankarlal Oswal
- Clinical Immunology and Rheumatology, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
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Brichova M, Klimova A, Heissigerova J, Svozilkova P, Vaneckova M, Dolezalova P, Nemcova D, Michalickova M, Jedlickova J, Dudakova L, Liskova P. Blau Syndrome: Challenging Molecular Genetic Diagnostics of Autoinflammatory Disease. Genes (Basel) 2024; 15:799. [PMID: 38927735 PMCID: PMC11203189 DOI: 10.3390/genes15060799] [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: 05/10/2024] [Revised: 06/13/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
The aim of this study was to describe the clinical and molecular genetic findings in seven individuals from three unrelated families with Blau syndrome. A complex ophthalmic and general health examination including diagnostic imaging was performed. The NOD2 mutational hot spot located in exon 4 was Sanger sequenced in all three probands. Two individuals also underwent autoinflammatory disorder gene panel screening, and in one subject, exome sequencing was performed. Blau syndrome presenting as uveitis, skin rush or arthritis was diagnosed in four cases from three families. In two individuals from one family, only camptodactyly was noted, while another member had camptodactyly in combination with non-active uveitis and angioid streaks. One proband developed two attacks of meningoencephalitis attributed to presumed neurosarcoidosis, which is a rare finding in Blau syndrome. The probands from families 1 and 2 carried pathogenic variants in NOD2 (NM_022162.3): c.1001G>A p.(Arg334Gln) and c.1000C>T p.(Arg334Trp), respectively. In family 3, two variants of unknown significance in a heterozygous state were found: c.1412G>T p.(Arg471Leu) in NOD2 and c.928C>T p.(Arg310*) in NLRC4 (NM_001199139.1). In conclusion, Blau syndrome is a phenotypically highly variable, and there is a need to raise awareness about all clinical manifestations, including neurosarcoidosis. Variants of unknown significance pose a significant challenge regarding their contribution to etiopathogenesis of autoinflammatory diseases.
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Affiliation(s)
- Michaela Brichova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Aneta Klimova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Jarmila Heissigerova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Petra Svozilkova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Manuela Vaneckova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Katerinska 30, 128 21 Prague, Czech Republic;
| | - Pavla Dolezalova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Dana Nemcova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Marcela Michalickova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
| | - Jana Jedlickova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Lubica Dudakova
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
| | - Petra Liskova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic; (M.B.); (J.H.); (P.S.); (M.M.)
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Ke Karlovu 2, 128 08 Prague, Czech Republic; (P.D.); (D.N.); (J.J.); (L.D.)
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Donis KC, Kalil MAB, Poswar F, Kok F, Kohem CL, Poloni S, Borsatto T, Vairo FPE, Pinheiro FC, Schwartz IVD. An adult with cystathionine beta-synthase deficiency, camptodactyly-arthropathy-coxa vara-pericarditis syndrome, and deafness: A case report. Genet Mol Biol 2024; 47:e20220335. [PMID: 38593426 PMCID: PMC11003653 DOI: 10.1590/1678-4685-gmb-2022-0335] [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: 11/07/2022] [Accepted: 11/11/2023] [Indexed: 04/11/2024] Open
Abstract
Massive sequencing platforms allow the identification of complex clinical phenotypes involving more than one autosomal recessive disorder. In this study, we report on an adult patient, born to a related couple (third degree cousins), referred for genetic evaluation due to ectopia lentis, deafness and previous diagnosis of juvenile idiopathic arthritis. He was biochemically diagnosed as having Classic Homocystinuria (HCU); Sanger sequencing of the CBS gene showed the genotype NM_000071.2(CBS):c.[833T>C];[833T>C], compatible with the diagnosis of pyridoxine-responsive HCU. As he also had symptoms not usually associated with HCU, exome sequencing was performed. In addition to the variants found in the Sanger sequencing, the following variants were identified: NM_001256317.1(TMPRSS3):c.[413C>A];[413C>A]; and the NM_005807.6(PRG4):c.[3756dup]:[3756dup], confirming the diagnosis of autosomal recessive nonsyndromic deafness and Camptodactyly-Arthropathy-Coxa Vara-Pericarditis Syndrome (CACP), respectively. Genomic analysis allowed the refinement of the diagnosis of a complex case and improvement of the patient's treatment.
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Affiliation(s)
- Karina Carvalho Donis
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Genética e Biologia Molecular, Porto Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Serviço de Genética Médica, Porto Alegre, RS, Brazil
| | | | - Fabiano Poswar
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Genética e Biologia Molecular, Porto Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Serviço de Genética Médica, Porto Alegre, RS, Brazil
| | - Fernando Kok
- Universidade de São Paulo, Hospital das Clínicas, Departamento de Neurologia, Unidade de Neurogenética, São Paulo, SP, Brazil
- Mendelics Análise Genômica, São Paulo, SP, Brazil
| | - Charles Lubianca Kohem
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Serviço de Reumatologia, Porto Alegre, RS, Brazil
| | - Soraia Poloni
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Centro de Pesquisa Experimental, Laboratório BRAIN, Porto Alegre, RS, Brazil
| | - Taciane Borsatto
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Centro de Pesquisa Experimental, Laboratório BRAIN, Porto Alegre, RS, Brazil
| | - Filippo Pinto e Vairo
- Mayo Clinic, Center for Individualized Medicine, Rochester, MN, USA
- Mayo Clinic, Department of Clinical Genomics, Rochester, MN, USA
| | - Franciele Cabral Pinheiro
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Genética e Biologia Molecular, Porto Alegre, RS, Brazil
| | - Ida Vanessa Doederlein Schwartz
- Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Genética e Biologia Molecular, Porto Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Serviço de Genética Médica, Porto Alegre, RS, Brazil
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Centro de Pesquisa Experimental, Laboratório BRAIN, Porto Alegre, RS, Brazil
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Singh S, Badiger VA, Balan S, Nampoothiri S, Rao AP, Shah H, Bhavani GS, Narayanan DL, Girisha KM. Thirteen Indians with camptodactyly-arthropathy-coxa vara-pericarditis syndrome. Clin Dysmorphol 2024:00019605-990000000-00067. [PMID: 38856641 DOI: 10.1097/mcd.0000000000000500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome (MIM# 208250) is a rare monogenic disorder, characterized by early onset of camptodactyly, progressive coxa vara, bilateral arthropathy and constrictive pericarditis. The syndrome is caused by biallelic loss-of-function variants in PRG4. Deficiency of PRG4 results in progressive worsening of joint deformity with age. Thirteen individuals with CACP syndrome from eight consanguineous Indian families were evaluated. We used exome sequencing to elucidate disease-causing variants in all the probands. These variants were further validated and segregated by Sanger sequencing, confirming the diagnosis of CACP syndrome in them. Seven females and six males aged 2-23 years were studied. Camptodactyly (13/13), coxa vara (11/13), short femoral neck (11/13) and arthritis in large joints (12/13) [wrists (11/13), ankle (11/13), elbow (10/13) and knee (10/13)] were observed commonly. Five novel disease-causing variants (c.3636G>T, c.1935del, c.1134dup, c.1699del and c.962T>A) and two previously reported variants (c.1910_1911del and c.2816_2817del) were identified in homozygous state in PRG4. We describe the phenotype and mutations in one of the large cohorts of patients with CACP syndrome, from India.
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Affiliation(s)
- Swati Singh
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
| | - Vaishnavi Ashok Badiger
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
| | - Suma Balan
- Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences and Research Centre
| | - Sheela Nampoothiri
- Department of Paediatric Genetics, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala
| | - Anand Prahalad Rao
- Department of Paediatric Rheumatology, Indira Gandhi Institute of Child Health, Bangalore
| | - Hitesh Shah
- Department of Paediatric Orthopaedics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
| | - Gandham SriLakshmi Bhavani
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
| | - Dhanya Lakshmi Narayanan
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
- DBT-Wellcome Trust India Alliance Early Career Clinical and Public Health Research Fellow, Hyderabad, Telangana, India
| | - Katta M Girisha
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka
- Department of Genetics, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Bağrul İ, Ceylaner S, Yildiz YT, Tuncez S, Aydin EA, Bağlan E, Ozdel S, Bülbül M. A novel mutation in the proteoglycan 4 gene causing CACP syndrome: two sisters report. Pediatr Rheumatol Online J 2023; 21:8. [PMID: 36694203 PMCID: PMC9875468 DOI: 10.1186/s12969-023-00793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome, caused by biallelic pathogenic mutations in the proteoglycan 4 (PRG4) gene, is characterized by early-onset camptodactyly, noninflammatory arthropathy, coxa vara deformity, and rarely, pericardial effusion. This syndrome can mimic juvenile idiopathic arthritis. CACP syndrome is caused by mutations in the proteoglycan 4 (PRG4) gene. To date, only 36 pathogenic mutations have been reported in this gene, but none have been reported from Azerbaijan. CASE PRESENTATION Herein, we report two siblings presented with chronic polyarthritis, had a prior diagnosis of juvenile idiopathic arthritis, but was subsequently diagnosed as CACP syndrome with novel mutation in the PRG4 gene. CONCLUSION Our report expands the knowledge of PRG4 mutations, which will aid in CACP patient counseling.
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Affiliation(s)
- İlknur Bağrul
- Department of Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Serdar Ceylaner
- Department of Genetics, Intergen Genetics Centre, Ankara, Turkey
| | - Yasemin Tasci Yildiz
- Department of Pediatric Radiology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Serife Tuncez
- Department of Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Elif Arslanoglu Aydin
- Department of Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Esra Bağlan
- Department of Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Semanur Ozdel
- Department of Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey.
| | - Mehmet Bülbül
- Department of Pediatric Rheumatology, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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Zhang JM, Gao FQ, Li CF, Kuang WY, Deng JH, Tan XH, Li C, Li SP. Camptodactyly-Arthropathy-Coxa Vara-Pericarditis Syndrome: The First Familial Case in China and Novel Mutations of the Proteoglycan 4 Gene. J Rheumatol 2022; 49:1400-1402. [PMID: 36109080 DOI: 10.3899/jrheum.220236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Jun-Mei Zhang
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Feng-Qiao Gao
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Cai-Feng Li
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
| | - Wei-Ying Kuang
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jiang-Hong Deng
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiao-Hua Tan
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chao Li
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shi-Peng Li
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Nishanth S, Ushagowry S. A Diagnosis of Camptodactyly With Benign Joint Hypermobility Syndrome in a Patient Presenting With Fixed Flexion Deformity of the Fingers and Striae. Cureus 2022; 14:e26148. [PMID: 35891877 PMCID: PMC9302035 DOI: 10.7759/cureus.26148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/12/2022] Open
Abstract
Camptodactyly is a genetic disorder that causes fixed flexion deformity of one or more fingers of single or both hands. It is very rare and the occurrence is very low amongst the children. It is linked to a handful of congenital connective tissue syndromes. It is passed onto generations with reduced expressivity. However, its association with benign joint hypermobility syndrome is rarely known. Joint hypermobility syndrome is a condition where there is extreme joint flexibility and it is related to a set of articular and extra-articular sequelae. We herein report a case of camptodactyly with benign joint hypermobility syndrome in a patient presenting with fixed flexion deformity of the fingers, joint hyperextensibility, and striae.
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Maniscalco V, Pizzetti C, Marrani E, Perrone A, Maccora I, Pagnini I, Artuso R, Simonini G, Mastrolia MV. Pseudo-rheumatic manifestations of limping: Camptodactyly-arthropathy-coxa vara-pericarditis syndrome: Single case report and review of the literature. Front Pediatr 2022; 10:981938. [PMID: 36545657 PMCID: PMC9760854 DOI: 10.3389/fped.2022.981938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022] Open
Abstract
Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome is a rare genetic disease characterized by tetrad camptodactyly, noninflammatory arthropathy, coxa vara deformity, and pericardial effusion. Arthropathy typically affects large joints and presents with joint swelling in the absence of other signs of inflammation. We described the case of a girl affected by CACP syndrome caused by a novel compound heterozygous variant in proteoglycan 4 gene (c.2831_2832insT; c.3892C > T) and associated with temporomandibular involvement. The patient received treatment with intra-articular hyaluronic acid injections, which presented rapid but transient improvements of pain and range of motion. A literature review of previously reported CACP patients has been performed. Of the patients. 69.2% (101 out of 146) were Middle Eastern, and 65.7% (96) were consanguineous. The median age of onset was 24 months (interquartile range of 12-36 months), and median age of diagnosis was 96 months (interquartile range of 48-156 months). Arthropathy was always present, mainly involving hips (95.2%), knees (92.4%), wrists (87.7%), elbows (79.5%), and ankles (57.5%). Camptodactyly and pericardial effusion were described, respectively, in 97.3% (142) and 15.1% (22) of patients. The main radiological findings were coxa vara (95.2%), femoral changes (64.4%), intraosseus cysts (14.4%), and bone erosion (5%). Of the patients, 32.9% (48) had received a previous juvenile idiopathic arthritis diagnosis. CACP syndrome can be easily misdiagnosed with juvenile idiopathic arthritis. A prolonged lack of response to immunosuppressive therapy associated with typical clinical and radiological features should prompt consideration of this rare syndrome.
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Affiliation(s)
| | - Camilla Pizzetti
- Department of Health Sciences, University of Florence, Firenze, Italy
| | - Edoardo Marrani
- Rheumatology Unit, Meyer Children's University Hospital, Firenze, Italy
| | - Anna Perrone
- Radiology Unit, Meyer Children's University Hospital, Firenze, Italy
| | - Ilaria Maccora
- Rheumatology Unit, Meyer Children's University Hospital, Firenze, Italy
| | - Ilaria Pagnini
- Rheumatology Unit, Meyer Children's University Hospital, Firenze, Italy
| | - Rosangela Artuso
- Medical Genetics Unit, Meyer Children's University Hospital, Firenze, Italy
| | - Gabriele Simonini
- NEUROFARBA Department, University of Florence, Rheumatology Unit, Meyer Children's University Hospital, Firenze, Italy
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