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Borchers J, Pukkala E, Mäkitie O, Laakso S. Epidemiology and Causes of Primary Adrenal Insufficiency in Children: A Population-Based Study. J Clin Endocrinol Metab 2023; 108:2879-2885. [PMID: 37216903 PMCID: PMC10583995 DOI: 10.1210/clinem/dgad283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/25/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
CONTEXT Incidence and causes of primary adrenal insufficiency (PAI) have not been comprehensively studied in children. OBJECTIVE Our objective was to describe the epidemiology and to assess causes of PAI in Finnish children. METHODS A population-based descriptive study of PAI in Finnish patients aged 0-20 years.Diagnoses referring to adrenal insufficiency in children born in 1996-2016 were collected from the Finnish National Care Register for Health Care. Patients with PAI were identified by studying patient records. Incidence rates were calculated in relation to person-years in the Finnish population of same age. RESULTS Of the 97 patients with PAI, 36% were female. The incidence of PAI was highest during the first year of life (in females 2.7 and in males 4.0/100 000 person-years). At 1-15 years of age, the incidence of PAI in females was 0.3/100 000 and in males 0.6/100 000 person-years. Cumulative incidence was 10/100 000 persons at age of 15 years and 13/100 000 at 20 years. Congenital adrenal hyperplasia was the cause in 57% of all patients and in 88% of patients diagnosed before age of 1 year. Other causes among the 97 patients included autoimmune disease (29%), adrenoleukodystrophy (6%), and other genetic causes (6%). From the age of 5 years, most of the new cases of PAI were due to autoimmune disease. CONCLUSION After the first-year peak, the incidence of PAI is relatively constant through ages 1-15 years, and 1 out of 10 000 children are diagnosed with PAI before the age of 15 years.
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Affiliation(s)
- Joonatan Borchers
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Eero Pukkala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Finnish Cancer Registry—Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Saila Laakso
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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2
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Bari A, Mahmood A, Chawla R, Sinha R. Ocular features of autoimmune polyendocrinopathy candidiasis ectodermal dystrophy. BMJ Case Rep 2023; 16:e252672. [PMID: 37437958 PMCID: PMC10347441 DOI: 10.1136/bcr-2022-252672] [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: 07/14/2023] Open
Abstract
Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is a multisystemic rare genetic disorder characterised by abnormalities of the immune system. We report the ocular features of APECED in two siblings of an Indian family, out of four who are still living. The ocular features of this disorder primarily included madarosis, refractive error, heterochromia, corneal opacity and peripheral retinal pigment epithelium degeneration. There is marked phenotypical heterogeneity in this disorder. We found differences even between monozygotic twins. While one of the twins did not have any ocular issues, the other one did. The child with corneal involvement was the most symptomatic; however, it did not lead to visual impairment. On genetic workup, homozygous p.M1V mutation was found in exon 1 of AIRE gene that has not been studied in Indian subjects with APECED. To the best of our knowledge, there is no report in literature describing ocular features of APECED in an Indian family with distinctive genetic involvement.
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Affiliation(s)
- Aafreen Bari
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Asjad Mahmood
- Orthopedics, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Chawla
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rajesh Sinha
- Ophthalmology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Oftedal BE, Assing K, Baris S, Safgren SL, Johansen IS, Jakobsen MA, Babovic-Vuksanovic D, Agre K, Klee EW, Majcic E, Ferré EM, Schmitt MM, DiMaggio T, Rosen LB, Rahman MO, Chrysis D, Giannakopoulos A, Garcia MT, González-Granado LI, Stanley K, Galant-Swafford J, Suwannarat P, Meyts I, Lionakis MS, Husebye ES. Dominant-negative heterozygous mutations in AIRE confer diverse autoimmune phenotypes. iScience 2023; 26:106818. [PMID: 37235056 PMCID: PMC10206195 DOI: 10.1016/j.isci.2023.106818] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/20/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
Autoimmune polyendocrine syndrome type 1 (APS-1) is an autosomal recessive disease characterized by severe and childhood onset organ-specific autoimmunity caused by mutations in the autoimmune regulator (AIRE) gene. More recently, dominant-negative mutations within the PHD1, PHD2, and SAND domains have been associated with an incompletely penetrant milder phenotype with later onset familial clustering, often masquerading as organ-specific autoimmunity. Patients with immunodeficiencies or autoimmunity where genetic analyses revealed heterozygous AIRE mutations were included in the study and the dominant-negative effects of the AIRE mutations were functionally assessed in vitro. We here report additional families with phenotypes ranging from immunodeficiency, enteropathy, and vitiligo to asymptomatic carrier status. APS-1-specific autoantibodies can hint to the presence of these pathogenic AIRE variants although their absence does not rule out their presence. Our findings suggest functional studies of heterozygous AIRE variants and close follow-up of identified individuals and their families.
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Affiliation(s)
- Bergithe E. Oftedal
- Department of Clinical Science, University of Bergen and Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Kristian Assing
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Safa Baris
- Marmara University, Faculty of Medicine, Pediatric Allergy and Immunology, Istanbul, Turkey
- Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Stephanie L. Safgren
- Center for Individualized Medicine, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Isik S. Johansen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | | | | | | | - Eric W. Klee
- Mayo Clinic, Department of Quantitative Health Sciences, Rochester, MN, USA
| | - Emina Majcic
- Department of Clinical Science, University of Bergen and Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Elise M.N. Ferré
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Monica M. Schmitt
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Tom DiMaggio
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Lindsey B. Rosen
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Muhammad Obaidur Rahman
- Department of Clinical Science, University of Bergen and Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Dionisios Chrysis
- Department of Pediatrics, Division of Pediatric Endocrinology, Medical School, University of Patras, Rion, Greece
| | - Aristeidis Giannakopoulos
- Department of Pediatrics, Division of Pediatric Endocrinology, Medical School, University of Patras, Rion, Greece
| | - Maria Tallon Garcia
- Pediatric Hematology and Oncology Department, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Luis Ignacio González-Granado
- Unidad de Inmunodeficiencias, Pediatría, Instituto de Investigación Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Katherine Stanley
- Mid-Atlantic Permanente Medical Group, Kaiser Permanente MidAtlantic, Rockville, MD, USA
| | | | - Pim Suwannarat
- Mid-Atlantic Permanente Medical Group, Kaiser Permanente MidAtlantic, Rockville, MD, USA
| | - Isabelle Meyts
- Department of Pediatrics, University Hospital Leuven, Laboratory for Inborn Errors of Immunity, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Michail S. Lionakis
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy & Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Eystein S. Husebye
- Department of Clinical Science, University of Bergen and Department of Medicine, Haukeland University Hospital, Bergen, Norway
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4
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Cruz Marino T, Leblanc J, Pratte A, Tardif J, Thomas MJ, Fortin CA, Girard L, Bouchard L. Portrait of autosomal recessive diseases in the French-Canadian founder population of Saguenay-Lac-Saint-Jean. Am J Med Genet A 2023; 191:1145-1163. [PMID: 36786328 DOI: 10.1002/ajmg.a.63147] [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: 09/28/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/15/2023]
Abstract
The population of the Saguenay-Lac-Saint-Jean (SLSJ) region, located in the province of Quebec, Canada, is recognized as a founder population, where some rare autosomal recessive diseases show a high prevalence. Through the clinical and molecular study of 82 affected individuals from 60 families, this study outlines 12 diseases identified as recurrent in SLSJ. Their carrier frequency was estimated with the contribution of 1059 healthy individuals, increasing the number of autosomal recessive diseases with known carrier frequency in this region from 14 to 25. We review the main clinical and molecular features previously reported for these disorders. Five of the studied diseases have a potential lethal effect and three are associated with intellectual deficiency. Therefore, we believe that the provincial program for carrier screening should be extended to include these eight disorders. The high-carrier frequency, together with the absence of consanguinity in most of these unrelated families, suggest a founder effect and genetic drift for the 12 recurrent variants. We recommend further studies to validate this hypothesis, as well as to extend the present study to other regions in the province of Quebec, since some of these disorders could also be present in other French-Canadian families.
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Affiliation(s)
- Tania Cruz Marino
- Department of Laboratory Medicine, CIUSSS Saguenay-Lac-St-Jean, Quebec, Canada
| | - Josianne Leblanc
- Department of Laboratory Medicine, CIUSSS Saguenay-Lac-St-Jean, Quebec, Canada
| | - Annabelle Pratte
- Department of Laboratory Medicine, CIUSSS Saguenay-Lac-St-Jean, Quebec, Canada
| | - Jessica Tardif
- Department of Laboratory Medicine, CIUSSS Saguenay-Lac-St-Jean, Quebec, Canada
| | | | - Carol-Ann Fortin
- Department of Biochemistry and Functional Genomics, Faculty of Medicine and Health Sciences (FMHS), Université de Sherbrooke, Quebec, Canada
| | - Lysanne Girard
- Department of Biochemistry and Functional Genomics, Faculty of Medicine and Health Sciences (FMHS), Université de Sherbrooke, Quebec, Canada
| | - Luigi Bouchard
- Department of Laboratory Medicine, CIUSSS Saguenay-Lac-St-Jean, Quebec, Canada.,Department of Biochemistry and Functional Genomics, Faculty of Medicine and Health Sciences (FMHS), Université de Sherbrooke, Quebec, Canada
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5
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Tyagi R, Kalra N, Khatri A, Goyal T, Yangdol P, Sabherwal P. A Rare Case of Autoimmune Polyendocrinopathy-candidiasis-ectodermal Dystrophy Syndrome: Dental Perspective on Diagnosis and Management. Int J Clin Pediatr Dent 2023; 16:139-146. [PMID: 37020766 PMCID: PMC10067979 DOI: 10.5005/jp-journals-10005-2496] [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] [Indexed: 04/07/2023] Open
Abstract
Aim To report a unique case of Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in a young boy and discuss the oral health impact and management of the disease. Background Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autoimmune disorder with various clinical manifestations. Biallelic mutations in the autoimmune regulator (AIRE) gene lead to impairment of central immune tolerance and a targeted attack on various endocrine and non-endocrine organs. Patients classically suffer from a triad of disorders, including chronic mucocutaneous candidiasis (CMC), hypoparathyroidism, and adrenocortical failure (Addison's disease). Results In recent times, it has been observed that oral manifestations of the disorder, such as enamel hypoplasia, appear early and frequently. Affected individuals require a comprehensive preventive and minimally invasive approach for oral health along with follow-up throughout their lifespan to manage potentially life-threatening disease manifestations. Conclusion Prompt recognition by a pediatric dentist can facilitate an earlier diagnosis and allow for screening, preventive and therapeutic services. Clinical Significance To deliver oral health care in an effective and comprehensive manner, clinicians should be able to recognize, diagnose and manage the signs and symptoms of the disease. How to cite this article Tyagi R, Kalra N, Khatri A, et al. A Rare Case of Autoimmune Polyendocrinopathy-candidiasis-ectodermal Dystrophy Syndrome: Dental Perspective on Diagnosis and Management. Int J Clin Pediatr Dent 2023;16(1):139-146.
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Affiliation(s)
- Rishi Tyagi
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Namita Kalra
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Amit Khatri
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Tavisha Goyal
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Padma Yangdol
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
| | - Puja Sabherwal
- Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi, India
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Sharma D, Ben Yakov G, Kapuria D, Viana Rodriguez G, Gewirtz M, Haddad J, Kleiner DE, Koh C, Bergerson JRE, Freeman AF, Heller T. Tip of the iceberg: A comprehensive review of liver disease in Inborn errors of immunity. Hepatology 2022; 76:1845-1861. [PMID: 35466407 DOI: 10.1002/hep.32539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/30/2022] [Accepted: 04/17/2022] [Indexed: 12/08/2022]
Abstract
Inborn errors of immunity (IEIs) consist of numerous rare, inherited defects of the immune system that affect about 500,000 people in the United States. As advancements in diagnosis through genetic testing and treatment with targeted immunotherapy and bone marrow transplant emerge, increasing numbers of patients survive into adulthood posing fresh clinical challenges. A large spectrum of hepatobiliary diseases now present in those with immunodeficiency diseases, leading to morbidity and mortality in this population. Awareness of these hepatobiliary diseases has lagged the improved management of the underlying disorders, leading to missed opportunities to improve clinical outcomes. This review article provides a detailed description of specific liver diseases occurring in various inborn errors of immunity. A generalized approach to diagnosis and management of hepatic complications is provided, and collaboration with hepatologists, immunologists, and pathologists is emphasized as a requirement for optimizing management and outcomes.
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Affiliation(s)
- Disha Sharma
- Department of Internal MedicineMedStar Washington Hospital Center & Georgetown UniversityWashingtonDCUSA.,Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Gil Ben Yakov
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,26744Center for Liver DiseaseSheba Medical CenterTel HaShomerIsrael
| | - Devika Kapuria
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,Department of GastroenterologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Gracia Viana Rodriguez
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Meital Gewirtz
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - James Haddad
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - David E Kleiner
- 3421Laboratory of PathologyNational Cancer InstituteBethesdaMarylandUSA
| | - Christopher Koh
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Jenna R E Bergerson
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Theo Heller
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
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Cruz Marino T, Villeneuve H, Leblanc J, Duranceau C, Caron P, Morin C, Milot M, Chrétien R, Gagnon MM, Mathieu J, Ellezam B, Buhas D. French-Canadian families from Saguenay-Lac-Saint-Jean: a new founder population for APECED. Endocrine 2022; 75:48-58. [PMID: 34846681 DOI: 10.1007/s12020-021-02826-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/11/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is more prevalent in some founder populations, but relatively unexplored in Canada. This study aimed at investigating the French-Canadian patients through phenotypic and genotypic characterization. METHOD Phenotype and demographic characterization were done for 12 affected individuals belonging to eight unrelated families. Samples from 11 cases were analyzed in a molecular clinical laboratory, and muscle biopsies were reviewed for two individuals with a limb-girdle muscle dystrophy. RESULTS The clinical phenotype was similar to that observed in European Caucasian populations but differed in the non-endocrine spectrum from the American-reported series of cases. Two cases exhibited a limb-girdle muscle dystrophy, and we found preliminary evidence of a mitochondrial dysfunction, since all three biopsies examined showed COX-deficient fibers in excess of what would be expected for age. Electron microscopy showed mitochondrial accumulation without abnormal cristea or inclusions. The c.1616C > T variant in the AIRE gene was responsible for 100% of APECED cases in the French-Canadian population of Saguenay-Lac-Saint-Jean in Quebec, Canada. CONCLUSIONS We report the first series of French-Canadian cases affected with APECED. The Saguenay-Lac-Saint-Jean region was uncovered as a new founder population for this condition. Muscle biopsy findings expanded the range of previously described APECED-related myopathology. Long term follow-up of our genetically homogeneous French-Canadian cases may help determine if the c.1616C > T variant increases the risk of muscle involvement. A neonatal screening program is under consideration to prevent undesired life-threatening endocrine manifestations.
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Affiliation(s)
- Tania Cruz Marino
- Department of Laboratory Medicine, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada.
| | - Hélène Villeneuve
- Department of Endocrinology, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Josianne Leblanc
- Department of Laboratory Medicine, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Caroline Duranceau
- Department of Endocrinology, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Philippe Caron
- Department of Endocrinology, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Charles Morin
- Department of Pediatrics, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Marcel Milot
- Department of Pediatrics, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Raphaëlle Chrétien
- Department of Pediatrics, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Maude-Marie Gagnon
- Clinique des Maladies Neuromusculaires, CIUSSS Saguenay-Lac-St-Jean, Saguenay, QC, Canada
| | - Jean Mathieu
- Department of Neurology, Université de Sherbrooke, QC, Sherbrooke, Canada
| | - Benjamin Ellezam
- Department of Pathology, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Daniela Buhas
- Division of Medical Genetics, Department of Specialized Medicine; Department of Human Genetics, McGill University, Montreal, QC, Canada
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Borchers J, Mäkitie O, Jääskeläinen J, Laakso S. Recurrent Hypokalemia and Adrenal Steroids in Patients With APECED. Front Endocrinol (Lausanne) 2022; 13:904507. [PMID: 35813662 PMCID: PMC9256963 DOI: 10.3389/fendo.2022.904507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/09/2022] [Indexed: 12/02/2022] Open
Abstract
CONTEXT Hypokalemia is a common finding in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) but its exact cause often remains unknown. OBJECTIVE To explore the prevalence and etiology of hypokalemia and the role of adrenal steroids therein in a cohort of patients with APECED. METHODS We performed a cross-sectional assessment and retrospective data collection on 44 Finnish patients with APECED to identify subjects with episodes of hypokalemia. Also 68 healthy matched controls attended the cross-sectional evaluation. Factors associating with a tendency for hypokalemia were analyzed by reviewing medical records during 1960-2021 and performing a cross-sectional analysis of serum adrenal steroids. RESULTS In total 14 of the 44 APECED patients (32%) had episodes of hypokalemia; 2 presented with hypokalemia at cross-sectional evaluation and 12 had a history of hypokalemia before the cross-sectional evaluation. Hypokalemic episodes started at the median age of 14.1 years; 12/14 (86%) had primary adrenal insufficiency (PAI). The median number of hypokalemic periods per year was 0.3 (range 0.04-2.2); the frequency correlated positively with the number of clinical APECED manifestations at the time of cross-sectional evaluation (r=0.811, p<0.001). Etiologies of hypokalemia varied but episodes often occurred when new clinical manifestations developed and during hospitalizations. Three patients had kidney defects, also associated with electrolyte imbalances. Severity of hypokalemia varied (range 2.2-3.2 mmol/L), but no severe complications were observed. At cross-sectional evaluation, patients with PAI (n = 30) had significantly lower median plasma potassium and higher sodium concentration than controls, suggesting that fludrocortisone treatment contributed to hypokalemia. Detailed analysis of adrenal steroids provided no conclusive differences between patients with and without episodes of hypokalemia. CONCLUSIONS In APECED, hypokalemia is common and varies in terms of frequency, etiology, and severity. PAI and kidney disease predispose to hypokalemia. In addition, hypokalemic periods seem to be more common in patients with more severe phenotype of APECED.
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Affiliation(s)
- Joonatan Borchers
- Children’s Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- *Correspondence: Joonatan Borchers,
| | - Outi Mäkitie
- Children’s Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Jarmo Jääskeläinen
- Kuopio Pediatric Research Unit, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Saila Laakso
- Children’s Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Folkhälsan Institute of Genetics, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Mahajan R, Kamat D, Chatterjee D, Yadav J, Kumar R, Dayal D, De D, Handa S. Clinical and genetic characteristics of ectodermal dysplasia in four Indian children. Indian J Dermatol 2022; 67:54-57. [PMID: 35656251 PMCID: PMC9154163 DOI: 10.4103/ijd.ijd_406_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: Ectodermal dysplasias (EDs) affect structures derived from the ectoderm such as skin, its appendages, nail, and teeth. In this series, we describe four patients presenting with a clinical phenotype of dysplasia of one or more ectodermal structures who underwent next-generation sequencing for mutational analysis. Case Series: The clinical phenotype of three patients was hypohidrotic ectodermal dysplasia (HED) and one patient was diagnosed with autoimmune polyglandular syndrome (APS) type 1. Two patients with classical clinical features of X-linked HED (XLHED) had mutations in EDA gene; variant c.924+ 8C>G (5′ proximal splice site) and c.760C>T (p.Gln254Ter). Case 3 had clinical phenotype of HED with urticaria pigmentosa, which was confirmed on skin biopsy and immunohistochemistry. This patient was found to have mutation in C1orf172; c.449G>A (p.Arg150Gln) which has not been reported previously. Case 4 was diagnosed to have APS type 1 with cutaneous features of discoloration of teeth and chronic mucocutaneous candidiasis. This patient had a compound heterozygous mutation of AIRE gene. The two variants detected were c.169C>T (p.Gln57Ter) and c.47C>T (p.Thr16Met). Conclusion: The present series highlights the clinic-genetic correlation in four patients with features of ED. Two variants of uncertain significance and two previously unreported variants were also found in this study.
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Garelli S, Dalla Costa M, Sabbadin C, Barollo S, Rubin B, Scarpa R, Masiero S, Fierabracci A, Bizzarri C, Crinò A, Cappa M, Valenzise M, Meloni A, De Bellis AM, Giordano C, Presotto F, Perniola R, Capalbo D, Salerno MC, Stigliano A, Radetti G, Camozzi V, Greggio NA, Bogazzi F, Chiodini I, Pagotto U, Black SK, Chen S, Rees Smith B, Furmaniak J, Weber G, Pigliaru F, De Sanctis L, Scaroni C, Betterle C. Autoimmune polyendocrine syndrome type 1: an Italian survey on 158 patients. J Endocrinol Invest 2021; 44:2493-2510. [PMID: 34003463 PMCID: PMC8502131 DOI: 10.1007/s40618-021-01585-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Autoimmune Polyglandular Syndrome type 1 (APS-1) is a rare recessive inherited disease, caused by AutoImmune Regulator (AIRE) gene mutations and characterized by three major manifestations: chronic mucocutaneous candidiasis (CMC), chronic hypoparathyroidism (CH) and Addison's disease (AD). METHODS Autoimmune conditions and associated autoantibodies (Abs) were analyzed in 158 Italian patients (103 females and 55 males; F/M 1.9/1) at the onset and during a follow-up of 23.7 ± 15.1 years. AIRE mutations were determined. RESULTS The prevalence of APS-1 was 2.6 cases/million (range 0.5-17 in different regions). At the onset 93% of patients presented with one or more components of the classical triad and 7% with other components. At the end of follow-up, 86.1% had CH, 77.2% AD, 74.7% CMC, 49.5% premature menopause, 29.7% autoimmune intestinal dysfunction, 27.8% autoimmune thyroid diseases, 25.9% autoimmune gastritis/pernicious anemia, 25.3% ectodermal dystrophy, 24% alopecia, 21.5% autoimmune hepatitis, 17% vitiligo, 13.3% cholelithiasis, 5.7% connective diseases, 4.4% asplenia, 2.5% celiac disease and 13.9% cancer. Overall, 991 diseases (6.3 diseases/patient) were found. Interferon-ω Abs (IFNωAbs) were positive in 91.1% of patients. Overall mortality was 14.6%. The AIRE mutation R139X was found in 21.3% of tested alleles, R257X in 11.8%, W78R in 11.4%, C322fsX372 in 8.8%, T16M in 6.2%, R203X in 4%, and A21V in 2.9%. Less frequent mutations were present in 12.9%, very rare in 9.6% while no mutations in 11% of the cases. CONCLUSIONS In Italy, APS-1 is a rare disorder presenting with the three major manifestations and associated with different AIRE gene mutations. IFNωAbs are markers of APS-1 and other organ-specific autoantibodies are markers of clinical, subclinical or potential autoimmune conditions.
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Affiliation(s)
- S Garelli
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
- Unit of Internal Medicine, Ospedale dell'Angelo, Mestre-Venice, Italy
| | - M Dalla Costa
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
- Unit of Internal Medicine, Ospedale di Feltre, Belluno, Italy
| | - C Sabbadin
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - S Barollo
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - B Rubin
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - R Scarpa
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - S Masiero
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - A Fierabracci
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Bizzarri
- Endocrine Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - A Crinò
- Endocrine Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - M Cappa
- Endocrine Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - M Valenzise
- Unit of Pediatrics, Department of Adulthood and Childhood Human Pathology, University of Messina, Messina, Italy
| | - A Meloni
- Ospedale Microcitemico and Dipartimento di Scienze Biomediche e Biotecnologiche, University of Cagliari, Cagliari, Italy
| | - A M De Bellis
- Unit of Endocrinology and Metabolic Diseases, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - C Giordano
- Endocrine Unit, Department of Biomedical Internal and Specialist Medicine (DIBIMIS), Palermo University, Palermo, Italy
| | - F Presotto
- Unit of Internal Medicine, Ospedale dell'Angelo, Mestre-Venice, Italy
| | - R Perniola
- Department of Pediatrics, Regional Hospital Vito Fazzi, Lecce, Italy
| | - D Capalbo
- Department of Mother and Child, University Federico II, Naples, Italy
| | - M C Salerno
- Pediatric Section, Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - A Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - G Radetti
- Marienklinik, General Hospital, Bolzano, Italy
| | - V Camozzi
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - N A Greggio
- EU-Endo-ERN Advisory Board Member, National Coordinator Endo-ERN Pediatric (SIEDP), Padua, Italy
| | - F Bogazzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - I Chiodini
- Unit of Bone Metabolism Diseases and Diabetes, Istituto Auxologico Italiano, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - U Pagotto
- Unit of Endocrinology and Prevention and Care of Diabetes, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - S K Black
- FIRS Laboratories RSR Ltd, Cardiff, UK
| | - S Chen
- FIRS Laboratories RSR Ltd, Cardiff, UK
| | | | | | - G Weber
- Unit of Pediatrics, Vita-Salute San Raffaele University, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - F Pigliaru
- Endocrine Unit, Azienda Ospedaliera-Universitaria of Cagliari, Cagliari, Italy
| | - L De Sanctis
- Pediatric Endocrinology, Department of Public Health and Pediatric Sciences, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - C Scaroni
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy.
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11
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Capra AP, Chiara E, Briuglia S. Autoimmune hepatitis in genetic syndromes: A literature review. World J Hepatol 2021; 13:1328-1340. [PMID: 34786169 PMCID: PMC8568577 DOI: 10.4254/wjh.v13.i10.1328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/25/2021] [Accepted: 09/06/2021] [Indexed: 02/06/2023] Open
Abstract
Genetic syndromes represent relevant and rare diseases. These conditions include a large amount of epidemiological, pathogenetic and clinical features. However, a systematic approach to genetic syndromes is often prevented by the rareness of these diseases. So, although clinical features are usually precisely defined, nowadays more uncommon associations between genetic syndromes and internal medicine related diseases have been insufficiently studied. Autoimmune hepatitis (AIH) is a chronic liver disease caused by loss of tolerance to hepatocyte-specific auto-antigens. Conversely, a better knowledge about specific genetic syndromes in which AIH is more frequent could be important in the clinical management of patients, both for an early diagnosis and for a prompt therapy. Furthermore, a systematic approach could explain if onset, clinical course, and response to treatment of AIH are typical for specific genetic syndromes. We took in consideration all the scientific articles reported in PubMed in the last 10 years, from 2010 to 2020. The purpose of this review is to explore the prevalence of AIH in genetic syndrome, but also to suggest new classification, that could be useful for pathogenetic hypothesis and clinical approach to genetic syndrome. From the 139 publications selected using keywords “autoimmune hepatitis” and “genetic syndrome”, 30 papers (21.6%) respected the chosen inclusion criteria, reporting the association between AIH in patients with a genetic syndrome. We have collected in all 47 patients with AIH and genetic syndrome, and with median age of 12.6-year-old. We suggest that when a patient presents a clinical picture of cryptogenic chronic hepatitis, that is unexplained, it is useful to explore differential diagnosis of AIH associated with genetic syndrome. Given the clinical relevance of this topic, further reports are needed to demonstrate our hypothesis and collect new evidence in this field.
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Affiliation(s)
- Anna Paola Capra
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina 98100, Italy
| | - Emanuele Chiara
- Department of Clinical Pathology, University of Messina, Messina 98100, Italy
| | - Silvana Briuglia
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina 98100, Italy
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12
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Peterson P, Kisand K, Kluger N, Ranki A. Loss of AIRE-Mediated Immune Tolerance and the Skin. J Invest Dermatol 2021; 142:760-767. [PMID: 34535292 DOI: 10.1016/j.jid.2021.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 02/08/2023]
Abstract
The core function of the immune response is to distinguish between self and foreign. The multiorgan human autoimmune disease, autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED/autoimmune polyendocrine syndrome type 1) is an example of what happens in the body when central immune tolerance goes astray. APECED revealed the existence and function of the autoimmune regulator gene, which has a central role in the development of tolerance. The discovery of autoimmune regulator was the start of a new period in immunology and in understanding the role of central and peripheral tolerance, also very relevant to many skin diseases as we highlight in this review.
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Affiliation(s)
- Pärt Peterson
- Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Kai Kisand
- Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Nicolas Kluger
- Department of Dermatology, Allergology and Venereology, Clinicum, University of Helsinki, and Inflammation Center, Helsinki University Hospital, Helsinki, Finland
| | - Annamari Ranki
- Department of Dermatology, Allergology and Venereology, Clinicum, University of Helsinki, and Inflammation Center, Helsinki University Hospital, Helsinki, Finland.
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13
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Sánchez-Borges M, Ansotegui IJ, Baiardini I, Bernstein J, Canonica GW, Ebisawa M, Gomez RM, González-Diaz S, Martin B, Morais de Almeida M, Ortega Martell JA. The challenges of chronic urticaria part 2: Pharmacological treatment, chronic inducible urticaria, urticaria in special situations. World Allergy Organ J 2021; 14:100546. [PMID: 34141049 PMCID: PMC8188551 DOI: 10.1016/j.waojou.2021.100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/22/2021] [Accepted: 04/21/2021] [Indexed: 11/29/2022] Open
Abstract
This is Part 2 of an updated follow-up review of the World Allergy Organization (WAO) position paper on the diagnosis and treatment of urticaria and angioedema. Since that document was published, new advances in the understanding of the pathogenesis of chronic urticaria, and greater experience with the use of biologics in patients with severe refractory disease, mainly omalizumab, have been gained. For these reasons, WAO decided to initiate an update targeted to general practitioners around the world, incorporating the most recent information on epidemiology, immunopathogenesis, comorbidities, quality of life, clinical case presentations, and the management of chronic spontaneous and chronic inducible urticaria, and urticaria in special situations such as childhood and pregnancy. A special task force of WAO experts was invited to write the different sections of the manuscript, and the final document was approved by the WAO Board of Directors. This paper is not intended to be a substitute for current national and international guidelines on the management of urticaria and angioedema, but to provide an updated simplified guidance for physicians around the world who have to manage patients with this common ailment.
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Affiliation(s)
- Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Clínica El Avila, Caracas, Venezuela
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quirónsalud Bizkaia, Bilbao, Spain
| | - Ilaria Baiardini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Jonathan Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati, USA
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | | | - Sandra González-Diaz
- Regional Center for Allergy and Clinical Immunology, Faculty of Medicine and “Dr. José Eleuterio González" University Hospital, Autonomous University of Nuevo León, Monterrey, Mexico
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Sanjeevi A, Asirvatham AR, Balachandran K, Mahadevan S. Atypical presentation of autoimmune polyglandular syndrome type 1 in the fifth decade. BMJ Case Rep 2021; 14:14/4/e241680. [PMID: 33906891 PMCID: PMC8076946 DOI: 10.1136/bcr-2021-241680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 45-year-old woman presented to us with a short-term history of nausea, vomiting and giddiness. On arrival at our hospital, examination revealed postural hypotension. Fluid resuscitation with intravenous normal saline was commenced. She also had chronic mucocutaneous candidiasis and nail changes suggestive of ectodermal dystrophy. Detailed history taking revealed that she had never attained menarche. Serum biochemistries showed hyponatraemia, hyperkalaemia, and hypocalcaemia (sodium, 127 mEq/L; potassium, 6 mEq/L; and albumin-corrected calcium, 6 mg/dL). Adrenocorticotropic hormone-stimulated cortisol (16.7 mcg/dL) was suboptimal favouring adrenal insufficiency. She was started on hydrocortisone and fludrocortisone supplementation. Additionally, the parathyroid hormone was inappropriately low (3.8 pg/mL) confirming hypoparathyroidism. Oral calcium and active vitamin D supplementation were added. With the above clinical and biochemical picture, namely, clustering of primary amenorrhoea, adrenal insufficiency and hypoparathyroidism, the diagnosis pointed towards autoimmune polyglandular syndrome. Genetic workup revealed a deletion in exon 8 of the autoimmune regulator gene confirming the diagnosis of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy/autoimmune polyglandular syndrome type 1 .
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Affiliation(s)
- Aditya Sanjeevi
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | | | - Karthik Balachandran
- Endocrinology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Shriraam Mahadevan
- Endocrinology, Sri Ramachandra University Medical College, Chennai, Tamil Nadu, India
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15
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Fierabracci A, Arena A, Toto F, Gallo N, Puel A, Migaud M, Kumar M, Chengappa KG, Gulati R, Negi VS, Betterle C. Autoimmune polyendocrine syndrome type 1 (APECED) in the Indian population: case report and review of a series of 45 patients. J Endocrinol Invest 2021; 44:661-677. [PMID: 32767280 DOI: 10.1007/s40618-020-01376-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Autoimmune polyendocrinopathy-candidiasis-ectodermal-dystrophy (APECED) or autoimmune polyglandular syndrome type 1 (APS-1) is a rare autosomal recessive genetic disease due to mutations in the AIRE (AutoImmune REgulator) gene. The clinical diagnosis is classically based on the presence of at least two of the three main components: chronic mucocutaneous candidiasis, hypoparathyroidism and primary adrenal insufficiency. Patients often suffer from other endocrine or non-endocrine autoimmune conditions throughout life. APECED etiopathogenesis is mediated by T lymphocytes. Autoantibodies against proteins of the affected organs are found in the serum of APECED patients as well as neutralizing antibodies against cytokines. We report here the clinical and genetic characteristics of 45 Indian APECED patients in comparison to Finnish, Sardinian, Turkish and North/South American cohorts from their published results. We also report a new case of APECED of Indian origin, a 2-year old child suffering from chronic mucocutaneous candidiasis since the age of 8 months, with confirmatory AIRE homozygous mutation c.274C > T (p.R92W). CONCLUSION With the inherent limitations of a retrospective study, analysis of Indian APECED patients suggested that compared to classic criteria, application of Ferre/Lionakis criteria validated in North/South American patients could help in earlier diagnosis in 3 of 8 (37.5%) patients for whom adequate information for evaluation was available.
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Affiliation(s)
- A Fierabracci
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - A Arena
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - F Toto
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - N Gallo
- Laboratory Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - A Puel
- Laboratory of Human Genetics of Infectious Diseases, INSERM UMR 1163, Imagine Institute, University of Paris, Paris, France
| | - M Migaud
- Laboratory of Human Genetics of Infectious Diseases, INSERM UMR 1163, Imagine Institute, University of Paris, Paris, France
| | - M Kumar
- Department of Clinical Immunology, JIPMER, Pondicherry, India
| | - K G Chengappa
- Department of Clinical Immunology, JIPMER, Pondicherry, India
| | - R Gulati
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - V S Negi
- Department of Clinical Immunology, JIPMER, Pondicherry, India
| | - C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
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16
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Borchers J, Pukkala E, Mäkitie O, Laakso S. Patients With APECED Have Increased Early Mortality Due to Endocrine Causes, Malignancies and infections. J Clin Endocrinol Metab 2020; 105:5809346. [PMID: 32185376 PMCID: PMC7150614 DOI: 10.1210/clinem/dgaa140] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/16/2020] [Indexed: 01/12/2023]
Abstract
CONTEXT Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is an autoimmune endocrinopathy with severe and unpredictable course. The impact of APECED on mortality has not been determined. OBJECTIVE To assess overall and cause-specific mortality of patients with APECED. DESIGN AND SETTING A follow-up study of Finnish patients with APECED from 1971 to 2018. Causes and dates of death were collected from Finnish registries. PATIENTS Ninety-one patients with APECED. MAIN OUTCOME MEASURE Overall and cause-specific standardized mortality ratios (SMRs) determined by comparing the observed numbers of death and those expected on the basis of respective population death rates in Finland. RESULTS The overall disease mortality was significantly increased (29 deaths, SMR 11; 95% confidence interval [CI] 7.2-16; P < 0.001). The relative risk (SMR) was highest in the youngest age groups but the absolute excess risk was similar (about 10 per 10 000 person-years) in all age categories. The highest SMRs were seen for endocrine and metabolic diseases (SMR 570; 95% CI, 270-1000; P < 0.001) and for oral and esophageal malignancies (SMR 170; 95% CI, 68-360; P < 0.001). Mortality was also increased for infections, diseases of digestive system, alcohol-related deaths, and for accidents. Due to the small number of cases we were unable to evaluate whether mortality was affected by disease severity. CONCLUSIONS Patients with APECED have significantly increased mortality in all age groups. Highest SMRs are found for causes that are directly related to APECED but also for infections. Increased alcohol- and accident-related deaths may be influenced by psychosocial factors.
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Affiliation(s)
- Joonatan Borchers
- Children’s Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Eero Pukkala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Finnish Cancer Registry – Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Outi Mäkitie
- Children’s Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Saila Laakso
- Children’s Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Correspondence and Reprint Requests: Saila Laakso, MD, PhD, PO. Box 347, 00029 HUS, Finland. E-mail:
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de Wit J, Brada RJK, van Veldhuizen J, Dalm VASH, Pasmans SGMA. Skin disorders are prominent features in primary immunodeficiency diseases: A systematic overview of current data. Allergy 2019; 74:464-482. [PMID: 30480813 DOI: 10.1111/all.13681] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/30/2018] [Accepted: 11/20/2018] [Indexed: 12/28/2022]
Abstract
Primary immunodeficiency diseases (PIDs) are characterized by an increased risk of infections, autoimmunity, autoinflammation, malignancy, and allergic disorders. Skin disorders are also common clinical features in PIDs and may be among the presenting manifestations. Recognition of specific PID-associated skin conditions in combination with other clinical features as described in the currently used warning signs could raise suspicion of an underlying PID. We aimed to provide a systematically obtained overview of skin disorders and their prevalence in PIDs. Secondary, the prevalence of Staphylococcus (S.) aureus-associated skin disorders and atopy was reviewed, as these are the most prominent skin features in PIDs. A systematic search was performed in EMBASE, MEDLINE, Web of Science, Cochrane, and Google Scholar (up to May 9, 2018). All original observational and experimental human studies that address the presence of skin disorders in PIDs were selected. We rated study quality using the Institute of Health Economics Quality Appraisal Checklist for Case Series Studies. Sixty-seven articles (5030 patients) were included. Study quality ranged from 18.2% to 88.5%. A broad spectrum of skin disorders was reported in 30 PIDs, mostly in single studies with a low number of included patients. An overview of associated PIDs per skin disorder was generated. Data on S. aureus-associated skin disorders and atopy in PIDs were limited. In conclusion, skin disorders are prominent features in PIDs. Through clustering of PIDs per skin disorder, we provide a support tool to use in clinical practice that should raise awareness of PIDs based on presenting skin manifestations.
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Affiliation(s)
- Jill de Wit
- Department of Dermatology; Erasmus MC University Medical Center; Rotterdam the Netherlands
| | - Romke J. K. Brada
- Department of Dermatology; Erasmus MC University Medical Center; Rotterdam the Netherlands
| | - Joyce van Veldhuizen
- Department of Dermatology; Erasmus MC University Medical Center; Rotterdam the Netherlands
| | - Virgil A. S. H. Dalm
- Department of Internal Medicine; Division of Clinical Immunology and Department of Immunology; Erasmus MC University Medical Center; Rotterdam the Netherlands
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18
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Naskali E, Dettmer K, Oefner PJ, Pereira PAB, Krohn K, Auvinen P, Ranki A, Kluger N. Serotonin and tryptophan metabolites, autoantibodies and gut microbiome in APECED. Endocr Connect 2019; 8:69-77. [PMID: 30608907 PMCID: PMC6365670 DOI: 10.1530/ec-18-0513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 01/04/2019] [Indexed: 12/28/2022]
Abstract
Objective Intestinal autoimmunity with gastrointestinal (GI) dysfunction has been shown in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). Patients lack entero-endocrine (EE) cells and have circulating autoantibodies (Aabs) against critical enzymes in serotonin (5-HT) biosynthesis. Design We sought to determine the serum levels of 5-HT, tryptophan (Trp) metabolites and L-DOPA in 37 Finnish APECED patients and to correlate their abundance with the presence of TPH and AADC Aabs, GI dysfunction and depressive symptoms. We also performed an exploratory analysis of the gut microbiome. Methods Serum 5-HT, L-DOPA and Trp metabolite levels were determined by liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS). TPH and AADC Aabs were measured by ELISA. Depression was assessed with a structured RBDI questionnaire. The V3-V4 regions of the bacterial 16S rRNA gene were sequenced for gut microbiome exploration. Results Serum 5-HT levels were significantly decreased (130 ± 131 nmol/L vs 686 ± 233 nmol/L, P < 0.0001) in APECED patients with TPH-1 (±AADC) Aabs compared to controls and patients with only AADC Aabs. Reduced 5-HT levels correlated with constipation. The genus Escherichia/Shigella was overrepresented in the intestinal microbiome. No correlation between serum Trp, 5-HT or l-DOPA levels and the RBDI total score, fatigue or sleep disorders was found. Conclusions This exploratory study found low serum levels of 5-HT to be associated with constipation and the presence of TPH-1 and AADC Aabs, but not with symptoms of depression. Hence, serum 5-HT, TPH1 and AADC Aabs should be determined in APECED patients presenting with GI symptoms.
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Affiliation(s)
- Emmi Naskali
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Helsinki University Central Hospital, Helsinki, Finland
| | - Katja Dettmer
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Peter J Oefner
- Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - Pedro A B Pereira
- Institute of Biotechnology, DNA Sequencing and Genomics Laboratory, University of Helsinki, Helsinki, Finland
| | - Kai Krohn
- Clinical Research Institute HUCH Ltd, Biomedicum Helsinki 1, Helsinki, Finland
| | - Petri Auvinen
- Institute of Biotechnology, DNA Sequencing and Genomics Laboratory, University of Helsinki, Helsinki, Finland
| | - Annamari Ranki
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Helsinki University Central Hospital, Helsinki, Finland
| | - Nicolas Kluger
- Department of Dermatology, Allergology and Venereology, University of Helsinki, and Helsinki University Central Hospital, Helsinki, Finland
- Correspondence should be addressed to N Kluger:
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Constantine GM, Lionakis MS. Lessons from primary immunodeficiencies: Autoimmune regulator and autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. Immunol Rev 2019; 287:103-120. [PMID: 30565240 PMCID: PMC6309421 DOI: 10.1111/imr.12714] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 08/19/2018] [Indexed: 12/12/2022]
Abstract
The discovery of the autoimmune regulator (AIRE) protein and the delineation of its critical contributions in the establishment of central immune tolerance has significantly expanded our understanding of the immunological mechanisms that protect from the development of autoimmune disease. The parallel identification and characterization of patient cohorts with the monogenic disorder autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), which is typically caused by biallelic AIRE mutations, has underscored the critical contribution of AIRE in fungal immune surveillance at mucosal surfaces and in prevention of multiorgan autoimmunity in humans. In this review, we synthesize the current clinical, genetic, molecular and immunological knowledge derived from basic studies in Aire-deficient animals and from APECED patient cohorts. We also outline major advances and research endeavors that show promise for informing improved diagnostic and therapeutic approaches for patients with APECED.
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Affiliation(s)
- Gregory M Constantine
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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Sanford E, Watkins K, Nahas S, Gottschalk M, Coufal NG, Farnaes L, Dimmock D, Kingsmore SF. Rapid whole-genome sequencing identifies a novel AIRE variant associated with autoimmune polyendocrine syndrome type 1. Cold Spring Harb Mol Case Stud 2018; 4:a002485. [PMID: 29437776 PMCID: PMC5983174 DOI: 10.1101/mcs.a002485] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022] Open
Abstract
Autoimmune polyendocrine syndrome type 1 (APS-1; OMIM #240300), also referred to as autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), is a rare monogenic autoimmune disorder caused by mutations in the autoimmune regulator (AIRE) gene. APS-1 is classically characterized by a triad of chronic mucocutaneous candidiasis, autoimmune hypoparathyroidism, and autoimmune adrenocortical insufficiency. We report a 5-yr-old female who presented with symptoms of tetany due to hypocalcemia and was subsequently found to be secondary to hypoparathyroidism. Rapid trio whole-genome sequencing revealed compound heterozygous variants in AIRE in the proband, with a paternally inherited, pathogenic, frameshift variant (c.1265delC; p.Pro422LeufsTer58) and a novel, likely pathogenic, maternally inherited missense variant (c.268T>C; p.Tyr90His).
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Affiliation(s)
- Erica Sanford
- Rady Children's Institute of Genomic Medicine, University of California, San Diego, San Diego, California 92123, USA
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, University of California, San Diego, San Diego, California 92161, USA
| | - Kelly Watkins
- Rady Children's Institute of Genomic Medicine, University of California, San Diego, San Diego, California 92123, USA
| | - Shareef Nahas
- Rady Children's Institute of Genomic Medicine, University of California, San Diego, San Diego, California 92123, USA
| | - Michael Gottschalk
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Diego, San Diego, California 92161, USA
| | - Nicole G Coufal
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, University of California, San Diego, San Diego, California 92161, USA
| | - Lauge Farnaes
- Rady Children's Institute of Genomic Medicine, University of California, San Diego, San Diego, California 92123, USA
| | - David Dimmock
- Rady Children's Institute of Genomic Medicine, University of California, San Diego, San Diego, California 92123, USA
| | - Stephen F Kingsmore
- Rady Children's Institute of Genomic Medicine, University of California, San Diego, San Diego, California 92123, USA
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21
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The immunobiology and clinical features of type 1 autoimmune polyglandular syndrome (APS-1). Autoimmun Rev 2018; 17:78-85. [DOI: 10.1016/j.autrev.2017.11.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 10/08/2017] [Indexed: 12/15/2022]
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Autoimmune comorbidity in chronic spontaneous urticaria: A systematic review. Autoimmun Rev 2017; 16:1196-1208. [PMID: 29037900 DOI: 10.1016/j.autrev.2017.10.003] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/05/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Numerous autoimmune diseases (AIDs) have been linked to chronic spontaneous urticaria (CSU). Here, we provide the first extensive and comprehensive evaluation of the prevalence of AIDs in patients with CSU and vice versa. METHODS A Pubmed and Google Scholar search was performed to identify studies reporting the prevalence of various AIDs in CSU and vice versa published before April 2017. RESULTS The prevalence of individual AIDs in CSU is increased (≥1% in most studies vs ≤1% in the general population). AIDs with relatively high prevalence in the general population are also quite common in CSU patients, whereas those with low prevalence remain a rare finding in CSU. The rates of comorbidity in most studies were ≥1% for insulin-dependent diabetes mellitus, rheumatoid arthritis (RA), psoriasis and celiac disease (CD), ≥2% for Graves' disease, ≥3% for vitiligo, and ≥5% for pernicious anemia and Hashimoto's thyroiditis. Organ-specific AIDs are more prevalent in CSU than systemic (multiorgan or non organ-specific) AIDs. >2% of CSU patients have autoimmune polyglandular syndromes encompassing autoimmune thyroid disease (ATD) and vitiligo or pernicious anemia. Antithyroid and antinuclear antibodies are the most prevalent AID-associated autoantibodies in CSU. >15% of CSU patients have a positive family history for AIDs. The prevalence of urticarial rash in AID patients is >1% in most studies. This rash is more prevalent in eosinophilic granulomatosis with polyangiitis, ATD, systemic lupus erythematosus, RA and CD. CONCLUSIONS CSU patients have an increased risk of AIDs, especially adult female patients and those with a positive family history and a genetic predisposition for AIDs, who should be screened for signs and symptoms of AIDs.
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