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Oprea Y, Antohi DR, Vague M, Delbourgo Patton C, Wu B, Ortega-Loayza AG. Human Inborn Errors of Immunity in Pyoderma Gangrenosum: A Systematic Review. Am J Clin Dermatol 2024:10.1007/s40257-024-00875-y. [PMID: 38951460 DOI: 10.1007/s40257-024-00875-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND AND OBJECTIVE Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic dermatosis that can be associated with primary immunodeficiency. The pathogenesis of PG has not yet been elucidated, although contributions from dysregulation of the immune system in patients with apparent genetic predispositions have been postulated. We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review with the objective of identifying inborn errors of immunity in the presence of PG as well as their clinical characteristics of severity including number of PG lesions and anatomic areas affected, and treatment outcomes. METHODS A literature search was performed using PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science through August 24, 2023, for studies published in English using the search terms: "pyoderma gangrenosum," "inborn error of immunity," "immune defect*," and a list of genetic mutations potentially associated with PG. RESULTS Seventy-four cases of PG associated with inborn errors of immunity were identified. The results demonstrate an association of PG with a variety of inborn errors of immunity, including genetic mutations not classically associated with the condition. Genetic mutations such as BTK, IL1RN, ITGB2, LPIN2, MEFV, NFkB1, NLRP3, NLRP12, NOD2, PSMB8, PLCG2, PSTPIP1, RAG1, TTC37, and WDR1, as well as complement component 2/complement component 4 (C2/C4) and complement component 7 (C7) deficiencies were identified in the presence of either idiopathic or syndromic PG. Of note, mutations in genes such as PSMB8, NLRP3, and IL1RN were found to be associated with a more severe and atypical course of PG, whereas mutations in RAG1 as well as those causing a C2/C4 deficiency were associated with the mildest clinical presentations of PG. Mutations in NFkB1, ITGB2, and PSTPIP1 were associated with the most heterogeneous clinical presentations. CONCLUSIONS Human inborn errors of immunity may be implicated in the genetic predisposition to PG and may influence the clinical presentation. Due to the rarity of these diseases, further work must be done to describe the association between inborn errors of immunity and PG. Identifying inborn errors of immunity that may contribute to the development of PG may assist in further elucidating the mechanism of PG, guiding targeted treatment, and improving clinical outcomes for these patients.
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Affiliation(s)
- Yasmine Oprea
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Daniel R Antohi
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Morgan Vague
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | | | - Benedict Wu
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA.
- OHSU Center for Health and Healing, 3303 S Bond Avenue, Building 1, 16th Floor, Portland, OR, 97239, USA.
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Sugiura K, Fujita H, Komine M, Yamanaka K, Akiyama M. The role of interleukin-36 in health and disease states. J Eur Acad Dermatol Venereol 2024. [PMID: 38779986 DOI: 10.1111/jdv.19935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/29/2024] [Indexed: 05/25/2024]
Abstract
The interleukin (IL)-1 superfamily upregulates immune responses and maintains homeostasis between the innate and adaptive immune systems. Within the IL-1 superfamily, IL-36 plays a pivotal role in both innate and adaptive immune responses. Of the four IL-36 isoforms, three have agonist activity (IL-36α, IL-36β, IL-36γ) and the fourth has antagonist activity (IL-36 receptor antagonist [IL-36Ra]). All IL-36 isoforms bind to the IL-36 receptor (IL-36R). Binding of IL-36α/β/γ to the IL-36R recruits the IL-1 receptor accessory protein (IL-1RAcP) and activates downstream signalling pathways mediated by nuclear transcription factor kappa B and mitogen-activated protein kinase signalling pathways. Antagonist binding of IL-36Ra to IL-36R inhibits recruitment of IL-1RAcP, blocking downstream signalling pathways. Changes in the balance within the IL-36 cytokine family can lead to uncontrolled inflammatory responses throughout the body. As such, IL-36 has been implicated in numerous inflammatory diseases, notably a type of pustular psoriasis called generalized pustular psoriasis (GPP), a chronic, rare, potentially life-threatening, multisystemic skin disease characterised by recurrent fever and extensive sterile pustules. In GPP, IL-36 is central to disease pathogenesis, and the prevention of IL-36-mediated signalling can improve clinical outcomes. In this review, we summarize the literature describing the biological functions of the IL-36 pathway. We also consider the evidence for uncontrolled activation of the IL-36 pathway in a wide range of skin (e.g., plaque psoriasis, pustular psoriasis, hidradenitis suppurativa, acne, Netherton syndrome, atopic dermatitis and pyoderma gangrenosum), lung (e.g., idiopathic pulmonary fibrosis), gut (e.g., intestinal fibrosis, inflammatory bowel disease and Hirschsprung's disease), kidney (e.g., renal tubulointerstitial lesions) and infectious diseases caused by a variety of pathogens (e.g., COVID-19; Mycobacterium tuberculosis, Pseudomonas aeruginosa, Streptococcus pneumoniae infections), as well as in cancer. We also consider how targeting the IL-36 signalling pathway could be used in treating inflammatory disease states.
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Affiliation(s)
- Kazumitsu Sugiura
- Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hideki Fujita
- Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Mayumi Komine
- Department of Dermatology, Faculty of Medicine, Jichi Medical University, Tochigi, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Masashi Akiyama
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Nurmi K, Silventoinen K, Keskitalo S, Rajamäki K, Kouri VP, Kinnunen M, Jalil S, Maldonado R, Wartiovaara K, Nievas EI, Denita-Juárez SP, Duncan CJA, Kuismin O, Saarela J, Romo I, Martelius T, Parantainen J, Beklen A, Bilicka M, Matikainen S, Nordström DC, Kaustio M, Wartiovaara-Kautto U, Kilpivaara O, Klein C, Hauck F, Jahkola T, Hautala T, Varjosalo M, Barreto G, Seppänen MRJ, Eklund KK. Truncating NFKB1 variants cause combined NLRP3 inflammasome activation and type I interferon signaling and predispose to necrotizing fasciitis. Cell Rep Med 2024; 5:101503. [PMID: 38593810 PMCID: PMC11031424 DOI: 10.1016/j.xcrm.2024.101503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/04/2024] [Accepted: 03/18/2024] [Indexed: 04/11/2024]
Abstract
In monogenic autoinflammatory diseases, mutations in genes regulating innate immune responses often lead to uncontrolled activation of inflammasome pathways or the type I interferon (IFN-I) response. We describe a mechanism of autoinflammation potentially predisposing patients to life-threatening necrotizing soft tissue inflammation. Six unrelated families are identified in which affected members present with necrotizing fasciitis or severe soft tissue inflammations. Exome sequencing reveals truncating monoallelic loss-of-function variants of nuclear factor κ light-chain enhancer of activated B cells (NFKB1) in affected patients. In patients' macrophages and in NFKB1-variant-bearing THP-1 cells, activation increases both interleukin (IL)-1β secretion and IFN-I signaling. Truncation of NF-κB1 impairs autophagy, accompanied by the accumulation of reactive oxygen species and reduced degradation of inflammasome receptor nucleotide-binding oligomerization domain, leucine-rich repeat-containing protein 3 (NLRP3), and Toll/IL-1 receptor domain-containing adaptor protein inducing IFN-β (TRIF), thus leading to combined excessive inflammasome and IFN-I activity. Many of the patients respond to anti-inflammatory treatment, and targeting IL-1β and/or IFN-I signaling could represent a therapeutic approach for these patients.
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Affiliation(s)
- Katariina Nurmi
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Kristiina Silventoinen
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Salla Keskitalo
- Systems Biology/Pathology Research Group, iCAN Digital Precision Cancer Medicine Flagship, Institute of Biotechnology, HiLIFE, UH, 00014 Helsinki, Finland
| | - Kristiina Rajamäki
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland; Department of Medical and Clinical Genetics, Applied Tumor Genomics Research Program, RPU, UH, 00014 Helsinki, Finland
| | - Vesa-Petteri Kouri
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Matias Kinnunen
- Systems Biology/Pathology Research Group, iCAN Digital Precision Cancer Medicine Flagship, Institute of Biotechnology, HiLIFE, UH, 00014 Helsinki, Finland
| | - Sami Jalil
- Clinical Genetics UH and Helsinki University Hospital (HUH), 00014 Helsinki, Finland
| | - Rocio Maldonado
- Clinical Genetics UH and Helsinki University Hospital (HUH), 00014 Helsinki, Finland
| | - Kirmo Wartiovaara
- Clinical Genetics UH and Helsinki University Hospital (HUH), 00014 Helsinki, Finland
| | | | | | - Christopher J A Duncan
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE1 4HH, UK
| | - Outi Kuismin
- Department of Clinical Genetics, Oulu University Hospital (OUH), 90014 Oulu, Finland; PEDEGO Research Unit and Medical Research Center Oulu, OUH and University of Oulu (OU), 90014 Oulu, Finland
| | - Janna Saarela
- Institute for Molecular Medicine Finland, HiLIFE, UH, 00014 Helsinki, Finland; Centre for Molecular Medicine Norway, University of Oslo, 0313 Oslo, Norway; Department of Medical Genetics, Oslo University Hospital, 0450 Oslo, Norway
| | - Inka Romo
- Inflammation Center, Department of Infectious Disease, HUH, 00029 Helsinki, Finland
| | - Timi Martelius
- Inflammation Center, Department of Infectious Disease, HUH, 00029 Helsinki, Finland
| | - Jukka Parantainen
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Arzu Beklen
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Marcelina Bilicka
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Sampsa Matikainen
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Dan C Nordström
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland; Department of Internal Medicine and Rehabilitation, HUH and UH, 00029 Helsinki, Finland
| | - Meri Kaustio
- Institute for Molecular Medicine Finland, HiLIFE, UH, 00014 Helsinki, Finland
| | - Ulla Wartiovaara-Kautto
- Department of Hematology, HUH, Comprehensive Cancer Center, UH, 00029 Helsinki, Finland; Applied Tumor Genomics Research Program, RPU, Faculty of Medicine, UH, 00014 Helsinki, Finland
| | - Outi Kilpivaara
- Applied Tumor Genomics Research Program, RPU, Faculty of Medicine, UH, 00014 Helsinki, Finland; Department of Medical and Clinical Genetics/Medicum, Faculty of Medicine, UH, 00014 Helsinki, Finland; iCAN Digital Precision Cancer Medicine Flagship, UH, 00014 Helsinki, Finland; HUS Diagnostic Center, HUSLAB Laboratory of Genetics, HUH, 00029 Helsinki, Finland
| | - Christoph Klein
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München, 80337 Munich, Germany
| | - Fabian Hauck
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München, 80337 Munich, Germany
| | - Tiina Jahkola
- Department of Plastic Surgery, HUH, 00029 Helsinki, Finland
| | - Timo Hautala
- Research Unit of Internal Medicine and Biomedicine, OU, and Infectious Diseases Clinic, OUH, 90014 Oulu, Finland
| | - Markku Varjosalo
- Systems Biology/Pathology Research Group, iCAN Digital Precision Cancer Medicine Flagship, Institute of Biotechnology, HiLIFE, UH, 00014 Helsinki, Finland
| | - Goncalo Barreto
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland
| | - Mikko R J Seppänen
- Adult Immunodeficiency Unit, Infectious Diseases, Inflammation Center, HUH and UH, 00029 Helsinki, Finland; Rare Disease Center, Children and Adolescents, HUH and UH, 00029 Helsinki, Finland.
| | - Kari K Eklund
- Faculty of Medicine, Clinicum, Translational Immunology Research Program, Research Program Unit (RPU), University of Helsinki (UH), 00014 Helsinki, Finland; Department of Rheumatology, HUH and UH, 00029 Helsinki, Finland; Orton Orthopaedic Hospital, 00280 Helsinki, Finland.
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Satoh TK. Genetic mutations in pyoderma gangrenosum, hidradenitis suppurativa, and associated autoinflammatory syndromes: Insights into pathogenic mechanisms and shared pathways. J Dermatol 2024; 51:160-171. [PMID: 38031879 DOI: 10.1111/1346-8138.17028] [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: 09/26/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
Pyoderma gangrenosum (PG), hidradenitis suppurativa (HS), and the associated autoinflammatory syndromes, including pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) syndrome, PSTPIP1-associated myeloid-related proteinemia inflammatory (PAMI) syndrome, pyoderma gangrenosum, acne, and hidradenitis suppurativa (PASH) syndrome, and pyogenic arthritis, pyoderma gangrenosum, acne, and suppurative hidradenitis (PAPASH) syndrome are dermatological conditions characterized by chronic inflammation and tissue damage. Recent advances in genetic research have identified specific mutations associated with these disorders, shedding light on their underlying pathogenic mechanisms. This review aims to summarize the current knowledge of identified mutations and presumed pathophysiology in PG, HS, and the associated autoinflammatory syndromes.
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Affiliation(s)
- Takashi K Satoh
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
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5
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Oprea Y, Kody S, Shakshouk H, Greiling TM, Anstey KM, Ortega-Loayza AG. What can inherited immunodeficiencies reveal about pyoderma gangrenosum? Exp Dermatol 2024; 33:e14954. [PMID: 37846943 PMCID: PMC10841371 DOI: 10.1111/exd.14954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/14/2023] [Accepted: 10/05/2023] [Indexed: 10/18/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic dermatosis that is occasionally associated with primary immunodeficiency. Though contributions from dysregulation of the innate immune system, neutrophil dysfunction and genetic predisposition have been postulated, the precise pathogenesis of PG has not yet been elucidated. This article reviews reported cases of coexisting PG and primary immunodeficiency in order to gain insight into the complex pathophysiology of PG. Our findings suggest that variations in genes such as RAG1, ITGB2, IRF2BP2 and NFκB1 might play a role in genetically predisposing patients to develop PG. These studies support the feasibility of the role of somatic gene variation in the pathogenesis of PG which warrants further exploration to guide targeted therapeutics.
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Affiliation(s)
- Yasmine Oprea
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Hadir Shakshouk
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Dermatology and Andrology, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Teri M Greiling
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Karen M Anstey
- Department of Medicine, Section of Allergy and Clinical Immunology, Oregon Health & Science University, Portland, Oregon, USA
| | - Alex G. Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
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6
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Santaniemi W, Åström P, Glumoff V, Pernaa N, Tallgren EN, Palosaari S, Nissinen A, Kaustio M, Kuismin O, Saarela J, Nurmi K, Eklund KK, Seppänen MRJ, Hautala T. Inflammation and Neutrophil Oxidative Burst in a Family with NFKB1 p.R157X LOF and Sterile Necrotizing Fasciitis. J Clin Immunol 2023; 43:1007-1018. [PMID: 36892687 PMCID: PMC10276129 DOI: 10.1007/s10875-023-01461-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Abstract
Loss-of-function (LOF) mutations in NFKB1, coding for p105, may cause common variable immunodeficiency due to dysregulation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κΒ) pathway. Monoallelic LOF variants of NFKB1 can predispose to uncontrolled inflammation including sterile necrotizing fasciitis or pyoderma gangrenosum. In this study, we explored the impact of a heterozygous NFKB1 c.C936T/p.R157X LOF variant on immunity in sterile fasciitis patients and their family members. The p50 or p105 protein levels were reduced in all variant carriers. Interleukin-1β (IL-1β) and interleukin-8 (IL-8) levels were elevated in vitro, potentially contributing to the very high neutrophil counts observed during fasciitis episodes. Phosphorylation of p65/RelA was reduced in p.R157X neutrophils suggesting defective activation of canonical NF-κB. Oxidative burst after NF-κB-independent phorbol 12-myristate 13-acetate (PMA) stimulation was similar in both p.R157X and control neutrophils. Comparable amounts of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex subunits were found in p.R157X and control neutrophils. However, a compromised oxidative burst was observed in p.R157X neutrophils following activation of NF-κB-dependent mechanisms following stimulation of toll-like receptor 2 (TLR2) and Dectin-1. Neutrophil extracellular trap formation was not affected by p.R157X. In summary, the NFKB1 c.C936T/p.R157X LOF variant has an impact on inflammation and neutrophil function and may play a role in the pathogenesis of sterile necrotizing fasciitis.
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Affiliation(s)
| | - Pirjo Åström
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
- Biocenter Oulu, University of Oulu, Oulu, Finland
| | - Virpi Glumoff
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
| | - Nora Pernaa
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
| | | | - Sanna Palosaari
- Cancer and Translational Medicine Research Unit, University of Oulu, Oulu, Finland
| | - Antti Nissinen
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland
| | - Meri Kaustio
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Outi Kuismin
- Department of Clinical Genetics, Oulu University Hospital, Oulu, Finland
| | - Janna Saarela
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
- Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
| | - Katariina Nurmi
- Faculty of Medicine, Clinicum, Translational Immunology Program, University of Helsinki, Helsinki, Finland
| | - Kari K Eklund
- Department of Rheumatology, Inflammation Center, University of Helsinki and Helsinki University Hospital and Orton Orthopedic Hospital, Helsinki, Finland
| | - Mikko R J Seppänen
- Adult Immunodeficiency Unit, Infectious Diseases, Inflammation Center, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- Rare Disease Center and Pediatric Research Center, Children and Adolescents, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Timo Hautala
- Research Unit of Biomedicine, University of Oulu, Oulu, Finland.
- Infectious Diseases, Oulu University Hospital, Oulu, Finland.
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Bhattacharya S, Basu S, Sheng E, Murphy C, Wei J, Kersh AE, Nelson CA, Bryer JS, Ashchyan HA, Steele K, Forrestel A, Seykora JT, Micheletti RG, James WD, Rosenbach M, Leung TH. Identification of a neutrophil-specific PIK3R1 mutation facilitates targeted treatment in a patient with Sweet syndrome. J Clin Invest 2023; 133:162137. [PMID: 36355435 PMCID: PMC9797331 DOI: 10.1172/jci162137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/26/2022] [Indexed: 11/12/2022] Open
Abstract
BackgroundAcute febrile neutrophilic dermatosis (Sweet syndrome) is a potentially fatal multiorgan inflammatory disease characterized by fever, leukocytosis, and a rash with a neutrophilic infiltrate. The disease pathophysiology remains elusive, and current dogma suggests that Sweet syndrome is a process of reactivity to an unknown antigen. Corticosteroids and steroid-sparing agents remain frontline therapies, but refractory cases pose a clinical challenge.MethodsA 51-year-old woman with multiorgan Sweet syndrome developed serious corticosteroid-related side effects and was refractory to steroid-sparing agents. Blood counts, liver enzymes, and skin histopathology supported the diagnosis. Whole-genome sequencing, transcriptomic profiling, and cellular assays of the patient's skin and neutrophils were performed.ResultsWe identified elevated IL-1 signaling in lesional Sweet syndrome skin caused by a PIK3R1 gain-of-function mutation specifically found in neutrophils. This mutation increased neutrophil migration toward IL-1β and neutrophil respiratory burst. Targeted treatment of the patient with an IL-1 receptor 1 antagonist resulted in a dramatic therapeutic response and enabled a tapering off of corticosteroids.ConclusionDysregulated PI3K/AKT signaling is the first signaling pathway linked to Sweet syndrome and suggests that this syndrome may be caused by acquired mutations that modulate neutrophil function. Moreover, integration of molecular data across multiple levels identified a distinct subtype within a heterogeneous disease that resulted in a rational and successful clinical intervention. Future patients will benefit from efforts to identify potential mutations. The ability to directly interrogate the diseased skin allows this method to be generalizable to other inflammatory diseases and demonstrates a potential personalized medicine approach for patients with clinically challenging disease.Funding SourcesBerstein Foundation, NIH, Veterans Affairs (VA) Administration, Moseley Foundation, and H.T. Leung Foundation.
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Affiliation(s)
- Shreya Bhattacharya
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Sayon Basu
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Emily Sheng
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Christina Murphy
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Jenny Wei
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Anna E. Kersh
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Caroline A. Nelson
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Joshua S. Bryer
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Hovik A. Ashchyan
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Katherine Steele
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Amy Forrestel
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - John T. Seykora
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Robert G. Micheletti
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - William D. James
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Misha Rosenbach
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
| | - Thomas H. Leung
- Dermatology Department, Perelman School of Medicine, University of Pennsylvania; Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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Dealing with Corticosteroid and High-Dose Cyclosporine Therapy in a Pyoderma Gangrenosum Patient Contracting a COVID-19 Infection. J Pers Med 2022; 12:jpm12020173. [PMID: 35207660 PMCID: PMC8875703 DOI: 10.3390/jpm12020173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/13/2022] [Accepted: 01/24/2022] [Indexed: 12/11/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare and chronic neutrophil inflammation belonging to the spectrum of autoinflammatory disorders. Immunosuppressive therapy is the cornerstone of successful treatment. However, due to the global COVID-19 pandemic, physicians struggle with therapeutic strategies during infection. This paper describes the case of a 58-year-old patient with a very painful, rapidly increasing wound on his right foot, which was diagnosed as pyoderma gangrenosum. Five weeks after the initial treatment with high-dose immunosuppressives (combination therapy with cyclosporine A and systemic methylprednisolone), he became infected with COVID-19. Reduction in the immunosuppressive dosage proved effective, as the patient recovered from COVID-19 without any complication and showed rapid wound healing.
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9
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Sun Q, Gehlhausen JR, Freudzon M, Kibbi N, Bale A, Choate K, Tomayko M, Odell I, Ramachandran S. A novel NFkB1 mutation linking pyoderma gangrenosum and common variable immunodeficiency. JAAD Case Rep 2021; 18:61-63. [PMID: 34825039 PMCID: PMC8605275 DOI: 10.1016/j.jdcr.2021.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Qisi Sun
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Correspondence to: Qisi Sun, MD, Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02120.
| | - Jeff R. Gehlhausen
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Marianna Freudzon
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Nour Kibbi
- Department of Dermatology, Stanford University School of Medicine, Stanford, California
| | - Allen Bale
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
| | - Keith Choate
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Mary Tomayko
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Ian Odell
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Sarika Ramachandran
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
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