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Bagyinszky E, An SSA. Genetic Mutations Associated With TNFAIP3 (A20) Haploinsufficiency and Their Impact on Inflammatory Diseases. Int J Mol Sci 2024; 25:8275. [PMID: 39125844 PMCID: PMC11311569 DOI: 10.3390/ijms25158275] [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: 06/13/2024] [Revised: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
TNF-α-induced protein 3 (TNFAIP3), commonly referred to as A20, is an integral part of the ubiquitin-editing complex that significantly influences immune regulation, apoptosis, and the initiation of diverse immune responses. The A20 protein is characterized by an N-terminal ovarian tumor (OTU) domain and a series of seven zinc finger (ZNF) domains. Mutations in the TNFAIP3 gene are implicated in various immune-related diseases, such as Behçet's disease, polyarticular juvenile idiopathic arthritis, autoimmune thyroiditis, autoimmune hepatitis, and rheumatoid arthritis. These mutations can lead to a spectrum of symptoms, including, but not limited to, recurrent fever, ulcers, rashes, musculoskeletal and gastrointestinal dysfunctions, cardiovascular issues, and respiratory infections. The majority of these mutations are either nonsense (STOP codon) or frameshift mutations, which are typically associated with immune dysfunctions. Nonetheless, missense mutations have also been identified as contributors to these conditions. These genetic alterations may interfere with several biological pathways, notably abnormal NF-κB signaling and dysregulated ubiquitination. Currently, there is no definitive treatment for A20 haploinsufficiency; however, therapeutic strategies can alleviate the symptoms in patients. This review delves into the mutations reported in the TNFAIP3 gene, the clinical progression in affected individuals, potential disease mechanisms, and a brief overview of the available pharmacological interventions for A20 haploinsufficiency. Mandatory genetic testing of the TNFAIP3 gene should be performed in patients diagnosed with autoinflammatory disorders to better understand the genetic underpinnings and guide treatment decisions.
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Affiliation(s)
- Eva Bagyinszky
- Graduate School of Environment Department of Industrial and Environmental Engineering, Gachon University, Seongnam 13120, Republic of Korea
| | - Seong Soo A. An
- Department of Bionano Technology, Gachon Medical Research Institute, Gachon University, Seongnam 13120, Republic of Korea
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Elhani I, Aouba A, Riller Q, Vergneault H, Boursier G, Rieux-Laucat F, Hentgen V, Georgin-Lavialle S. [A20 haploinsufficiency: what do clinicians need to know?]. Rev Med Interne 2024; 45:415-422. [PMID: 38160098 DOI: 10.1016/j.revmed.2023.12.004] [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: 08/07/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
A20 Haploinsufficiency (HA20) is a monogenic autoinflammatory disease associated with an autosomal dominant mutation in the TNFAIP3 gene. It induces a defect in the inactivation of the pro-inflammatory NF-κB pathway. Less than 200 cases have been described worldwide. The clinical picture of the disease is essentially based on the association of recurrent fever and/or biologic inflammatory syndrome, aphtosis, often bipolar, and cutaneous folliculitis. However, the clinical spectrum of HA20 is very broad, including gastrointestinal (mainly colonic ulceration), articular, cutaneous, pericardial and lymph node involvement, as well as frequent association with organ-specific or non-specific autoimmune manifestations and/or autoantibodies, including antinuclear antibodies and anti-dsDNA. As a result, the diagnosis of a number of systemic or organic disorders, most notably Behçet's disease, Crohn's disease, and sometimes even systemic lupus, has been corrected to HA20 by molecular research for a heterozygous mutation with functional deficiency of TNFAIP3. Although the first signs of the disease often appear in the first years of life, the diagnosis is often made in adulthood and requires the involvement of both paediatric and adult physicians. Treatment for HA20 is not codified and relies on conventional or biological immunomodulators and immunosuppressants adapted to the patient's symptomatology. This review highlights the enormous diagnostic challenges in this autoinflammatory disease.
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Affiliation(s)
- I Elhani
- Centre de référence des maladies auto-inflammatoires rares et des amyloses, service de pédiatrie générale, hôpital de Versailles, Versailles, France; Sorbonne université, centre de recherche Saint-Antoine (CRSA) INSERM UMRS-938.
| | - A Aouba
- Département de médecine Interne et immunologie clinique, Normandie Univ, UNICAEN, UR4650 PSIR, CHU de Caen Normandie, Caen, France
| | - Q Riller
- Université Paris Cité, Institut Imagine, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, 75015 Paris, France
| | - H Vergneault
- AP-HP, hôpital Tenon, Service de médecine interne, Paris, France
| | - G Boursier
- Centre national de référence des maladies auto-inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Montpellier, France; Laboratoire de Génétique des Maladies rares et autoinflammatoires, Service de Génétique moléculaire et cytogénomique, CHU Montpellier, Univ Montpellier, Montpellier, France
| | - F Rieux-Laucat
- Université Paris Cité, Institut Imagine, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, 75015 Paris, France
| | - V Hentgen
- Centre de référence des maladies auto-inflammatoires rares et des amyloses, service de pédiatrie générale, hôpital de Versailles, Versailles, France
| | - S Georgin-Lavialle
- Sorbonne université, centre de recherche Saint-Antoine (CRSA) INSERM UMRS-938; AP-HP, hôpital Tenon, Service de médecine interne, Paris, France.
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Elhani I, Riller Q, Boursier G, Hentgen V, Rieux-Laucat F, Georgin-Lavialle S. A20 Haploinsufficiency: A Systematic Review of 177 Cases. J Invest Dermatol 2024; 144:1282-1294.e8. [PMID: 38128752 DOI: 10.1016/j.jid.2023.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 12/04/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
A20 haploinsufficiency is an autoinflammatory disease caused by defective inactivation of the NF-κB pathway. We conducted a systematic literature review of articles reporting patients with TNFAIP3 sequence variants from 2016 to August 2023 following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data from 177 patients from 65 articles were retrieved (108 women). The principal features were mucosal ulcers (n = 129); fever (n = 93) followed by gastrointestinal (n = 81); skin features (n = 76); autoimmunity (n = 61), including thyroiditis (n = 25) and lupus (n = 16); and joint involvements (n = 54). Five patients had died at the time of publication. In 54 of 63 patients, CRP was significantly elevated during flares, with a median of 51 mg/l. The most commonly used treatment included corticosteroids and nonsteroidal anti-inflammatory drugs (n = 32), TNF blockers (n = 29), colchicine (n = 28), and methotrexate (n = 14). TNFAIP3 variants impacted the ovarian tumor domain in 92 cases and a Zinc finger domain in 68 cases. Geographic origin, reported sex, and variant type significantly impacted phenotype. A better understanding of the wide A20 haploinsufficiency phenotype could facilitate the diagnosis process. Much remains to be elucidated about pathogenesis and treatment to improve outcome in patients with A20 haploinsufficiency.
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Affiliation(s)
- Inès Elhani
- Department of Internal Medicine, Tenon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Saint-Antoine Research Center (CRSA) INSERM UMRS 938, Sorbonne Université, Paris, France; National French Reference Centre for Auto-inflammatory Diseases and Inflammatory Amyloidosis (CEREMAIA), Montpellier, France; Department of General Pediatrics, Versailles Hospital, Versailles, France.
| | - Quentin Riller
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Institut Imagine, Université Paris Cité, Paris, France
| | - Guilaine Boursier
- National French Reference Centre for Auto-inflammatory Diseases and Inflammatory Amyloidosis (CEREMAIA), Montpellier, France; Laboratory of Rare and Autoinflammatory Genetic Diseases, Department of genetics, CHU Montpellier, Univ Montpellier, Montpellier, France
| | - Véronique Hentgen
- National French Reference Centre for Auto-inflammatory Diseases and Inflammatory Amyloidosis (CEREMAIA), Montpellier, France; Department of General Pediatrics, Versailles Hospital, Versailles, France
| | - Frédéric Rieux-Laucat
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Institut Imagine, Université Paris Cité, Paris, France
| | - Sophie Georgin-Lavialle
- Department of Internal Medicine, Tenon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Saint-Antoine Research Center (CRSA) INSERM UMRS 938, Sorbonne Université, Paris, France; National French Reference Centre for Auto-inflammatory Diseases and Inflammatory Amyloidosis (CEREMAIA), Montpellier, France.
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Iwasa T, Miwa T, Unome S, Hanai T, Imai K, Takai K, Miwa Y, Hori T, Ohnishi H, Matsumoto M, Niwa A, Miyazaki T, Shimizu M. A case of A20 haploinsufficiency complicated by autoimmune hepatitis. Hepatol Res 2024; 54:606-611. [PMID: 38126665 DOI: 10.1111/hepr.14003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/20/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
AIM A20 haploinsufficiency (HA20) is a recently described autoinflammatory disease that manifests symptoms similar to those of Behçet's disease. However, little is known about the involvement of the liver in HA20. Here, we report a case of HA20 complicated by autoimmune hepatitis (AIH). CASE PRESENTATION A 33-year-old woman was previously diagnosed with HA20 and chronic thyroiditis, and was treated with prednisolone (PSL; 7.5 mg/day) and levothyroxine sodium hydrate (125 μg/day). She experienced general malaise and jaundice, and biochemical evaluation revealed elevated liver function with an aspartate aminotransferase level of 817 U/L, an alanine aminotransferase level of 833 U/L, and a total bilirubin of 8.3 mg/dL. Pathological evaluation of the liver biopsy revealed interface hepatitis and the patient was diagnosed with acute exacerbation of AIH. Upon increasing the PSL dose to 60 mg/day, the liver enzyme levels rapidly decreased. During tapering of PSL, azathioprine 50 mg/day was added, and there was no relapse of AIH with combination therapy of PSL 7 mg/day and azathioprine 50 mg/day. CONCLUSION This is the first report of biopsy-proven AIH in an Asian patient with HA20. This case has significant implications for the pathogenesis and treatment of AIH in patients with HA20.
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Affiliation(s)
- Taisei Iwasa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Takao Miwa
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shinji Unome
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Yuki Miwa
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tomohiro Hori
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | | | - Ayumi Niwa
- Department of Pathology, Gifu University Hospital, Gifu, Japan
| | | | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Graduate School of Medicine, Gifu University, Gifu, Japan
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Zhang F, Zhang L. A20 haploinsufficiency in a neonate caused by a large deletion on chromosome 6q. Pediatr Rheumatol Online J 2024; 22:12. [PMID: 38183052 PMCID: PMC10770963 DOI: 10.1186/s12969-023-00947-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/16/2023] [Indexed: 01/07/2024] Open
Abstract
Haploinsufficiency of A20 (HA20) is a rare monogenic disease caused by heterozygous loss-of-function mutations in the tumor necrosis factor alpha-induced protein 3 (TNFAIP3) gene located on chromosome 6q23.3. The majority of disease-causing mutations in most cases of HA20 comprise single nucleotide variations, small insertions, or deletions in TNFAIP3, which result in a premature termination codon and subsequent disruption of its anti-inflammatory role. Large deletions have been reported sporadically. HA20 patients may present with a variety of autoinflammatory and autoimmune features during early childhood; however, cases with neonatal onset are rare. Here, we describe a Chinese neonate presenting with concomitant inflammatory and other syndromic manifestations caused by a 5.15 Mb interstitial deletion in chromosome 6; these deletions affect TNFAIP3. Taken together, the data extend the clinical and genetic spectra of HA20.
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Affiliation(s)
- Fan Zhang
- Department of Neonatology, Hunan Children's Hospital, Changsha, Hunan, China
| | - Liang Zhang
- Department of Nephrology, Rheumatology and Immunology, Hunan Provincial Key Laboratory of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, Hunan, China.
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Lina S, Ya'nan H, Ying Y, Fengfan W, Xin H, Xiaoxia R, Ying F. Haploinsufficiency of A20 caused by a novel pathogenic missense variant of TNFAIP3 and successfully treated with anti-TNF and immunosuppressive therapies. Cell Immunol 2023; 391-392:104753. [PMID: 37535999 DOI: 10.1016/j.cellimm.2023.104753] [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: 04/05/2023] [Revised: 06/13/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
Loss-of-function of protein A20, encoded by TNFAIP3, leads to an early-onset haploinsufficiency of A20 (HA20). This study reports one Chinese child with HA20 and explores the genetic etiology of TNFAIP3 variant. The patient exhibited transient recurrent episodes of fever, intermittent signs of arthritis, gastrointestinal symptoms and multiple colonic ulcers. Laboratory tests revealed elevated inflammatory indicators and mild to moderate anemia. Genetic analysis identified a heterozygous de novo variant in his TNFAIP3 gene (c.740C>T, p. P247L), which had never been reported before. The novel missense variation was validated to be pathogenic through causing insufficient expression of A20, over-activation of NF-κB signaling pathway and elevated levels of proinflammatory cytokines in response to stimulation by lipopolysaccharide. A combination of oral corticosteroids, TNF-α inhibitors and thalidomide freed him from symptoms and abnormal inflammatory indicators. Furthermore, continual improvement of the patient's condition was observed during a follow-up period of five months. We demonstrate a case with a de novo missense variant resulting in a loss-of-function of TNFAIP3, which expands the clinical spectrum of HA20. Cytokine antagonists and immunosuppressants may be effective drugs.
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Affiliation(s)
- Sun Lina
- Department of Gastroenterology, Xi'an Children's Hospital, Xi'an, China
| | - Han Ya'nan
- Department of Gastroenterology, Xi'an Children's Hospital, Xi'an, China
| | - Yang Ying
- Shaanxi Institute of Pediatric Diseases, Xi'an Children's Hospital, Xi'an, China
| | - Wang Fengfan
- Department of Gastroenterology, Xi'an Children's Hospital, Xi'an, China
| | - Hou Xin
- Department of Imaging, Xi'an Children's Hospital, Xi'an, China
| | - Ren Xiaoxia
- Department of Gastroenterology, Xi'an Children's Hospital, Xi'an, China
| | - Fang Ying
- Department of Gastroenterology, Xi'an Children's Hospital, Xi'an, China.
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Rodolfi S, Nasone I, Folci M, Selmi C, Brunetta E. Autoinflammatory manifestations in adult patients. Clin Exp Immunol 2022; 210:295-308. [PMID: 36334040 PMCID: PMC9985169 DOI: 10.1093/cei/uxac098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/14/2022] [Accepted: 11/04/2022] [Indexed: 11/06/2022] Open
Abstract
Autoinflammatory diseases represent a family of immune-mediated conditions characterized by the unchecked activation of innate immunity. These conditions share common clinical features such as recurrent fever, inflammatory arthritis, and elevation of acute phase reactants, in the absence of an identified infectious etiology, generally without detectable serum autoantibodies, with variable response to glucocorticoids and in some cases colchicine, which represented the mainstay of treatment until cytokine blockade therapies became available. The first autoinflammatory diseases to be described were monogenic disorders caused by missense mutations in inflammasome components and were recognized predominantly during childhood or early adulthood. However, the progress of genetic analyses and a more detailed immunological phenotyping capacity led to the discovery a wide spectrum of diseases, often becoming manifest or being diagnosed in the adult population. The beneficial role of targeting hyperinflammation via interleukin 1 in complex non-immune-mediated diseases is a field of growing clinical interest. We provide an overview of the autoinflammatory diseases of interest to physicians treating adult patients and to analyze the contribution of hyperinflammation in non-immune-mediated diseases; the result is intended to provide a roadmap to orient scientists and clinicians in this broad area.
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Affiliation(s)
- Stefano Rodolfi
- Rheumatology and Clinical Immunology IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Irene Nasone
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Emergency Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marco Folci
- Nephrology and Internal Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Carlo Selmi
- Correspondence: Carlo Selmi, Division of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center IRCCS and Humanitas University, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
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