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Hassan LM, Hassan MM, Abou Shady H, Khedr D. VKH with APECED in a Two-Year-Old Child: A Rare Concomitant Diagnosis in an Unprecedented Age. Ocul Immunol Inflamm 2024; 32:433-436. [PMID: 38412247 DOI: 10.1080/09273948.2023.2208212] [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: 01/29/2023] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 02/29/2024]
Abstract
PURPOSE To present a case of Vogt Koyanagi Harada (VKH) associated with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome (APECED) in a two-year-old. CASE PRESENTATION A two-year-old type 1 diabetic with hypothyroidism presented with impaired fixation. Ocular examination revealed right vitritis, choroiditis, a hyperemic disc, and an area of exudative detachment. At the same time, there was no fundus view in the left eye, and ultrasonographic assessment revealed vitritis and a thickened choroid. Patient developed sunset glow fundus with alopecia, poliosis and vitiligo and a diagnosis of complete VKH with APECED was made. CONCLUSION APECED is a rare endocrine disorder and has been reported to be associated with VKH twice. Likewise, VKH is commonly present in much older patients; this is the first time ever to be diagnosed in a two-year-old child.
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Affiliation(s)
| | | | | | - Dina Khedr
- Pediatrics, Cairo University, Cairo, Egypt
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2
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Brad GF, Nicoară DM, Scutca AC, Bugi MA, Asproniu R, Olariu LG, Jugănaru I, Cristun LI, Mărginean O. Exploring Chronic Hypocalcemia: Insights into Autoimmune Polyglandular Syndrome Type 1-A Case Study and Literature Review. J Clin Med 2024; 13:2368. [PMID: 38673639 PMCID: PMC11051075 DOI: 10.3390/jcm13082368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/07/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Hypocalcemia is a common occurrence in pediatric patients, attributed to various causes and presenting with diverse clinical manifestations. A prompt evaluation is necessary to determine its underlying cause, whether it presents acutely or chronically, and to tailor treatment based on its severity. Among the potential causes of chronic hypocalcemia, primary hypoparathyroidism stands out. The case of a seven-year-old male patient with hypocalcemia reported in this article serves as an illustration, wherein targeted next-generation sequencing revealed a homozygous p.R257X mutation in the AIRE gene, indicative of autoimmune polyendocrine syndrome type 1 (APS-1). It poses challenges due to its multisystemic nature and involvement of specific autoantibodies, often leading to underdiagnosis, owing to its rarity, varied manifestations, and incomplete penetrance. A comprehensive review of the APS-1 literature was conducted to provide insights into the clinical manifestations, genetic spectrum, potential immunological mechanisms, and current medical strategies. Additionally, the recognition of AIRE gene mutations is crucial for facilitating genetic diagnosis, prognosis, and potential treatment strategies for APS-1. The management of such cases involves individualized approaches to treatment, regular monitoring, medication adjustments, and the early identification of associated conditions.
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Affiliation(s)
- Giorgiana-Flavia Brad
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Delia-Maria Nicoară
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
| | - Alexandra-Cristina Scutca
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Meda-Ada Bugi
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Raluca Asproniu
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Laura-Gratiela Olariu
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
| | - Iulius Jugănaru
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Lucian-Ioan Cristun
- Ph.D. School Department, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania;
| | - Otilia Mărginean
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (G.-F.B.); (A.-C.S.); (R.A.); (L.-G.O.); (I.J.); (O.M.)
- 1st Department of Pediatrics, Children’s Emergency Hospital ‘Louis Turcanu’, 300011 Timisoara, Romania;
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babes’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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3
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Aytekin ES, Cagdas D. APECED and the place of AIRE in the puzzle of the immune network associated with autoimmunity. Scand J Immunol 2023; 98:e13299. [PMID: 38441333 DOI: 10.1111/sji.13299] [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: 09/08/2022] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 03/07/2024]
Abstract
In the last 20 years, discoveries about the autoimmune regulator (AIRE) protein and its critical role in immune tolerance have provided fundamental insights into understanding the molecular basis of autoimmunity. This review provides a comprehensive overview of the effect of AIRE on immunological tolerance and the characteristics of autoimmune diseases in Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED), which is caused by biallelic AIRE mutations. A better understanding of the immunological mechanisms of AIRE deficiency may enlighten immune tolerance mechanisms and new diagnostic and treatment strategies for autoimmune diseases. Considering that not all clinical features of APECED are present in a given follow-up period, the diagnosis is not easy in a patient at the first visit. Longer follow-up and a multidisciplinary approach are essential for diagnosis. It is challenging to prevent endocrine and other organ damage compared with other diseases associated with multiple autoimmunities, such as FOXP3, LRBA, and CTLA4 deficiencies. Unfortunately, no curative therapy like haematopoietic stem cell transplantation or specific immunomodulation is present that is successful in the treatment.
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Affiliation(s)
- Elif Soyak Aytekin
- Pediatric Allergy and Immunology, Department of Pediatrics, SBU Dr. Sami Ulus Children Hospital, Ankara, Turkey
| | - Deniz Cagdas
- Division of Pediatric Immunology, Department of Pediatrics, Ihsan Dogramaci Children`s Hospital, Institute of Child Health, Hacettepe University Medical School, Ankara, Turkey
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4
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Mancuso G, Bechi Genzano C, Fierabracci A, Fousteri G. Type 1 diabetes and inborn errors of immunity: Complete strangers or 2 sides of the same coin? J Allergy Clin Immunol 2023:S0091-6749(23)00427-X. [PMID: 37097271 DOI: 10.1016/j.jaci.2023.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/26/2023]
Abstract
Type 1 diabetes (T1D) is a polygenic disease and does not follow a mendelian pattern. Inborn errors of immunity (IEIs), on the other hand, are caused by damaging germline variants, suggesting that T1D and IEIs have nothing in common. Some IEIs, resulting from mutations in genes regulating regulatory T-cell homeostasis, are associated with elevated incidence of T1D. The genetic spectrum of IEIs is gradually being unraveled; consequently, molecular pathways underlying human monogenic autoimmunity are being identified. There is an appreciable overlap between some of these pathways and the genetic variants that determine T1D susceptibility, suggesting that after all, IEI and T1D are 2 sides of the same coin. The study of monogenic IEIs with a variable incidence of T1D has the potential to provide crucial insights into the mechanisms leading to T1D. These insights contribute to the definition of T1D endotypes and explain disease heterogeneity. In this review, we discuss the interconnected pathogenic pathways of autoimmunity, β-cell function, and primary immunodeficiency. We also examine the role of environmental factors in disease penetrance as well as the circumstantial evidence of IEI drugs in preventing and curing T1D in individuals with IEIs, suggesting the repositioning of these drugs also for T1D therapy.
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Affiliation(s)
- Gaia Mancuso
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Camillo Bechi Genzano
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | | | - Georgia Fousteri
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.
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5
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Popoviciu MS, Kaka N, Sethi Y, Patel N, Chopra H, Cavalu S. Type 1 Diabetes Mellitus and Autoimmune Diseases: A Critical Review of the Association and the Application of Personalized Medicine. J Pers Med 2023; 13:jpm13030422. [PMID: 36983604 PMCID: PMC10056161 DOI: 10.3390/jpm13030422] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023] Open
Abstract
Type 1 Diabetes Mellitus (T1DM) is a common hyperglycemic disease characterized by the autoimmune destruction of insulin-producing beta cells of the pancreas. Various attempts have been made to understand the complex interplay of genetic and environmental factors which lead to the development of the autoimmune response in an individual. T1DM is frequently associated with other autoimmune illnesses, the most common being autoimmune thyroid disorders affecting more than 90% of people with T1D and autoimmune disorders. Antithyroid antibodies are present in around 20% of children with T1D at the start of the illness and are more frequent in girls. Patients with T1DM often have various other co-existing multi-system autoimmune disorders including but not limited to thyroid diseases, parathyroid diseases, celiac disease, vitiligo, gastritis, skin diseases, and rheumatic diseases. It is a consistent observation in clinics that T1DM patients have other autoimmune disorders which in turn affect their prognosis. Concomitant autoimmune illness might affect diabetes care and manifest itself clinically in a variety of ways. A thorough understanding of the complex pathogenesis of this modern-day epidemic and its association with other autoimmune disorders has been attempted in this review in order to delineate the measures to prevent the development of these conditions and limit the morbidity of the afflicted individuals as well. The measures including antibody screening in susceptible individuals, early identification and management of other autoimmune disorders, and adoption of personalized medicine can significantly enhance the quality of life of these patients. Personalized medicine has recently gained favor in the scientific, medical, and public domains, and is frequently heralded as the future paradigm of healthcare delivery. With the evolution of the ‘omics’, the individualization of therapy is not only closer to reality but also the need of the hour.
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Affiliation(s)
| | - Nirja Kaka
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Yashendra Sethi
- PearResearch, Dehradun 248001, India
- Department of Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun 248001, India
| | - Neil Patel
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Hitesh Chopra
- Chitkara College of Pharmacy, Chitkara University, Rajpura 140401, India
| | - Simona Cavalu
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
- Correspondence:
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6
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Characterisation of APS-1 Experimental Models Is Crucial for Development of Novel Therapies. BIOMED RESEARCH INTERNATIONAL 2023; 2023:7960443. [PMID: 36685668 PMCID: PMC9848810 DOI: 10.1155/2023/7960443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/02/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023]
Abstract
Autoimmune polyglandular syndrome type 1 (APS-1) is an inherited autosomal disorder. The most common clinical features of the disease include adrenocortical failure, hypoparathyroidism (HP), and chronic mucocutaneous candidiasis (CMC). APS-1 is caused by mutations in the autoimmune regulator (AIRE) gene. AIRE is a transcriptional factor involved in the regulation of thousands of genes in the thymus. It facilitates central tolerance by promoting the ectopic expression of tissue-specific antigens (TSAs) in medullary thymic epithelial cells (mTECs), leading to the deletion of self-reactive thymocytes. Several Aire-deficient mice were developed separately, on different backgrounds; seven published Aire knockout mice show a variety of phenotypes depending on the strain used to generate the experimental model. The first Aire-deficient mice were generated on a "black 6" background almost 20 years ago. The model showed mild phenotype with relatively modest penetrance compared to models generated on BALBc or NOD backgrounds. The generation of all these experimental models is crucial for development and testing new therapeutics as well as reading the response to treatments.
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7
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Fierabracci A, Belcastro E, Carbone E, Pagliarosi O, Palma A, Pacillo L, Giancotta C, Zangari P, Finocchi A, Cancrini C, Delfino DV, Cappa M, Betterle C. In Search for the Missing Link in APECED-like Conditions: Analysis of the AIRE Gene in a Series of 48 Patients. J Clin Med 2022; 11:jcm11113242. [PMID: 35683627 PMCID: PMC9181695 DOI: 10.3390/jcm11113242] [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] [Received: 04/14/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022] Open
Abstract
Autoimmune diseases are a heterogeneous group of disorders of the immune system. They can cluster in the same individual, revealing various preferential associations for polyendocrine autoimmune syndromes. Clinical observation, together with advances in genetics and the understanding of pathophysiological processes, has further highlighted that autoimmunity can be associated with immunodeficiency; autoimmunity may even be the first primary immunodeficiency manifestation. Analysis of susceptibility genes for the development of these complex phenotypes is a fundamental issue. In this manuscript, we revised the clinical and immunologic features and the presence of AIRE gene variations in a cohort of 48 patients affected by high polyautoimmunity complexity, i.e., APECED-like conditions, also including patients affected by primary immunodeficiency. Our results evidenced a significant association of the S278R polymorphism of the AIRE gene with APECED-like conditions, including both patients affected by autoimmunity and immunodeficiency and patients with polyautoimmunity compared to healthy controls. A trend of association was also observed with the IVS9+6 G>A polymorphism. The results of this genetic analysis emphasize the need to look for additional genetic determinants playing in concert with AIRE polymorphisms. This will help to improve the diagnostic workup and ensure a precision medicine approach to targeted therapies in APECED-like patients.
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Affiliation(s)
- Alessandra Fierabracci
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children’s Hospital, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), 00146 Rome, Italy; (E.B.); (E.C.); (O.P.)
- Correspondence: ; Tel.: +39-06-6859-2656
| | - Eugenia Belcastro
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children’s Hospital, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), 00146 Rome, Italy; (E.B.); (E.C.); (O.P.)
| | - Elena Carbone
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children’s Hospital, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), 00146 Rome, Italy; (E.B.); (E.C.); (O.P.)
| | - Olivia Pagliarosi
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children’s Hospital, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), 00146 Rome, Italy; (E.B.); (E.C.); (O.P.)
| | - Alessia Palma
- Research Laboratories, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy;
| | - Lucia Pacillo
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (L.P.); (A.F.); (C.C.)
- PhD Program in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Carmela Giancotta
- Immunology and Vaccinology, DPUO, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (C.G.); (P.Z.)
| | - Paola Zangari
- Immunology and Vaccinology, DPUO, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (C.G.); (P.Z.)
| | - Andrea Finocchi
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (L.P.); (A.F.); (C.C.)
- Chair of Pediatrics, Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Caterina Cancrini
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (L.P.); (A.F.); (C.C.)
- Chair of Pediatrics, Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Marco Cappa
- Endocrinology Unit, DPUO, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Corrado Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy;
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8
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Tenório JR, Tuma MM, Andrade NS, Santana T, Gallottini M. Oral manifestations of autoimmune polyglandular syndrome type 1. SPECIAL CARE IN DENTISTRY 2022; 42:531-535. [PMID: 35182449 DOI: 10.1111/scd.12703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022]
Abstract
AIMS Autoimmune polyglandular syndrome type I (APS-I) is a rare condition of autosomal recessive and monogenic inheritance, which is characterized clinically by at least two signs of the classic triad: mucocutaneous candidosis, hypoparathyroidism, and Addison's disease. This study aims to report the oral manifestations of APS-I in a 42-year-old woman, who attended the Special Care Dentistry Center. METHODS AND RESULTS The patient presented with hypoparathyroidism, diabetes mellitus, and autoimmune hepatitis. Chronic hyperplastic candidosis (CHC) was the main oral manifestation and it was diagnosed based on clinical and cytologic characteristics. Microstomia, angular cheilitis, xerostomia, enamel hypoplasia, and microdontia were also present. CONCLUSIONS CHC was treated with topical nystatin and oral fluconazole, resulting in a significant improvement of the lesions.
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Affiliation(s)
- Jefferson R Tenório
- Department of Oral Pathology and Diagnosis, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marina Maués Tuma
- Department of Oral Pathology, School of Dentistry, São Paulo University, São Paulo, Brazil
| | - Natália Silva Andrade
- Department of Dentistry, School of Dentistry, Federal University of Sergipe, Sergipe, Brazil
| | | | - Marina Gallottini
- Department of Stomatology, Special Care Dentistry Center, University of São Paulo, São Paulo, Brazil
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9
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Sirbe C, Simu G, Szabo I, Grama A, Pop TL. Pathogenesis of Autoimmune Hepatitis-Cellular and Molecular Mechanisms. Int J Mol Sci 2021; 22:13578. [PMID: 34948375 PMCID: PMC8703580 DOI: 10.3390/ijms222413578] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 02/05/2023] Open
Abstract
Pediatric autoimmune liver disorders include autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis (ASC), and de novo AIH after liver transplantation. AIH is an idiopathic disease characterized by immune-mediated hepatocyte injury associated with the destruction of liver cells, causing inflammation, liver failure, and fibrosis, typically associated with autoantibodies. The etiology of AIH is not entirely unraveled, but evidence supports an intricate interaction among genetic variants, environmental factors, and epigenetic modifications. The pathogenesis of AIH comprises the interaction between specific genetic traits and molecular mimicry for disease development, impaired immunoregulatory mechanisms, including CD4+ T cell population and Treg cells, alongside other contributory roles played by CD8+ cytotoxicity and autoantibody production by B cells. These findings delineate an intricate pathway that includes gene to gene and gene to environment interactions with various drugs, viral infections, and the complex microbiome. Epigenetics emphasizes gene expression through hereditary and reversible modifications of the chromatin architecture without interfering with the DNA sequence. These alterations comprise DNA methylation, histone transformations, and non-coding small (miRNA) and long (lncRNA) RNA transcriptions. The current first-line therapy comprises prednisolone plus azathioprine to induce clinical and biochemical remission. Further understanding of the cellular and molecular mechanisms encountered in AIH may depict their impact on clinical aspects, detect biomarkers, and guide toward novel, effective, and better-targeted therapies with fewer side effects.
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Affiliation(s)
- Claudia Sirbe
- 2nd Pediatric Discipline, Department of Mother and Child, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.S.); (T.L.P.)
- 2nd Pediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Gelu Simu
- Cardiology Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Cardiology Department, Rehabilitation Hospital, 400066 Cluj-Napoca, Romania
| | - Iulia Szabo
- Department of Rheumatology, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Alina Grama
- 2nd Pediatric Discipline, Department of Mother and Child, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.S.); (T.L.P.)
- 2nd Pediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Tudor Lucian Pop
- 2nd Pediatric Discipline, Department of Mother and Child, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.S.); (T.L.P.)
- 2nd Pediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
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10
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Nasser NH, Samra NG, Naccache DD. Hypoadrenalism as the Single Presentation of Autoimmune Polyglandular Syndrome Type 1. J Endocr Soc 2021; 5:bvab151. [PMID: 34877443 PMCID: PMC8645161 DOI: 10.1210/jendso/bvab151] [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: 04/26/2021] [Indexed: 11/19/2022] Open
Abstract
Type 1 autoimmune polyglandular syndrome (APS1) is a rare hereditary disease affecting nearly 600 patients worldwide. The first of its cardinal manifestations, chronic mucocutaneous candidiasis, hypoparathyroidism, or Addison's disease, presents in childhood. Additional nonclassical landmarks of APS1 continue to develop as late as the fifth decade of life. Two thirds of patients develop the full triad before 25 years of age. Only 20% of patients develop the entire triad simultaneously. Addison's disease is rarely reported as the first manifestation. According to APS1 classifications, restricted criteria for a single cardinal component, although elements of suspicion are not sufficient to diagnose APS1. This case report is peculiar as hypoadrenalism was the first and only manifestation of APS1 for nearly 3 decades since its diagnosis. Theoretically, exceptions from the protocol of APS1 diagnostic criteria would be recognized as acceptable for diagnosis in the future, when similar case reports of only 1 component of APS1 appear.
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Affiliation(s)
- Nadim H Nasser
- Clalit Health Organization, Haifa, Israel.,Bar-Ilan University Faculty of Medicine, Safed, Israel
| | | | - Deeb D Naccache
- Institute of Endocrinology and Centre for Excellence in Diabetes and Obesity, Rambam Health Care Campus, Haifa, Israel
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11
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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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Fierabracci A, Lanzillotta M, Vorgučin I, Palma A, Katanić D, Betterle C. Report of two siblings with APECED in Serbia: is there a founder effect of c.769C>T AIRE genotype? Ital J Pediatr 2021; 47:126. [PMID: 34078422 PMCID: PMC8173724 DOI: 10.1186/s13052-021-01075-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Autoimmune polyendocrinopathy-candidiasis-ectodermal-dystrophy (APECED) or autoimmune polyglandular syndrome Type 1 is a rare autosomal recessive syndrome. The disorder is caused by mutations in the AIRE (AutoImmune Regulator) gene. According to the classic criteria, clinical diagnosis requires the presence of at least two of three main components: chronic mucocutaneous candidiasis, hypoparathyroidism and primary adrenal insufficiency. Furthermore, patients are often affected by other endocrine or non-endocrine associated autoimmune conditions. The enrichment of the non-classical triad seems to occur differently in different cohorts. Screenings of the population revealed that homozygous AIRE mutations c.769C > T, c.415C > T and c.254A > G have a founder effect in Finnish, Sardinian and Iranian Jew populations respectively. CASE PRESENTATION We report here the clinical and genetic characteristics of two new Serbian APECED siblings, one male and one female, actual age of 27 and 24 respectively, born from non-consanguineous parents. Addison's disease was diagnosed in the male at the age of 3.5 and hypoparathyroidism at the age of 4. The female developed hypoparathyroidism at 4 years of age. She presented diffuse alopecia, madarosis, onychomycosis, teeth enamel dysplasia. She further developed Addison's disease at the age of 11 and Hashimoto's thyroiditis at the age of 13.5. She had menarche at the age of 14 but developed autoimmune oophoritis and premature ovarian failure at the age of 16. A treatment with hydrocortisone, fludrocortisone and alfacalcidiol was established for both siblings; L-T4 (levo-thyroxine) for thyroid dysfunction and levonorgestrel and etinilestradiol for POF were also administered to the female. Genetic screening revealed a homozygous c.769C > T (R257X (p.Arg257X)) AIRE mutation. We additionally reviewed the literature on 11 previously published Serbian patients and evaluated the frequency of their main diseases in comparison to Finnish, Sardinian, Turkish, Indian and North/South American cohorts. CONCLUSION A founder effect was discovered for the R257X genotype detected in the DNA of 10 homozygous and 2 heterozygous patients. Of note, all Serbian APECED patients were affected by adrenal insufficiency and 10 out of 13 patients presented CMC.
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Affiliation(s)
- Alessandra Fierabracci
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Mariafrancesca Lanzillotta
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ivana Vorgučin
- Institute for Child and Youth Health Care of Vojvodina, Faculty of Medicine Novi Sad, Vojvodina, Serbia
| | - Alessia Palma
- Research Laboratories, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dragan Katanić
- Institute for Child and Youth Health Care of Vojvodina, Faculty of Medicine Novi Sad, Vojvodina, Serbia
| | - Corrado Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
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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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Carpino A, Buganza R, Matarazzo P, Tuli G, Pinon M, Calvo PL, Montin D, Licciardi F, De Sanctis L. Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy in Two Siblings: Same Mutations but Very Different Phenotypes. Genes (Basel) 2021; 12:genes12020169. [PMID: 33530632 PMCID: PMC7912139 DOI: 10.3390/genes12020169] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/21/2021] [Accepted: 01/21/2021] [Indexed: 01/31/2023] Open
Abstract
Autoimmune polyendocrinopathy–candidiasis–ectodermal dystrophy (APECED), caused by mutations in the AIRE gene, is mainly characterized by the triad of hypoparathyroidism, primary adrenocortical insufficiency and chronic mucocutaneous candidiasis, but can include many other manifestations, with no currently clear genotype–phenotype correlation. We present the clinical features of two siblings, a male and a female, with the same mutations in the AIRE gene associated with two very different phenotypes. Interestingly, the brother recently experienced COVID-19 infection with pneumonia, complicated by hypertension, hypokalemia and hypercalcemia. Although APECED is a monogenic disease, its expressiveness can be extremely different. In addition to the genetic basis, epigenetic and environmental factors might influence the phenotypic expression, although their exact role remains to be elucidated.
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Affiliation(s)
- Andrea Carpino
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
- Correspondence:
| | - Raffaele Buganza
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (R.B.); (G.T.); (P.M.); (L.D.S.)
| | - Patrizia Matarazzo
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (R.B.); (G.T.); (P.M.); (L.D.S.)
| | - Gerdi Tuli
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (R.B.); (G.T.); (P.M.); (L.D.S.)
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (P.L.C.); (M.P.)
| | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (P.L.C.); (M.P.)
| | - Davide Montin
- Pediatric Immunology and Rheumatology, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (F.L.); (D.M.)
| | - Francesco Licciardi
- Pediatric Immunology and Rheumatology, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (F.L.); (D.M.)
| | - Luisa De Sanctis
- Pediatric Endocrinology Unit, Regina Margherita Children’s Hospital, 10126 Turin, Italy; (R.B.); (G.T.); (P.M.); (L.D.S.)
- Department of Public Health and Pediatric Sciences, University of Turin, 10126 Turin, Italy
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Toraih EA, Ameen HM, Hussein MH, Youssef Elabd AA, Mohamed AM, Abdel-Gawad AR, Fawzy MS. Association of Autoimmune Regulator Gene Rs2075876 Variant, but Not Gene Expression with Alopecia Areata in Males: A Case-control Study. Immunol Invest 2020; 49:146-165. [PMID: 31601134 DOI: 10.1080/08820139.2019.1671450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Alopecia areata (AA) is a non-scarring hair loss of autoimmune etiology. The autoimmune regulator (AIRE) gene is believed to be an important driver in AA pathogenesis. Genetic variants can alter mRNA expression levels which may provoke an autoimmune response. A total of 337 males (97 AA patients and 240 controls) were enrolled in the current case-control study. On screening of the most frequent variants in the gene, rs2075876 (A/G) polymorphism in intron 5 was selected and genotyped using Real-Time PCR (polymerase chain reaction) technology. Additionally, circulatory AIRE expression levels were quantified by quantitative reverse-transcription PCR (qRT-PCR). Allelic discrimination analysis revealed GG genotype to be more frequent in patients (90.7% in AA compared to 32.5% in controls, p < .001). G variant conferred increased risk to alopecia under homozygote comparison (GG versus AA: OR = 16.1, 95%CI = 5.57-46.3), dominant model (GG+AG versus AA: OR = 7.24, 95%CI = 2.5-20.5), recessive model (GG versus AG+AA: OR = 20.3, 95%CI = 9.7-42.4), and allelic model (G versus A: OR = 11.6, 95%CI = 6.47-21.1). The expression levels of AIRE gene did not differ significantly between patients and controls and were not related to rs2075876 variant. In conclusion, the intronic variant (rs2075876) is suggested to be a potent susceptibility variant for AA development in the studied population.Abbreviations: AA: Alopecia areata; AIRE: Autoimmune Regulator; APECED: Autoimmune, Polyendocrinopathy Candidiasis Ectodermal Dystrophy; DLQI: Dermatology life quality index questionnaire; MIQE: Minimum information for publication of quantitative real-time PCR experiments; mTEC: Medullary thymic epithelial cells; PHD: Plant homeodomain; qRT-PCR: Quantitative reversetranscription-polymerase chain reaction; RA: Rheumatoid arthritis.
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Affiliation(s)
- Eman A Toraih
- Genetics Unit, Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
- Center of Excellence of Molecular and Cellular Medicine, Suez Canal University, Ismailia, Egypt
| | - Hatem M Ameen
- Department of Dermatology, Al Qantara East Central Hospital, Ismailia, Egypt
| | - Mohammad H Hussein
- Department of Chest Diseases, Ministry of Health and Population, Cairo, Egypt
| | - Ahmed A Youssef Elabd
- Department of Dermatology, El-Sheikh Zaied Aal Nahyan hospital, Cairo, Egypt
- Department of Dermatology, Emirates Medical Center, Salalah Oman, Oman
| | - Abeer M Mohamed
- Department of Clinical Pathology and Clinical Chemistry, Faculty of Medicine, Sohag University, Sohag, Egypt
- Department of Clinical Laboratory Sciences, Al-Ghad International College for Applied Medical Sciences, Abha, Saudi Arabia
| | | | - Manal S Fawzy
- Deprtment of Biochemistry, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Ilonen J, Lempainen J, Veijola R. The heterogeneous pathogenesis of type 1 diabetes mellitus. Nat Rev Endocrinol 2019; 15:635-650. [PMID: 31534209 DOI: 10.1038/s41574-019-0254-y] [Citation(s) in RCA: 213] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 12/14/2022]
Abstract
Type 1 diabetes mellitus (T1DM) results from the destruction of pancreatic β-cells that is mediated by the immune system. Multiple genetic and environmental factors found in variable combinations in individual patients are involved in the development of T1DM. Genetic risk is defined by the presence of particular allele combinations, which in the major susceptibility locus (the HLA region) affect T cell recognition and tolerance to foreign and autologous molecules. Multiple other loci also regulate and affect features of specific immune responses and modify the vulnerability of β-cells to inflammatory mediators. Compared with the genetic factors, environmental factors that affect the development of T1DM are less well characterized but contact with particular microorganisms is emerging as an important factor. Certain infections might affect immune regulation, and the role of commensal microorganisms, such as the gut microbiota, are important in the education of the developing immune system. Some evidence also suggests that nutritional factors are important. Multiple islet-specific autoantibodies are found in the circulation from a few weeks to up to 20 years before the onset of clinical disease and this prediabetic phase provides a potential opportunity to manipulate the islet-specific immune response to prevent or postpone β-cell loss. The latest developments in understanding the heterogeneity of T1DM and characterization of major disease subtypes might help in the development of preventive treatments.
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Affiliation(s)
- Jorma Ilonen
- Institue of Biomedicine, University of Turku and Clinical Microbiology, Turku University Hospital, Turku, Finland.
| | - Johanna Lempainen
- Institue of Biomedicine, University of Turku and Clinical Microbiology, Turku University Hospital, Turku, Finland
- Department of Paediatrics, University of Turku and Turku University Hospital, Turku, Finland
| | - Riitta Veijola
- Department of Paediatrics, University of Oulu and Oulu University Hospital, Oulu, Finland
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Lin MC, Tsai MH, Leu JG, Fang YW. Hyperkalemia in a patient with myasthenia gravis: case presentation. BMC Endocr Disord 2019; 19:80. [PMID: 31349821 PMCID: PMC6660675 DOI: 10.1186/s12902-019-0406-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is the most common disorder of neuromuscular transmission, and it is typified by fluctuating degrees and variable combinations of weakness in the ocular, bulbar, limb, and respiratory muscles. Under rare circumstances, MG can be accompanied by Addison's disease. CASE PRESENTATION Here, we reported the case of a 57-year-old Chinese woman with MG. She experienced progressive muscle weakness for 1 week. MG with acute exacerbation was initially suspected. However, further biochemistry tests found mild hyperkalemia (5.6 mEq/L) and a lower renal potassium excretion rate. Consequently, low aldosterone action was highly suspected. Further findings included a suppressed cortisol level, a higher adrenocorticotropic hormone concentration, and 21-hydroxylase antibody positivity, supporting a diagnosis of primary adrenal insufficiency due to autoimmune adrenalitis. CONCLUSION We successfully demonstrated that adrenal insufficiency could be diagnosed, due to the presence of hyperkalemia. This case suggested a need for clinicians to consider the possible coincidence of adrenal insufficiency in a patient with MG and hyperkalemia. Early hormone supplementation should be begun.
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Affiliation(s)
- Mi-Chu Lin
- Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Republic of China
| | - Ming-Hsien Tsai
- Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Republic of China
- Fu-Jen Catholic University School of Medicine, Taipei, Taiwan, Republic of China
| | - Jyh-Gang Leu
- Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Republic of China
- Fu-Jen Catholic University School of Medicine, Taipei, Taiwan, Republic of China
| | - Yu-Wei Fang
- Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Republic of China
- Fu-Jen Catholic University School of Medicine, Taipei, Taiwan, Republic of China
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Amaya-Uribe L, Rojas M, Azizi G, Anaya JM, Gershwin ME. Primary immunodeficiency and autoimmunity: A comprehensive review. J Autoimmun 2019; 99:52-72. [PMID: 30795880 DOI: 10.1016/j.jaut.2019.01.011] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023]
Abstract
The primary immunodeficiency diseases (PIDs) include many genetic disorders that affect different components of the innate and adaptive responses. The number of distinct genetic PIDs has increased exponentially with improved methods of detection and advanced laboratory methodology. Patients with PIDs have an increased susceptibility to infectious diseases and non-infectious complications including allergies, malignancies and autoimmune diseases (ADs), the latter being the first manifestation of PIDs in several cases. There are two types of PIDS. Monogenic immunodeficiencies due to mutations in genes involved in immunological tolerance that increase the predisposition to develop autoimmunity including polyautoimmunity, and polygenic immunodeficiencies characterized by a heterogeneous clinical presentation that can be explained by a complex pathophysiology and which may have a multifactorial etiology. The high prevalence of ADs in PIDs demonstrates the intricate relationships between the mechanisms of these two conditions. Defects in central and peripheral tolerance, including mutations in AIRE and T regulatory cells respectively, are thought to be crucial in the development of ADs in these patients. In fact, pathology that leads to PID often also impacts the Treg/Th17 balance that may ease the appearance of a proinflammatory environment, increasing the odds for the development of autoimmunity. Furthermore, the influence of chronic and recurrent infections through molecular mimicry, bystander activation and super antigens activation are supposed to be pivotal for the development of autoimmunity. These multiple mechanisms are associated with diverse clinical subphenotypes that hinders an accurate diagnosis in clinical settings, and in some cases, may delay the selection of suitable pharmacological therapies. Herein, a comprehensively appraisal of the common mechanisms among these conditions, together with clinical pearls for treatment and diagnosis is presented.
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Affiliation(s)
- Laura Amaya-Uribe
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia; Doctoral Program in Biomedical Sciences, Universidad Del Rosario, Bogota, Colombia
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA.
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Pellegrino M, Bellacchio E, Dhamo R, Frasca F, Betterle C, Fierabracci A. A Novel Homozygous Mutation of the AIRE Gene in an APECED Patient From Pakistan: Case Report and Review of the Literature. Front Immunol 2018; 9:1835. [PMID: 30150985 PMCID: PMC6099424 DOI: 10.3389/fimmu.2018.01835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/25/2018] [Indexed: 11/13/2022] Open
Abstract
Autoimmune-poly-endocrinopathy-candidiasis-ectodermal-dystrophy syndrome (APECED) is a rare monogenic recessive disorder caused by mutations in the autoimmune regulator (AIRE) gene. Criteria for the diagnosis of APECED are the presence of two of the following disorders: chronic mucocutaneous candidiasis (CMC), chronic hypoparathyroidism (CHP), and Addison's disease. APECED develops at high incidence in Finns, Sardinians, and Iranian Jews and presents with a wide range of clinical phenotypes and genotypes. In this manuscript, we report the clinical, endocrinological, and molecular features of a 16-year-old female patient from Pakistan living in Italy and presenting the major APECED clinical manifestations CMC, CHP, and primary adrenal insufficiency. Premature ovarian failure, chronic bronchopneumopathy, vitiligo, Hashimoto's thyroiditis emerged as associated diseases. In our patient, AIRE gene screening revealed the novel c.396G>C (p.Arg132Ser; p.R132S) mutation in homozygosity thus confirming APECED diagnosis. This is the first reported mutation within the nuclear localization signal (NLS) that is associated with APECED. The NLS mutation affects the nuclear import of classical transcription factors through nuclear pore by recognition of nuclear import receptors, the importin α molecules. By displaying crystal structures of the peptide containing the KRK basic residue cluster bound to α importins, we show that p.R132S replacement in 131-KRK-133 does not reproduce these interactions. Thus, we propose that the novel mutation exerts its pathogenetic effect by impairing the nuclear import of the Aire protein. The present case report is added to a limited series of Pakistani APECED patients who we reviewed from the scientific literature, mostly diagnosed on clinical findings.
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Affiliation(s)
- Marsha Pellegrino
- Infectivology and Clinical Trials Research Division, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Emanuele Bellacchio
- Molecular Genetics and Functional Genomics, Genetics and Rare Diseases Research Division, Bambino Gesù Children’s Hospital, Rome, Italy
| | | | - Federica Frasca
- Infectivology and Clinical Trials Research Division, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Corrado Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Alessandra Fierabracci
- Infectivology and Clinical Trials Research Division, Bambino Gesù Children’s Hospital, Rome, Italy
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21
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APECED in Turkey: A case report and insights on genetic and phenotypic variability. Clin Immunol 2018; 194:60-66. [PMID: 30018023 DOI: 10.1016/j.clim.2018.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 01/06/2023]
Abstract
APECED is a rare monogenic recessive disorder caused by mutations in the AIRE gene. In this manuscript, we report a male Turkish patient with APECED syndrome who presented with chronic mucocutaneous candidiasis associated with other autoimmune manifestations developed over the years. The presence of the homozygous R257X mutation of the AIRE gene confirmed the diagnosis of APECED syndrome. We further performed literature review in 23 published Turkish APECED patients and noted that Finnish major mutation R257X is common in Turks. In particular, we assessed retrospectively how often the Ferre/Lionakis criteria would have resulted in earlier diagnosis in Finns, Sardinians and Turks in respect to the classic criteria. Since an earlier diagnosis could have been possible in 18.8% of Turkish, in 23.8% of Sardinian and 38.55% of Finnish patients we reviewed from literature, Ferre/Lionakis criteria could indeed allow in future earlier initiation of immunomodulatory treatments, if found effective in future studies.
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Lovewell TRJ, McDonagh AJG, Messenger AG, Azzouz M, Tazi-Ahnini R. Meta-Analysis of Autoimmune Regulator-Regulated Genes in Human and Murine Models: A Novel Human Model Provides Insights on the Role of Autoimmune Regulator in Regulating STAT1 and STAT1-Regulated Genes. Front Immunol 2018; 9:1380. [PMID: 30002654 PMCID: PMC6031710 DOI: 10.3389/fimmu.2018.01380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 06/04/2018] [Indexed: 12/14/2022] Open
Abstract
Autoimmune regulator (AIRE) regulates promiscuous expression of tissue-restricted antigens in medullary epithelial cells (mTEC) of the thymus. To understand the diverse effects of AIRE, it is crucial to elucidate the molecular mechanisms underlying the process of AIRE-regulated gene expression. In this study, we generated a recombinant AIRE expression variant of the TEC 1A3 human cell line, TEC 1A3 AIREhi, to determine genes targeted by AIRE, and using microarray analysis, we identified 482 genes showing significant differential expression (P < 0.05; false discovery rate <5%), with 353 upregulated and 129 downregulated by AIRE expression. Microarray data were validated by quantitative PCR, confirming the differential expression of 12 known AIRE-regulated genes. Comparison of AIRE-dependent differential expression in our cell line model with murine datasets identified 447 conserved genes with a number of transcription regulatory interactions, forming several key nodes, including STAT1, which had over 30 interactions with other AIRE-regulated genes. As STAT1 mutations cause dominant chronic mucocutaneous candidiasis and decreased STAT1 levels in monocytes of autoimmune polyglandular syndrome 1 (APS-1) patients, it was important to further characterize AIRE–STAT1 interactions. TEC 1A3AIREhi were treated with the STAT1 phosphorylation inhibitors fludarabine and LLL3 showed that phosphorylated STAT1 (p-STAT1) was not responsible for any of the observed differential expression. Moreover, treatment of TEC 1A3 AIREhi with STAT1 shRNA did not induce any significant variation in the expression of unphosphorylated STAT1 (U-STAT1) downstream genes, suggesting that these genes were directly regulated by AIRE but not via U-STAT1. The novel model system we have developed provides potential opportunities for further analysis of the pathogenesis of (APS-1) and the wider roles of the AIRE gene.
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Affiliation(s)
- Thomas R J Lovewell
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Andrew J G McDonagh
- Department of Dermatology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Andrew G Messenger
- Department of Dermatology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Mimoun Azzouz
- Department of Neuroscience, The Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Rachid Tazi-Ahnini
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School, University of Sheffield, Sheffield, United Kingdom
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23
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Letourneau LR, Greeley SAW. Congenital Diabetes: Comprehensive Genetic Testing Allows for Improved Diagnosis and Treatment of Diabetes and Other Associated Features. Curr Diab Rep 2018; 18:46. [PMID: 29896650 PMCID: PMC6341981 DOI: 10.1007/s11892-018-1016-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to provide updates on congenital (neonatal) diabetes from 2011 to present, with an emphasis on publications from 2015 to present. RECENT FINDINGS There has been continued worldwide progress in uncovering the genetic causes of diabetes presenting within the first year of life, including the recognition of nine new causes since 2011. Management has continued to be refined based on underlying molecular cause, and longer-term experience has provided better understanding of the effectiveness, safety, and sustainability of treatment. Associated conditions have been further clarified, such as neurodevelopmental delays and pancreatic insufficiency, including a better appreciation for how these "secondary" conditions impact quality of life for patients and their families. While continued research is essential to understand all forms of congenital diabetes, these cases remain a compelling example of personalized genetic medicine.
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Affiliation(s)
- Lisa R Letourneau
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Kovler Diabetes Center, The University of Chicago, MC 1027/N235; 5841 S. Maryland Ave., Chicago, IL, 60637, USA
| | - Siri Atma W Greeley
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Kovler Diabetes Center, The University of Chicago, MC 1027/N235; 5841 S. Maryland Ave., Chicago, IL, 60637, USA.
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Abstract
Type 1 diabetes (T1D) affects millions of people worldwide and is the prevalent form of all pediatric diabetes diagnoses. T1D is recognized to have an autoimmune etiology, since failure in specific self-tolerance mechanisms triggers immune reactions towards self-antigens and causes disease onset. Among all the different immunocytes involved in T1D etiopathogenesis, a relevant role of natural killer cells (NKs) is currently emerging. NKs represent the interface between innate and adaptive immunity; they intervene in the defense against infections and present, at the same time, typical features of the adaptive immune cells, such as expansion and generation of memory cells. Several recent studies, performed both in animal models and in human diabetic patients, revealed aberrations in NK cell frequency and functionality in the peripheral blood and in damaged tissues, suggesting their possible redirection towards affected tissues. NKs oscillate from a quiescent to an activated state through a delicate balance of activating and inhibitory signals transduced via surface receptors. Further accurate investigations are needed to elucidate the exact role of NKs in T1D, in order to develop novel immune-based therapies able to reduce the disease risk or delay its onset.
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Abstract
About two decades ago, cloning of the autoimmune regulator (AIRE) gene materialized one of the most important actors on the scene of self-tolerance. Thymic transcription of genes encoding tissue-specific antigens (ts-ags) is activated by AIRE protein and embodies the essence of thymic self-representation. Pathogenic AIRE variants cause the autoimmune polyglandular syndrome type 1, which is a rare and complex disease that is gaining attention in research on autoimmunity. The animal models of disease, although not identically reproducing the human picture, supply fundamental information on mechanisms and extent of AIRE action: thanks to its multidomain structure, AIRE localizes to chromatin enclosing the target genes, binds to histones, and offers an anchorage to multimolecular complexes involved in initiation and post-initiation events of gene transcription. In addition, AIRE enhances mRNA diversity by favoring alternative mRNA splicing. Once synthesized, ts-ags are presented to, and cause deletion of the self-reactive thymocyte clones. However, AIRE function is not restricted to the activation of gene transcription. AIRE would control presentation and transfer of self-antigens for thymic cellular interplay: such mechanism is aimed at increasing the likelihood of engagement of the thymocytes that carry the corresponding T-cell receptors. Another fundamental role of AIRE in promoting self-tolerance is related to the development of thymocyte anergy, as thymic self-representation shapes at the same time the repertoire of regulatory T cells. Finally, AIRE seems to replicate its action in the secondary lymphoid organs, albeit the cell lineage detaining such property has not been fully characterized. Delineation of AIRE functions adds interesting data to the knowledge of the mechanisms of self-tolerance and introduces exciting perspectives of therapeutic interventions against the related diseases.
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Affiliation(s)
- Roberto Perniola
- Department of Pediatrics, Neonatal Intensive Care, Vito Fazzi Regional Hospital, Lecce, Italy
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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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Insights into the Diagnostic Potential of Extracellular Vesicles and Their miRNA Signature from Liquid Biopsy as Early Biomarkers of Diabetic Micro/Macrovascular Complications. Int J Mol Sci 2017; 18:ijms18091974. [PMID: 28906481 PMCID: PMC5618623 DOI: 10.3390/ijms18091974] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/07/2017] [Accepted: 09/13/2017] [Indexed: 12/15/2022] Open
Abstract
Extracellular vesicles (EVs) represent a heterogeneous population of small vesicles, consisting of a phospholipidic bilayer surrounding a soluble interior cargo. Almost all cell types release EVs, thus they are naturally present in all body fluids. Among the several potential applications, EVs could be used as drug delivery vehicles in disease treatment, in immune therapy because of their immunomodulatory properties and in regenerative medicine. In addition to general markers, EVs are characterized by the presence of specific biomarkers (proteins and miRNAs) that allow the identification of their cell or tissue origin. For these features, they represent a potential powerful diagnostic tool to monitor state and progression of specific diseases. A large body of studies supports the idea that endothelial derived (EMPs) together with platelet-derived microparticles (PMPs) are deeply involved in the pathogenesis of diseases characterized by micro- and macrovascular damages, including diabetes. Existing literature suggests that the detection of circulating EMPs and PMPs and their specific miRNA profile may represent a very useful non-invasive signature to achieve information on the onset of peculiar disease manifestations. In this review, we discuss the possible utility of EVs in the early diagnosis of diabetes-associated microvascular complications, specifically related to kidney.
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Pathogenic and Protective Autoantibodies in Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED). Antibodies (Basel) 2017; 6:antib6010001. [PMID: 31548517 PMCID: PMC6698825 DOI: 10.3390/antib6010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 01/13/2017] [Indexed: 12/31/2022] Open
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare disorder caused by mutations in the autoimmune regulator (AIRE) gene, leading to defects in T cell selection. The disease manifestations include both autoimmune tissue destruction and immunodeficiency, with specific susceptibility to chronic mucocutaneous candidiasis. Studies have demonstrated a wide repertoire of high affinity tissue- and cytokine-specific antibodies in patients with APECED. Here, we review the antigenic targets and function of these disease-causing and disease-ameliorating antibodies.
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