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Zhong L, Wang W, Tang X, Zhang Y, Gou L, Wang L, Wang C, Jian S, Quan M, Zhang Z, Yu Z, Qiu Z, Wei M, Song H. Phenotype of Takayasu-like vasculitis and cardiopathy in patients with Blau syndrome. Clin Rheumatol 2024; 43:1171-1181. [PMID: 38253779 DOI: 10.1007/s10067-024-06876-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 12/24/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVES We aimed to determine the prevalence of cardiovascular involvement in our Blau syndrome (BS) cohort and provide detailed analysis of their cardiovascular manifestations and outcome. We also tried to find out the risk factors for developing cardiovascular involvement. METHODS Clinical manifestations, laboratory findings, and treatments were reviewed. Clinical features were compared between children with cardiovascular involvement and those without angiocardiopathy. RESULTS A total of 38 BS children were eligible for final analysis. Among them, 13 (34.2%) developed Takayasu-like vasculitis and/or cardiopathy. Compared with those without angiocardiopathy, recurrent fever was more frequent in BS patients with cardiovascular involvement (p < 0.001). What is more, tumor necrosis factor alpha antagonists (anti-TNF) were more urgently needed in children with cardiovascular involvement (p = 0.015). BS patients with cardiovascular involvement include 4 with Takayasu-like vasculitis and 9 with cardiopathy. The onset of cardiovascular manifestations ranged from 0.75 to 18.5 years of age, with most cases occurring before school period. Symptoms were elusive and lacked specificity, such as dizziness, short of breath, and edema. Some patients were even identified because of the unexpected hypertension during follow-up. Cardiopathy and vasculitis occurred in patients with different genotypes. Imaging changes were discovered before the presentation of the typical triad in 3/4 patients with Takayasu-like vasculitis. Three children developed left ventricular dysfunction with decreased left ventricular ejection fraction. Combination of glucocorticoids and methotrexate with anti-TNF agents is a common treatment option for these BS patients. In the cohort, BS-related cardiovascular involvement was controlled well, with cardiac structural and functional abnormalities completely recovered and slower progression of vasculitis lesions. CONCLUSION Cardiovascular manifestations is not rare in BS patients. Because of its insidious onset, a systematic and comprehensive assessment of cardiovascular involvement should be performed in newly diagnosed patients with BS. Aggressive initiation of anti-TNF agents may be beneficial to improve the prognosis. Key Points • About 34.2% patients with Blau syndrome developed Takayasu-like vasculitis and/or cardiopathy. • Compared with those without angiocardiopathy, recurrent fever and application of anti-TNF agents were more frequent in BS patients with cardiovascular involvement (p < 0.001, p = 0.015) • Regular assessment of cardiovascular involvement is extremely necessary because of its insidious onset.
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Affiliation(s)
- Linqing Zhong
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Wei Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xiaoyan Tang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yu Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lijuan Gou
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Lin Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Changyan Wang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Shan Jian
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Meiying Quan
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhenjie Zhang
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhongxun Yu
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zhengqing Qiu
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Min Wei
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Hongmei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Kreps EO, Al Julandani D, Guly CM, Arostegui JI, Dick AD, Ramanan AV. Long-Term Visual Outcome of Patients with Blau Syndrome. Ocul Immunol Inflamm 2024:1-5. [PMID: 38180755 DOI: 10.1080/09273948.2023.2293922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE To document the long-term visual outcomes in patients with Blau syndrome. METHODS A retrospective institutional cohort study was conducted, and 13 patients with genetically confirmed Blau syndrome were included. Demographic and clinical data were collected from standardised medical charts. Baseline was defined as the first detected uveitis and data were recorded onwards at intervals of 1, 3, 5, 10, 15 and 20 years. RESULTS Anterior uveitis was the most common classification at baseline (57.1%). Among patients with documented uveitis lasting 10 years or more, all of them developed panuveitis. Median logMAR visual acuity at baseline was 0 (range -0.5; 0.7), 0.19 (range 0; 1.5) at year 5, and 0.7 (range 0.1 - no perception of light) at year 20, as recorded in 13, 16, and 10 eyes, respectively. All patients received treatment with topical and oral steroids, and multiple systemic immunosuppressants including biologics. Disease control, defined as having cells <1+ in both eyes and using topical steroid eye drops less than twice daily, was achieved in 14.3% to 37.5% of patients at the different time points. Cataract surgery was performed in 12 eyes of 8 patients, 3 eyes of 3 patients necessitated glaucoma surgery, and 4 eyes of 4 patients required surgery for retinal detachment. CONCLUSION Uveitis associated with Blau syndrome commonly leads to severe, chronic panuveitis, requiring long-term systemic immunosuppression. Early diagnosis and timely initiation of biologics may prevent significant visual impairment.
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Affiliation(s)
- Elke O Kreps
- Department of Ophthalmology, Ghent University Hospital, Ghent, Belgium
| | - Dalila Al Julandani
- Department of Pediatric Rheumatology, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Catherine M Guly
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Juan I Arostegui
- Department of Immunology, Hospital Clínic, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain
| | - Andrew D Dick
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Institute of Ophthalmology, University College London, London, UK
- Academic Unit of Ophthalmology, Translational Health Sciences, University of Bristol, Bristol, UK
- NIHR Biomedical Research Centre of Ophthalmology, Moorfields Eye Hospital, London, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Pediatric Rheumatology, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
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Saigal K, Maleki A. Intravitreal Fluocinolone Acetonide 0.19 mg Implant in a Patient with Resistant Blau Syndrome: A Case Report. Case Rep Ophthalmol 2024; 15:63-70. [PMID: 38250196 PMCID: PMC10798681 DOI: 10.1159/000535984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/17/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Blau syndrome is a progressive disease with an unknown etiology and pathogenesis. It can cause severe damage, especially in the eye with severe involvement. Case Presentation A six-year-old female was referred to us complaining about blurry vision and floaters in both eyes for 1 year. She had been diagnosed with Blau syndrome and Blau syndrome-associated anterior uveitis. Her best-corrected visual acuity in the right and left eyes was 20/70 and 20/80, respectively. Slit-lamp exam revealed faint bilateral band keratopathy along with 1+ anterior chamber cells and posterior synechia 360° in both eyes. During dilated fundoscopy, 2+ haze in the media was observed, along with swollen and hyperemic disc OU. Based on changes in optical coherence tomography, fluorescein angiography, and indocyanine green angiography, she was diagnosed with panuveitis and retinal vasculitis. Given her complicated history, we decided to proceed with an intravitreal fluocinolone acetonide 0.19 mg implant implantation in both eyes. During the 1-month follow-up visit, vitreous haze, retinal vasculitis, and active choroiditis were resolved. At 6-month follow-up visit, no changes were observed compared to the 1-month follow-up visit. Conclusion In cases of Blau syndrome that display resistance to systemic immunomodulatory therapies, the inclusion of local treatments, such as the intravitreal fluocinolone acetonide 0.19 mg implant, should be considered as an adjunctive therapeutic option.
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Affiliation(s)
- Khushi Saigal
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Arash Maleki
- Department of Ophthalmology, University of Florida, Gainesville, FL, USA
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
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Lassoued Ferjani H, Kharrat L, Ben Nessib D, Kaffel D, Maatallah K, Hamdi W. Management of Blau syndrome: review and proposal of a treatment algorithm. Eur J Pediatr 2024; 183:1-7. [PMID: 37735224 DOI: 10.1007/s00431-023-05204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/16/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
Blau syndrome is a rare genetic granulomatosis affecting children. It could be responsible for vision-threatening complications and articular deformation. Due to the rarity of this disease, there are no standardized guidelines for its management. This work aimed to provide an updated overview of the different therapeutic options for Blau syndrome. We conducted research in the PubMed database for the different treatments used in Blau syndrome patients, and we proposed a therapeutic algorithm for disease management. High doses of corticosteroids are considered as a bridging therapy in Blau syndrome. Methotrexate should be initiated if the patient has articular or ocular involvement. An anti-tumor necrosis factor α should be added for patients with uveitis or residual arthritis. If the patient remains symptomatic, a switch to another anti-tumor necrosis factor α is the best option. In non-responders to the first- and second-line biotherapies, a switch to an anti-interleukin 1, an anti-interleukin 6, or tofacitinib is necessary. CONCLUSION This article suggested an algorithm for the treatment of Blau syndrome. Other studies are necessary to confirm the efficacy of these treatments. WHAT IS KNOWN • Blau syndrome is a rare but severe granulomatosis that could be responsible for vision-threatening complications and articular deformation. • Blau syndrome seems to be refractory to treatments. WHAT IS NEW • High doses of corticosteroids are usually insufficient and should be considered only as a bridging therapy. • Blau syndrome could be considered as a poor factor for uveitis, thus, an anti-tumor necrosis factor α should be initiated for patients with uveitis or with residual arthritis.
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Affiliation(s)
- Hanene Lassoued Ferjani
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Lobna Kharrat
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Dorra Ben Nessib
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Dhia Kaffel
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Kaouther Maatallah
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Wafa Hamdi
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
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Ma Z, Gao X, Zhu S. Late-Onset Panuveitis in a Chinese Girl with Sporadic Blau Syndrome: A Case Report. Case Rep Ophthalmol 2024; 15:388-393. [PMID: 38660583 PMCID: PMC11042796 DOI: 10.1159/000536005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/15/2023] [Indexed: 04/26/2024] Open
Abstract
Introduction Blau syndrome (BS) is a rare autoimmune disease. We report here an atypical case of BS. Case Presentation We present a case of late-onset eye manifestations in a Chinese girl of 18 years old with sporadic BS, presenting with panuveitis. We performed comprehensive ocular examinations including fluorescein fundus angiography and indocyanine green angiography for her. The oral hormone plus local anti-inflammatory eye drops have well controlled the inflammation of her eyes. Conclusion Our case highlights the necessity of systemic medical history inquiry for every eye discomfort.
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Affiliation(s)
- Zicheng Ma
- Department of Ophthalmology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xinxiao Gao
- Department of Ophthalmology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Siquan Zhu
- Department of Ophthalmology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Zhong Z, Dai L, Ding J, Gao Y, Su G, Zhu Y, Deng Y, Li F, Gao Y, Yang P. Molecular diagnostic yield for Blau syndrome in previously diagnosed juvenile idiopathic arthritis with uveitis or cutaneous lesions. Rheumatology (Oxford) 2023:kead596. [PMID: 37941393 DOI: 10.1093/rheumatology/kead596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/24/2023] [Accepted: 10/03/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE Diagnostic pitfalls often arise in the community because of potentially misleading similarities between juvenile idiopathic arthritis (JIA) and Blau syndrome, an immune-related disorder caused by NOD2 gene mutations. It remains unclear in which population and to which extent next-generation sequencing techniques can aid in diagnosis. METHODS We evaluated clinical usefulness of targeted next-generation sequencing in previously diagnosed JIA. Participants were required to have symptoms and signs suspected of Blau syndrome, including at least uveitis or cutaneous lesions in addition to arthritis. Targeted sequencing was conducted on NOD2 gene to detect diagnostic variants classified as pathogenic or likely pathogenic for Blau syndrome. We assessed the molecular diagnostic yield and clinical implications on patient care. RESULTS Between May 1, 2008, and June 1, 2021, sequencing data were accrued from 123 previously diagnosed JIA (median age: 5 years; female: 62.6%). Targeted NOD2 sequencing yielded a positive molecular diagnosis of Blau syndrome in 21.1% (95% CI, 14.9%-29.2%), encompassing six heterozygous missense mutations classified as pathogenic variants. Among those receiving a molecular diagnosis, changes in clinical management and treatment were considered as having occurred in 38.5%. Nine predictors were identified to be associated with a higher diagnostic yield, providing clinical clues to suspect the possibility of Blau syndrome. CONCLUSION Among some patients with pediatric-onset arthritis complicated with uveitis or cutaneous lesions, reassessing their diagnosis of JIA may be warranted. Targeted NOD2 sequencing established the molecular diagnosis of Blau syndrome in nearly one fifth of these cases and provided clinically relevant information for patient-care decisions.
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Affiliation(s)
- Zhenyu Zhong
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, and Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, China
| | - Lingyu Dai
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, and Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, China
| | - Jiadong Ding
- The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, and Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, Zhengzhou, China
| | - Yu Gao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, and Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, China
| | - Guannan Su
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, and Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, China
| | - Yunyun Zhu
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, and Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, China
| | - Yang Deng
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, and Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, China
| | - Fuzhen Li
- The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, and Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, Zhengzhou, China
| | - Yuan Gao
- Southwest Hospital/Southwest Eye Hospital, Third Military Medical University, and Key Lab of Visual Damage and Regeneration & Restoration of Chongqing, Chongqing, China
| | - Peizeng Yang
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, and Chongqing Branch of National Clinical Research Center for Ocular Diseases, Chongqing, China
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Jensen ME, Harrell K, McBride JD. Case Report: Methotrexate and hydroxychloroquine in combination for the treatment of NOD2-mutation-associated Blau syndrome. Front Immunol 2023; 14:1279329. [PMID: 37868966 PMCID: PMC10585138 DOI: 10.3389/fimmu.2023.1279329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/11/2023] [Indexed: 10/24/2023] Open
Abstract
Mutations in nucleotide binding oligomerization domain containing 2 receptor (NOD2) are associated with Blau syndrome (also known as early-onset sarcoidosis)-a rare autosomal dominant, chronic granulomatous disease that typically presents before 5 years of age. Blau syndrome is characterized by the clinical triad of arthritis, granulomatous dermatitis, and recurrent uveitis. Here, we report a case of NOD2-mutation-associated early-onset sarcoidosis in which a combination of methotrexate and hydroxychloroquine was used to achieve improvement in arthritis, granulomatous dermatitis, and uveitis. A 13-month-old boy presented with a sudden-onset cutaneous eruption affecting the face, trunk, and extremities that initially mimicked papular atopic dermatitis but progressively worsened despite topical steroid therapy. The patient had no other known medical comorbidities or abnormalities except for heterochromia of the right eye. However, prior to presentation to dermatology, the patient began experiencing frequent falls, conjunctival injection, and apparent eye and joint pain. Skin biopsy from the right shoulder demonstrated rounded aggregates of epithelioid histiocytes and multinucleated giant cells without a significant lymphocytic component ("naked granulomas"), consistent with sarcoidal granulomatous dermatitis. Given the concern for Blau syndrome, the patient was sent for evaluation by ophthalmology and was found to have bilateral subconjunctival nodules. Our patient underwent genetic testing and was found to have a mutation in codon 1000 C > T (protein R334W) in the NOD2 gene. The patient responded to oral prednisolone 2 mg/kg/day for 8 weeks, but quickly relapsed, requiring a second 8-week course with taper upon starting methotrexate 7.5 mg subcutaneously weekly with 1 mg folic acid orally daily. After 8 weeks on methotrexate, due to persistent arthritis, conjunctival injection, and pruritus, and in consultation with rheumatology, the patient was started on hydroxychloroquine 75 mg orally daily along with continuation of 7.5 mg methotrexate subcutaneously weekly for 8 weeks, achieving significant reduction in arthritis, pruritus, and uveitis. After 8 weeks of this combination therapy, due to concerns of long-term macular toxicity, hydroxychloroquine was discontinued in favor of continuing methotrexate alone. The patient has remained free of significant side effects and stable with good disease control on 7.5 mg methotrexate weekly injected subcutaneously.
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Affiliation(s)
- Mary Ellen Jensen
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Katelin Harrell
- Department of Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Jeffrey D. McBride
- Department of Dermatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Wang Z, Yang M, Zhang Q, Zhang S, Sui H, Liu J, Yang Q. Blau syndrome with NOD2 mutation in a 54-year-old man: A case report. Int J Rheum Dis 2023; 26:2080-2084. [PMID: 37246600 DOI: 10.1111/1756-185x.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/16/2023] [Indexed: 05/30/2023]
Abstract
Blau syndrome (BS) is a rare genetic immune disease which commonly presents in childhood. Currently, the miss-rate of BS diagnosis is very high, and an effective clinical management of BS has not been well established. This case report depicts a 54-year-old male Chinese patient presenting with hand malformation, fever, skin rash and joint pain. His diagnosis was ultimately confirmed according to typical medical history and genetic analysis. This case report will further help clinicians to be aware of this rare clinical entity for correct diagnosis and proper treatment.
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Affiliation(s)
- Zhiyan Wang
- Department of Immunology and Rheumatology, Shouguang People's Hospital, Shouguang, China
| | - Mingdong Yang
- Department of Immunology and Rheumatology, Shouguang People's Hospital, Shouguang, China
| | - Qunqun Zhang
- Department of Immunology and Rheumatology, Shouguang People's Hospital, Shouguang, China
| | - Suhua Zhang
- Department of Immunology and Rheumatology, Shouguang People's Hospital, Shouguang, China
| | - Haifang Sui
- Department of Immunology and Rheumatology, Shouguang People's Hospital, Shouguang, China
| | - Jiane Liu
- Department of Reproductive Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qingrui Yang
- Department of Immunology and Rheumatology, Shandong Provincial Hospital, Jinan, China
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Deek SM, Shubietah AR, Atatri Y, Najjar M, Zakaria Z, Abu Tayyem N, Habayeb L, Maree M, AbuMohsen H. A diagnostic challenge: misdiagnosing Blau syndrome as juvenile dermatomyositis in a pediatric patient. Ann Med Surg (Lond) 2023; 85:4619-4623. [PMID: 37663701 PMCID: PMC10473286 DOI: 10.1097/ms9.0000000000001090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/09/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Blau syndrome (BS) and juvenile dermatomyositis (JDM) are distinct conditions with different pathophysiological mechanisms. Accurate diagnosis of BS can be challenging due to overlapping clinical features with other inflammatory conditions. This case is being reported to highlight a pediatric case initially diagnosed with JDM, and subsequently found to have BS through genetic testing. Case Presentation We present the case of a 4-year-old Arab male initially diagnosed with JDM based on skin manifestations, negative histology for another disease, and no other clinical features suggestive of an alternate diagnosis. However, subsequent symptoms suggestive of BS emerged, leading to genetic testing confirmation of BS, marking the second reported case in the region. This unique clinical scenario highlights the challenges in diagnosing BS and the potential for misinterpretation of the skin rash as JDM. Accurate differentiation between these conditions is crucial to guide appropriate management and prevent delays in treatment. Discussion The diagnostic process for JDM involves clinical evaluation, laboratory investigations, imaging, and biopsy findings. However, muscle biopsy may yield false-negative results. BS has been misdiagnosed as other conditions, such as Kawasaki disease and juvenile idiopathic arthritis, due to overlapping clinical features. This case highlights the significance of a thorough diagnostic strategy for BS that takes into account any potentially negative histopathology findings. A precise diagnosis is essential since misdiagnosis can result in inadequate or delayed therapy. Conclusion The diverse presentation of the skin rash in BS can pose difficulties for physicians in distinguishing it from other pediatric rheumatological conditions, such as JDM.
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Affiliation(s)
- Soud M.S. Deek
- Faculty of Medicine and Health Sciences, An-Najah National University
| | | | - Yazid Atatri
- Faculty of Medicine and Health Sciences, An-Najah National University
| | - Mohab Najjar
- Palestinian Ministry of Health, Thabet Thabet Government Hospital, Tulkarm
| | - Zaid Zakaria
- Department of Surgery, Rafidia Government Surgical Hospital
| | - Nours Abu Tayyem
- Palestinian Ministry of Health, Darwish Nazzal Government Hospital, Qalqilya
| | - Lanah Habayeb
- Faculty of Medicine and Health Sciences, An-Najah National University
| | - Mosab Maree
- Department of Radiology, An-Najah National University Hospital
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus
| | - Haytham AbuMohsen
- Palestinian Ministry of Health, Tubas Government Hospital, Tubas, Palestine
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Alotaibi BM, Lopez Rodriguez R, Garrido CV, Gonzalez Bravo L, Khalidi N, Nair P. Autoinflammatory gene mutations associated with eosinophilia and asthma. Allergy Asthma Clin Immunol 2023; 19:76. [PMID: 37644591 PMCID: PMC10463689 DOI: 10.1186/s13223-023-00837-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Respiratory conditions, such as asthma, are infrequently associated with auto-inflammatory diseases. We describe five patients with uncontrolled respiratory symptoms that were seen at St. Joesph's Healthcare in Hamilton for severe asthma management diagnosed with rare autoinflammatory conditions using genetic molecular analysis. CASE PRESENTATION Five patients are included in this case series. Gene mutations associated with familial Mediterranean fever, Yao syndrome, Cryopyrin-associated periodic syndrome, and Majeed syndrome were considered to explain partly the patient's clinical manifestation after comprehensive clinical, biochemical, hematological investigations ruled out other disorders such as parasitosis, Allergic Bronchopulmonary Fungosis, Eosinophilic Granulomatosis with Poly Angitis, IgG4 disease, and Hypereosinophilia syndrome. CONCLUSIONS Complex patients initially presenting with respiratory conditions in addition to unexplained autoinflammatory conditions are a diagnostic challenge. Genetic molecular testing provides healthcare practitioners with useful information that may diagnose underlying auto-inflammatory diseases in undifferentiated patients. Role of inflammasome-activation in asthma and eosinophilia needs further investigation.
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Affiliation(s)
- Bashayr M Alotaibi
- Divisions of Respirology, Department of Medicine, McMaster University & St Joseph's Healthcare, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
- Division of Pulmonary Medicine, Department of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Raquel Lopez Rodriguez
- Divisions of Respirology, Department of Medicine, McMaster University & St Joseph's Healthcare, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - Carmen Venegas Garrido
- Divisions of Respirology, Department of Medicine, McMaster University & St Joseph's Healthcare, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - Lucia Gonzalez Bravo
- Divisions of Respirology, Department of Medicine, McMaster University & St Joseph's Healthcare, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - Nader Khalidi
- Divisions of Rheumatology, Department of Medicine, McMaster University & St Joseph's Healthcare, Hamilton, ON, Canada
| | - Parameswaran Nair
- Divisions of Respirology, Department of Medicine, McMaster University & St Joseph's Healthcare, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada.
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11
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Yao F, Tan B, Wu D, Shen M. Blau syndrome with hypertension and hepatic granulomas: a case report and literature review. Front Pediatr 2023; 11:1063222. [PMID: 37576148 PMCID: PMC10415045 DOI: 10.3389/fped.2023.1063222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 07/05/2023] [Indexed: 08/15/2023] Open
Abstract
Background Blau syndrome (BS) is a monogenic disorder caused by NOD2 gene variants characterized by the triad of granulomatous polyarthritis, rash, and uveitis. Atypical symptoms were recognized in one-third to one-half of individuals with BS. This study aims to describe the clinical features of BS patients with hypertension and digestive system involvement. Methods The complete clinical data of a BS patient complicated with hypertension and hepatic granulomas were collected and documented. We also performed a literature search to find all reported cases of BS with hypertension and digestive system involvement. Results We reported the case of a 19-year-old man who presented with early onset symmetric polyarthritis and hypertension at age 5 and hepatic granulomas and cirrhosis at age 19. He was diagnosed with BS by the finding of a variant of the NOD2 gene (R334W). Through the literature review, 24 patients with BS were found who were reported to have hypertension, and 38 patients were found who had different digestive system manifestations such as hepatic granulomas, hepatosplenomegaly, diverticulitis, and intestinal granuloma. Among the 38 BS patients with digestive system involvement, 14 had hepatic granulomas proven by liver biopsy. Conclusions Hypertension and digestive system involvement are rare manifestations of BS. Clinicians, especially rheumatologists, must be aware of atypical symptoms of BS.
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Affiliation(s)
- Fangling Yao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- Department of Rheumatology and Immunology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Bei Tan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Di Wu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Min Shen
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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12
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Liu M, Zeng Y, Zhong J. Blau syndrome with persistent fetal vasculature: a case report. J Med Case Rep 2023; 17:301. [PMID: 37386644 DOI: 10.1186/s13256-023-03983-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/13/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Blau Syndrome (BS) is a rare autosomal dominant noncaseous granulomatous disease caused by mutations in the NOD2 gene. The disease is characterized by granulomatous dermatitis, symmetrical arthritis, and uveitis, which, if left untreated, can progress to blindness. The diagnosis of BS can be challenging because of its rarity and overlap with other rheumatologic disorders. Early detection of ocular involvement is critical to prevent vision loss and improve the prognosis of patients with BS. CASE PRESENTATION In this report, we present a case of a five-year-old Chinese girl diagnosed with BS one year ago after presenting with a systemic rash and urinary calculi. Genetic testing was recommended by a physician, and a heterozygous mutation of the NOD2 gene c.1538T > C (p.M513T) was identified. Eight months ago, due to bilateral corneal punctate opacity, we had examined and diagnosed bilateral uveitis, bilateral corneal zonal degeneration, persistent fetal vasculature (PFV) in the right eye, and perivascular granuloma in the right eye. As a result, Vitrectomy was performed on the right eye, resulting in a significant improvement in visual acuity from 1/50 on the first day after surgery to 3/10 after 1 week. After 6 months, the visual acuity of the right eye was maintained at 3/20, but opacification of the lens posterior capsule was observed. Follow-up appointments are ongoing to monitor the condition of the affected eyes. Our report underscores the importance of prompt detection and management of ocular involvement in BS accompany with PFV to prevent vision loss and improve patient outcomes. CONCLUSIONS This report details the case of a child diagnosed with BS who accompanied a periretinal granuloma and PFV in the right eye. Regrettably, the left eye was observed to have no light perception (NLP) with the fundus not being visible. The occurrence of ocular complications in patients with BS, must be closely monitored to prevent vision loss and enhance treatment outcomes. This case underscores the importance of prompt diagnosis and management of ocular complications in patients with BS to prevent further damage and optimize patient outcomes.
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Affiliation(s)
- Miao Liu
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yong Zeng
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jie Zhong
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
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13
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Ueki Y, Takimoto-Ito R, Saito MK, Tanizaki H, Kambe N. Tofacitinib, a suppressor of NOD2 expression, is a potential treatment for Blau syndrome. Front Immunol 2023; 14:1211240. [PMID: 37415984 PMCID: PMC10321295 DOI: 10.3389/fimmu.2023.1211240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Blau syndrome is a rare autosomal dominant autoinflammatory granulomatous disease caused by a mutation in the NOD2 gene. It is characterized by a clinical trial of granulomatous dermatitis, arthritis, and uveitis. Tofacitinib is a pan Janus kinase (JAK) inhibitor used for treatment of Blau syndrome and idiopathic sarcoidosis. Here, we evaluated its effect on inflammatory pathways associated with Blau syndrome. The effect of tofacitinib on downstream pathways regulated by mutant NOD2 was analyzed using luciferase assays with overexpression of NOD2 mutants. Methods The effect of tofacitinib on the upstream pathway for the induction of NOD2 expression and proinflammatory cytokine production was assessed using monocytic cell lines differentiated from Blau syndrome patient-derived induced pluripotent stem cells. Results Tofacitinib did not suppress the increased spontaneous transcriptional activity of NF-κB by mutant NOD2. In addition, mutant NOD2 was not involved in the transcription of ISRE and GAS, which are activated by type 1 and type 2 interferons (IFN), respectively. On the other hand, IFNγ induced the expression of NOD2, which led to the production of inflammatory cytokines by an autoinflammatory mechanism only in cells with mutant NOD2. Discussion Tofacitinib suppressed the induction of NOD2 by IFNγ, thereby inhibiting the production of pro-inflammatory cytokines. Thus, tofacitinib showed anti-inflammatory effects through suppression of NOD2 expression. The JAK inhibitor tofacitinib is a potential therapeutic agent for Blau syndrome because it suppresses the autoinflammation seen in Blau syndrome by inhibiting the expression of NOD2.
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Affiliation(s)
- Yoko Ueki
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Riko Takimoto-Ito
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumu K. Saito
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Hideaki Tanizaki
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Naotomo Kambe
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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14
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Dow CT, Lin NW, Chan ED. Sarcoidosis, Mycobacterium paratuberculosis and Noncaseating Granulomas: Who Moved My Cheese. Microorganisms 2023; 11:microorganisms11040829. [PMID: 37110254 PMCID: PMC10143120 DOI: 10.3390/microorganisms11040829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/29/2023] Open
Abstract
Clinical and histological similarities between sarcoidosis and tuberculosis have driven repeated investigations looking for a mycobacterial cause of sarcoidosis. Over 50 years ago, "anonymous mycobacteria" were suggested to have a role in the etiology of sarcoidosis. Both tuberculosis and sarcoidosis have a predilection for lung involvement, though each can be found in any area of the body. A key histopathologic feature of both sarcoidosis and tuberculosis is the granuloma-while the tuberculous caseating granuloma has an area of caseous necrosis with a cheesy consistency; the non-caseating granuloma of sarcoidosis does not have this feature. This article reviews and reiterates the complicity of the infectious agent, Mycobacterium avium subsp. paratuberculosis (MAP) as a cause of sarcoidosis. MAP is involved in a parallel story as the putative cause of Crohn's disease, another disease featuring noncaseating granulomas. MAP is a zoonotic agent infecting ruminant animals and is found in dairy products and in environmental contamination of water and air. Despite increasing evidence tying MAP to several human diseases, there is a continued resistance to embracing its pleiotropic roles. "Who Moved My Cheese" is a simple yet powerful book that explores the ways in which individuals react to change. Extending the metaphor, the "non-cheesy" granuloma of sarcoidosis actually contains the difficult-to-detect "cheese", MAP; MAP did not move, it was there all along.
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Affiliation(s)
- Coad Thomas Dow
- McPherson Eye Research Institute, University of Wisconsin, Madison, WI 53705, USA
| | - Nancy W Lin
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO 80206, USA
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Edward D Chan
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Academic Affairs, National Jewish Health, Denver, CO 80206, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Department of Medicine, Aurora, CO 80045, USA
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15
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Zeng Q, Liu H, Li G, Li Y, Guan W, Zhang T, Gong Y, Zhang X, Lv Q, Wu B, Xu H, Sun L. A Chinese girl of Blau syndrome with renal arteritis and a literature review. Pediatr Rheumatol Online J 2023; 21:23. [PMID: 36915122 DOI: 10.1186/s12969-023-00804-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/26/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Blau syndrome is a rare autoinflammatory disease caused by autosomal dominant mutations in the CARD15/NOD2 gene. Vascular involvement is a rare phenotype in Blau syndrome patients. In this study, we aimed to describe a 20-year- old Chinese girl with Blau syndrome complicated by renal arteritis. In addition, we summarized a literature review of published cases of vascular involvement in patients with Blau syndrome. CASE PRESENTATION We describe a 20-year-old girl who was initially misdiagnosed with juvenile idiopathic arthritis (JIA) almost 15 years prior. In October 2019, she developed renal arteritis at the age of 17 years and was eventually diagnosed with Blau syndrome. A de-novo M513T mutation was found in her gene testing. A review of the literature on patients with Blau syndrome and vasculitis showed that a total of 18 cases were reported in the past 40 years. The vast majority of them were predominantly involved medium and large vessel arteritis. Of the 18 patients included in our literature review, 14 patients had aorto-arteritis, and 4 of them had renal artery involvement. Two patients presented with renal artery stenosis, 1with a sinus of Valsalva aneurysm, and 1 with retinal vasculitis. CONCLUSION A detailed medical history inquiry and a careful physical examination are helpful for the early identification of Blau syndrome, especially for infant onset refractory JIA. Medium-and large-vessel arteritis is a rare clinical manifestation in Blau syndrome patients. Careful examination of the peripheral pulse and measurement of blood pressure at every regular visit may be helpful in the early identification of Blau syndrome-arteritis. Early diagnosis and appropriate treatment may prevent or delay the occurrence of severe symptoms in patients to improve the patient's quality of life.
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16
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Schofield TS, Sup Lee C, Peppers BP, Mauger T. Corneal Ulcers with NOD2 Mutations Presenting with Mixed Syndromic Phenotype. Ocul Immunol Inflamm 2023; 31:119-122. [PMID: 34802386 DOI: 10.1080/09273948.2021.1993268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE To report a case of corneal ulcers in a patient with NOD2 mutations unique to but phenotypically resembling well-characterized syndromic phenotypes like Blau syndrome. OBSERVATION A 25-year-old female with a medical history of type I diabetes mellitus, Asperger syndrome, and neuropathy presented with bilateral corneal ulcers. Her visual acuity was 20/200 OU. Macular edema was identified OS, and posterior synechiae OS suggested a history of anterior uveitis.Genetic testing confirmed NOD2 mutations, and her tear film was positive for matrix metallopeptidase 9. Recent intravenous immunoglobulin therapy improved her neuropathy, and an aggressive regimen of erythromycin ointment and lubrication has improved her ophthalmic symptoms. CONCLUSION AND IMPORTANCE This case advances our understanding of NOD2's role in regulating inflammatory processes of the eye. In addition to precipitating uveitis, patients with these mutations may also be at increased risk of developing corneal pathology related to their reduced capacity to moderate inflammatory processes.
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Affiliation(s)
- Travis Scott Schofield
- Department of Ophthalmology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Chang Sup Lee
- Department of Ophthalmology, West Virginia University Eye Institute, Morgantown, West Virginia, USA
| | - Brian Patrick Peppers
- Department of Pediatrics, Division of Allergy and Immunology, West Virginia University Health System, Morgantown, West Virginia, USA
| | - Thomas Mauger
- Department of Ophthalmology, West Virginia University Eye Institute, Morgantown, West Virginia, USA
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17
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Chang SY, Kambe N, Fan WL, Huang JL, Lee WI, Wu CY. Incomplete penetrance of NOD2 C483W mutation underlining Blau syndrome. Pediatr Rheumatol Online J 2022; 20:86. [PMID: 36192768 PMCID: PMC9531522 DOI: 10.1186/s12969-022-00743-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blau syndrome (BS) is a rare autoinflammatory disorder with NOD2 gain-of-function mutation and characterized by autoactivation of the NFκB pathway. Classically considered a disease of high penetrance, reports on NOD2 mutations underlining BS with incomplete penetrance is limited. CASE PRESENTATION The proband is a 9-year-old girl presented with brownish annular infiltrative plaques and symmetric boggy polyarthritis over bilateral wrists and ankles. Her skin biopsy revealed noncaseating granulomas inflammation with multinucleated giant cells. A novel C483W NOD2 mutation was identify in the proband and her asymptomatic father. Functional examinations including autoactivation of the NFκB pathway demonstrated by in vitro HEK293T NOD2 overexpression test as well as intracellular staining of phosphorylated-NFκB in patient's CD11b+ cells were consistent with BS. CONCLUSIONS We reported a novel C483W NOD2 mutation underlining BS with incomplete penetrance. Moreover, a phosphorylated-NFκB intracellular staining assay of CD11b+ was proposed to assist functional evaluation of NFκB autoactivation in patient with BS.
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Affiliation(s)
- Shao-Yu Chang
- grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Naotomo Kambe
- grid.258799.80000 0004 0372 2033Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Wen-Lang Fan
- grid.413801.f0000 0001 0711 0593Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan ,grid.413804.aDepartment of Medical Research, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jing-Long Huang
- grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, Taiwan ,grid.413801.f0000 0001 0711 0593Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, No.5 Fu-Hsing St., Taoyuan, Taiwan, R.O.C. ,Department of Pediatrics, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Wen-I Lee
- grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, Taiwan ,grid.413801.f0000 0001 0711 0593Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, No.5 Fu-Hsing St., Taoyuan, Taiwan, R.O.C.
| | - Chao-Yi Wu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, No.5 Fu-Hsing St., Taoyuan, Taiwan, R.O.C..
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18
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Matsuda T, Kambe N, Takimoto-Ito R, Ueki Y, Nakamizo S, Saito MK, Takei S, Kanazawa N. Potential Benefits of TNF Targeting Therapy in Blau Syndrome, a NOD2-Associated Systemic Autoinflammatory Granulomatosis. Front Immunol 2022; 13:895765. [PMID: 35711422 PMCID: PMC9195515 DOI: 10.3389/fimmu.2022.895765] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
Blau syndrome is a systemic autoinflammatory granulomatous disease caused by mutations in the nucleotide-binding oligomerization domain 2 (NOD2) gene. NOD2 is an intracellular pathogen recognition receptor. Upon binding to muramyl dipeptide (MDP), NOD2 activates the NF-κB pathway, leading to the upregulation of proinflammatory cytokines. Clinical manifestations of Blau syndrome appear in patients before the age of four. Skin manifestations resolve spontaneously in some cases; however, joint and eye manifestations are progressive, and lead to serious complications, such as joint contracture and blindness. Currently, there is no specific curative treatment for the disease. Administration of high-dose oral steroids can improve clinical manifestations; however, treatments is difficult to maintain due to the severity of the side effects, especially in children. While several new therapies have been reported, including JAK inhibitors, anti-IL-6 and anti-IL-1 therapies, anti-TNF therapy plays a central role in the treatment of Blau syndrome. We recently performed an ex vivo study, using peripheral blood and induced pluripotent stem cells from patients. This study demonstrated that abnormal cytokine expression in macrophages from untreated patients requires IFNγ stimulation, and that anti-TNF treatment corrects the abnormalities associated with Blau syndrome, even in the presence of IFNγ. Therefore, although the molecular mechanisms by which the genetic mutations in NOD2 lead to granuloma formation remain unclear, it is possible that prior exposure to TNFα combined with IFNγ stimulation may provide the impetus for the clinical manifestations of Blau syndrome.
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Affiliation(s)
- Tomoko Matsuda
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Naotomo Kambe
- Department of Dermatology, Kansai Medical University, Hirakata, Japan.,Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Riko Takimoto-Ito
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Ueki
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Satoshi Nakamizo
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumu K Saito
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Syuji Takei
- Department of Pediatrics, Kagoshima University, Kagoshima, Japan
| | - Nobuo Kanazawa
- Department of Dermatology, Hyogo Medical University, Nishinomiya, Japan
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19
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Furness L, Riley P, Wright N, Banka S, Eyre S, Jackson A, Briggs TA. Monogenic disorders as mimics of juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2022; 20:44. [PMID: 35717242 PMCID: PMC9206249 DOI: 10.1186/s12969-022-00700-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis is the most common chronic rheumatic disease of childhood. The term JIA encompasses a heterogenous group of diseases. The variability in phenotype of patients affected by the disease means it is not uncommon for mimics of JIA to be misdiagnosed. CASE PRESENTATION We present four cases who were treated in single tertiary rheumatology centre for JIA who were subsequently diagnosed with a rare monogenic disease. All four patients shared the unifying features of presenting in early childhood and subsequently suffered with refractory disease, not amenable to usual standards of treatment. Multicentric Carpotarsal Osteolysis Syndrome and Camptodactyly-arthropathy-coxa vara-pericarditis syndrome are non-inflammatory conditions and patients typically present with arthropathy, normal inflammatory markers and atypical radiological features. Blau syndrome is an autosomal dominant condition and patients will typically have symmetrical joint involvement with a strong family history of arthritis, signifying the genetic aetiology. CONCLUSIONS We share our learning from these cases to add to the growing portfolio of JIA mimics and to highlight when to consider an alternative diagnosis. In cases of refractory disease and diagnostic uncertainty further imaging and genetic testing can play a crucial role in establishing the aetiology. In all of these cases the correct diagnosis was made due to careful, longitudinal clinical phenotyping and a close working relationship between rheumatology, radiology and clinical genetics; highlighting the importance of the multidisciplinary team in managing complex patients.
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Affiliation(s)
- Laura Furness
- Royal Manchester Childrens Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Phil Riley
- grid.498924.a0000 0004 0430 9101Department of Paediatric Rheumatology, Royal Manchester Childrens Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Neville Wright
- grid.498924.a0000 0004 0430 9101Department of Paediatric Rheumatology, Royal Manchester Childrens Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Siddharth Banka
- grid.498924.a0000 0004 0430 9101NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK ,grid.5379.80000000121662407Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Stephen Eyre
- grid.5379.80000000121662407The University of Manchester, Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, Manchester, UK ,grid.498924.a0000 0004 0430 9101Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Adam Jackson
- grid.5379.80000000121662407Manchester Centre for Genomic Medicine, Division of Evolution & Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9WL UK
| | - Tracy A. Briggs
- grid.498924.a0000 0004 0430 9101NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK ,grid.5379.80000000121662407Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
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20
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Zhang S, Cai Z, Mo X, Zeng H. Tofacitinib effectiveness in Blau syndrome: a case series of Chinese paediatric patients. Pediatr Rheumatol Online J 2021; 19:160. [PMID: 34781959 PMCID: PMC8594202 DOI: 10.1186/s12969-021-00634-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/25/2021] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Blau syndrome (BS), a rare, autosomal-dominant autoinflammatory syndrome, is characterized by a clinical triad of granulomatous recurrent uveitis, dermatitis, and symmetric arthritis and associated with mutations of the nucleotide-binding oligomerization domain containing 2 (NOD2) gene. Aim of this study was to assess the efficacy of tofacitinib in Chinese paediatric patients with BS. METHODS Tofacitinib was regularly administered to three BS patients (Patient 1, Patient 2, and Patient 3) at different dosages: 1.7 mg/day (0.11 mg/kg), 2.5 mg/day (0.12 mg/kg), and 2.5 mg/day (0.33 mg/kg). The clinical manifestations of the patients, magnetic resonance imaging results, serological diagnoses, therapeutic measures and outcomes of treatments are described in this report. RESULTS The clinical characteristics and serological diagnoses of all BS patients were greatly improved after the administration of tofacitinib treatment. All patients reached clinical remission of polyarthritis and improvements in the erythrocyte sedimentation rate (ESR) and levels of C-reactive protein (CRP) and inflammatory cytokines. CONCLUSION Tofacitinib, a Janus kinase (JAK) inhibitor, is a promising agent for BS patients who have unsatisfactory responses to corticosteroids, traditional disease-modifying antirheumatic drugs, and biological agents.
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Affiliation(s)
- Song Zhang
- grid.413428.80000 0004 1757 8466Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children’s Medical Center, Guangzhou, 510120 Guangdong China
| | - Zhe Cai
- grid.413428.80000 0004 1757 8466Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children’s Medical Center, Guangzhou, 510120 Guangdong China
| | - Xiaolan Mo
- grid.410737.60000 0000 8653 1072Department of Pharmacy, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huasong Zeng
- Department of Allergy, Immunology and Rheumatology, Guangzhou Women and Children's Medical Center, Guangzhou, 510120, Guangdong, China.
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21
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Deguchi A, Mano T, Iwasa N, Ozaki M, Nakase K, Kanazawa N, Sugie K. [A case of hydrocephalus during the course of sporadic Blau syndrome]. Rinsho Shinkeigaku 2021; 61:692-695. [PMID: 34565750 DOI: 10.5692/clinicalneurol.cn-001600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Blau syndrome (BS) is a rare granulomatous inflammatory disease presenting in early childhood as dermatitis, arthritis, and uveitis. Here, we describe a case of hydrocephalus in a patient with sporadic BS. A 36-year-old female, with mutations in the NOD2 gene on chromosome 16, who had been diagnosed with BS at the age of 19 years, had visual impairment and required support when walking for a long time. She was admitted to our hospital due to deterioration in her walking ability and an inability to stand by herself. We diagnosed an obstructive hydrocephalus based on head MRI. The aqueductal stenosis and obstructive hydrocephalus associated with granulomatous lesions were considered in this case. After third ventricle fenestration, her standing movement and walking improved immediately.
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Affiliation(s)
| | - Tomoo Mano
- Department of Neurology, Nara Medical University.,Department of Rehabilitation Medicine, Nara Medical University
| | - Naoki Iwasa
- Department of Neurology, Nara Medical University
| | - Maki Ozaki
- Department of Neurology, Nara Medical University
| | - Kenta Nakase
- Department of Neurosurgery, Nara Medical University
| | | | - Kazuma Sugie
- Department of Neurology, Nara Medical University
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22
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P R, Ramireddy S, Chakraborty S, Mukherjee S, J S, C S. Structural localization of pathogenic mutations in the central nucleotide-binding domain (NBD) of nucleotide-binding oligomerization domain-2 (NOD2) protein and their inference in inflammatory disorders. Nucleosides Nucleotides Nucleic Acids 2021; 40:1198-1219. [PMID: 34622739 DOI: 10.1080/15257770.2021.1986719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The human NBD domain which is centrally located in the NOD2 protein displays an essential role in oligomerization and initiates the immune response via CARD-RIPK2 interaction. The mutations associated with the NBD domain have been largely implicated in inflammatory disorders such as Blau syndrome and sarcoidosis. This study aims to determine the structural and phenotypic effect of a lethal mutation that occurs in the NBD domain which has an axiomatic impact on protein dysfunction. Initially, the most deleterious missense mutations were screened through various in silico analysis. Out of 33 variants, I-Mutant 3.0, SIFT, PolyPhen 2, Align GVGD, PHD SNP and SNP&GO have statistically identified 5 variants (R42W, D90E, E91K, G189D & W198L) as less stable, deleterious and damaging. Our predicted models have paved the way to understand the various structural properties such as physiochemical, secondary structural arrangements and stabilizing residues in folding associated with the native and mutant NBD domain especially of the functionally important regions. From the aforementioned results, R42W and G189D were found to be the more predominant among the mutants. Precisely, through molecular simulation, we have strongly justified the significant conformational disruption of R42W and G189D through the stabilization factors, folding and essential dynamics. Conclusively, these regions (α341-44, α13185-191 and β6133-143β7) seem to adopt such structures that are not conducive to wild-type-like functionality. Our prediction and validation of lethal mutations based on structural stability may be useful for conducting experimental studies in detail to uncover the protein deregulation leading to inflammatory disorders.
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Affiliation(s)
- Raghuraman P
- Department of Biotechnology, School of Bioscience and Technology, Vellore Institute of Technology, Vellore, India
| | - Sriroopreddy Ramireddy
- Department of Biotechnology, School of Bioscience and Technology, Vellore Institute of Technology, Vellore, India
| | - Sulagno Chakraborty
- Department of Biotechnology, School of Bioscience and Technology, Vellore Institute of Technology, Vellore, India
| | - Sayani Mukherjee
- Department of Biotechnology, School of Bioscience and Technology, Vellore Institute of Technology, Vellore, India
| | - Sreeshma J
- Department of Biotechnology, School of Bioscience and Technology, Vellore Institute of Technology, Vellore, India
| | - Sudandiradoss C
- Department of Biotechnology, School of Bioscience and Technology, Vellore Institute of Technology, Vellore, India
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23
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Abstract
BACKGROUND This case study documents the first familial case of Blau syndrome (BS) in Palestine characterized with mutation in CARD15/NOD2. CASE PRESENTATION Eighteen years old female was initially misdiagnosed with Juvenile idiopathic arthritis (JIA). The patient had been on steroids and methotrexate treatment for the last 16 years, but did not respond well to treatment. Initial examination at Saint John of Jerusalem Eye Hospital Group clinic showed bilateral intermediate uveitis with camptodactyly. The patient's sister (aged 19 years) had bilateral intermediate uveitis and camptodactyly. Both eyes of their father had signs of old posterior uveitis. Father's left eye showed 360 degrees posterior synechia, mature cataract with old Keratic precipitates (KPs). He also had camptodactyly. The patient was referred to pediatric rheumatologist to rule out sarcoidosis. Lung CT scan showed bronchiectasis, genetic consultation followed. Complete eye examination, full history, refraction, and Optical coherence tomography (oct) were done. Systemic and topical steroid therapy could not control the ocular inflammation. The family then was referred to a geneticist. Genetic analyses showed that the proband and all three family members had an R334q mutation in the CARD15/Nod2 gene. CONCLUSIONS BS should be considered in the differential diagnosis of childhood uveitis, especially in low and middle income countries where it is misdiagnosed in many cases, which delay appropriate diagnosis and thus control. Genetic analysis of the CARD15/Nod2 gene is helpful in the diagnosis. Steroids alone are not enough to control the disease, other immunosuppressants and biologics are needed.
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Affiliation(s)
- Salam Iriqat
- Head of Ocular Inflammatory Diseases Head of Clinical Research Uveitis and Medical Retina Consultant, Saint John of Jerusalem Eye Hospital Group, Jerusalem, Palestine
| | | | - Manuel Fatouleh
- Saint John of Jerusalem Eye Hospital Group, Jerusalem, Palestine
| | - Abdulsalam Alkaiyat
- Public Health Department, Faculty of Medicine and Health Sciences, An-Najah National University, P.O.Box:7, Nablus, Palestine.
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24
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Rodrigues FG, Petrushkin H, Webster AR, Bickerstaff M, Moraitis E, Rowczenio D, Aróstegui JI, Westcott M. A Novel Pathogenic NOD2 Variant in a Mother and Daughter with Blau Syndrome. Ophthalmic Genet 2021; 42:753-764. [PMID: 34251956 DOI: 10.1080/13816810.2021.1946701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Blau syndrome (BS) is a rare dominantly-inherited autoinflammatory disorder characterized by the triad of arthritis, uveitis and dermatitis that is consequence of gain-of-function NOD2 mutations. We describe the clinical features and genetic basis of a family with two affected members in consecutive generations affected with childhood onset arthritis and uveitis. MATERIALS AND METHODS Clinical features were retrospectively collected from clinical records. Genetic studies were performed using the Sanger method of DNA sequencing. RESULTS The proband is a 44 years-old female, who was diagnosed with juvenile onset arthritis at the age of 9 years. She subsequently developed uveitis at age 12 and since then she was managed between the uveitis and rheumatology services. The proband's daughter developed episcleritis at the age of 7 years, and arthritis with bilateral intermediate uveitis two years later. NOD2 analyses revealed in both patients the heterozygous c.1494A>C transversion, predicted to lead the novel, missense p.E498D variant in the NOD2 protein. Additional studies including databases searches and in silico bioinformatic predictions strongly support the "likely pathogenic" classification for this novel variant. CONCLUSIONS We report a novel pathogenic NOD2 variant in a multiplex family with clinical features compatible with the BS diagnosis. This condition is inherited as a dominant trait in its familial form and should be considered in patients with granulomatous uveitis in association with arthritis and/or dermatitis. Further insight into NOD2 variants and their downstream effects may have implications in the treatment of BS and other inflammatory granulomatous diseases.
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Affiliation(s)
- Filipa G Rodrigues
- Uveitis and Scleritis Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.,UCL Institute of Ophthalmology, London, UK
| | - Harry Petrushkin
- Uveitis and Scleritis Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Rheumatology Department, Great Ormond Street Hospital for Children, London, UK
| | - Andrew R Webster
- National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK.,UCL Institute of Ophthalmology, London, UK.,Genetics Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Elena Moraitis
- Rheumatology Department, Great Ormond Street Hospital for Children, London, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, University College London, London, UK
| | - Juan I Aróstegui
- Department of Immunology, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain.,School of Medicine, Universitat De Barcelona, Barcelona, Spain
| | - Mark Westcott
- Uveitis and Scleritis Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,UCL Institute of Ophthalmology, London, UK
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25
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Kitagawa Y, Kawasaki Y, Yamasaki Y, Kambe N, Takei S, Saito MK. Anti-TNF treatment corrects IFN-γ-dependent proinflammatory signatures in Blau syndrome patient-derived macrophages. J Allergy Clin Immunol 2021:S0091-6749(21)00888-5. [PMID: 34175136 DOI: 10.1016/j.jaci.2021.05.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/12/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Blau syndrome (BS) is an autoinflammatory disease associated with mutations in nucleotide-binding oligomerization domain 2. Although treatments with anti-TNF agents have been reported to be effective, the underlying molecular mechanisms remain unclear. OBJECTIVE We aimed to elucidate the mechanisms of autoinflammation in patients with BS and to clarify how anti-TNF treatment controls the disease phenotype at the cellular level in clinical samples. METHODS Macrophages were differentiated from monocytes of 7 BS patients, and global transcriptional profiles of 5 patients were analyzed with or without IFN-γ stimulation. Macrophages were also generated from BS-specific induced pluripotent stem cells (iPSCs), and their transcriptome was examined for comparison. RESULTS Aberrant inflammatory responses were observed upon IFN-γ stimulation in macrophages from untreated BS patients, but not in those from patients treated with anti-TNF. iPSC-derived macrophages carrying a disease-associated mutation also showed IFN-γ-dependent accelerated inflammatory responses. Comparisons of peripheral blood- and iPSC-derived macrophages revealed the upregulation of nuclear factor kappa-light-chain enhancer of activated B cells (NF-κB) targets in unstimulated macrophages as a common feature. CONCLUSIONS IFN-γ stimulation is one of the key signals driving aberrant inflammatory responses in BS-associated macrophages. However, long-term treatment with anti-TNF agents ameliorates such abnormalities even in the presence of IFN-γ stimulation. Our data thus suggest that preexposure to TNF or functionally similar cytokines inducing NF-κB-driven proinflammatory signaling during macrophage development is a prerequisite for accelerated inflammatory responses upon IFN-γ stimulation in BS.
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26
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Şahin N, Çiçek SÖ, Kısaarslan AP, Gündüz Z, Poyrazoğlu MH, Düşünsel R. Unexpected condition in a rare disease: encephalopathy in early-onset sarcoidosis. Turk J Pediatr 2021; 63:323-328. [PMID: 33929124 DOI: 10.24953/turkjped.2021.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Granulomatous autoinflammatory diseases are monogenic syndromes caused by mutations in the region encoding the nucleotide-binding domain of the nucleotide-binding oligomerization domain-containing 2 gene. Blau syndrome and early-onset sarcoidosis are familial and sporadic forms of the same disease and are very rare. Many organ systems may be involved; however, neurologic involvement is infrequent. We reported a case of encephalitis in a 12-year-old girl followed with a diagnosis of early-onset sarcoidosis. CASE The patient was diagnosed with juvenile idiopathic arthritis at 3 years of age. We considered druginduced sarcoidosis at 6 years of age with granulomatous inflammation of liver and kidney. Small joint involvement and camptodactyly developed during follow-up. M315T mutation was detected in the NOD2 gene supporting the diagnosis of early-onset sarcoidosis. The patient suffered from encephalopathy when she was under methotrexate, infliximab, and systemic steroid treatment at 12 years of age. Cerebrospinal fluid limbic encephalitis antibody panel was negative. CONCLUSION Encephalopathy is not common in Blau syndrome and early-onset sarcoidosis. The cause of encephalopathy in our patient was interpreted as autoimmune encephalitis.
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Affiliation(s)
- Nihal Şahin
- Department of Pediatric Rheumatology, Erciyes University Faculty of Medicine, Kayseri
| | - Sümeyra Özdemir Çiçek
- Department of Pediatric Rheumatology, Erciyes University Faculty of Medicine, Kayseri
| | | | - Zübeyde Gündüz
- Department of Pediatric Rheumatology, Acıbadem Hospital, Kayseri, Turkey
| | | | - Ruhan Düşünsel
- Department of Pediatric Rheumatology, Erciyes University Faculty of Medicine, Kayseri
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27
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Nishiyama M, Li HJ, Okafuji I, Fujisawa A, Ehara M, Kambe N, Furukawa F, Kanazawa N. Sustained Surface ICAM-1 Expression and Transient PDGF-B Production by Phorbol Myristate Acetate-Activated THP-1 Cells Harboring Blau Syndrome-Associated NOD2 Mutations. Children (Basel) 2021; 8:children8050335. [PMID: 33923123 PMCID: PMC8145400 DOI: 10.3390/children8050335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/21/2022]
Abstract
Objectives: Blau syndrome is a distinct class of autoinflammatory syndrome presenting with early-onset systemic granulomatosis. Blau syndrome-causing NOD2 mutations located in the central nucleotide-oligomerization domain induce ligand-independent basal NF-κB activation in an in vitro reporter assay. However, the precise role of this signaling on granuloma formation has not yet been clarified. Methods: Blau syndrome-causing NOD2 mutations were introduced into human monocytic THP-1 cells, and their morphological and molecular changes from parental cells were analyzed. Identified molecules with altered expression were examined in the patient’s lesional skin by immunostaining. Results: Although the production of proinflammatory cytokines was not altered without stimulation, mutant NOD2-expressing THP-1 cells attached persistently to the culture plate after stimulation with phorbol myristate acetate. Sustained surface ICAM-1 expression was observed in association with this phenomenon, but neither persistent ICAM-1 mRNA expression nor impaired ADAM17 mRNA expression was revealed. However, the transient induction of PDGF-B mRNA expression was specifically observed in stimulated THP-1 derivatives. In the granulomatous skin lesion of a Blau syndrome patient, ICAM-1 and PDGF-B were positively immunostained in NOD2-expressing giant cells. Conclusions: Sustained surface ICAM-1 expression and transient PDGF-B production by newly differentiating macrophages harboring mutant NOD2 might play a role in granuloma formation in Blau syndrome.
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Affiliation(s)
- Mizuho Nishiyama
- Department of Dermatology, School of Medicine, Wakayama Medical University, Wakayama 641-0012, Japan; (M.N.); (H.-j.L.); (F.F.)
| | - Hong-jin Li
- Department of Dermatology, School of Medicine, Wakayama Medical University, Wakayama 641-0012, Japan; (M.N.); (H.-j.L.); (F.F.)
| | - Ikuo Okafuji
- Department of Pediatrics, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan;
| | - Akihiko Fujisawa
- Department of Dermatology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (A.F.); (N.K.)
| | - Mizue Ehara
- Department of Dermatology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan;
| | - Naotomo Kambe
- Department of Dermatology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan; (A.F.); (N.K.)
- Department of Dermatology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan;
| | - Fukumi Furukawa
- Department of Dermatology, School of Medicine, Wakayama Medical University, Wakayama 641-0012, Japan; (M.N.); (H.-j.L.); (F.F.)
| | - Nobuo Kanazawa
- Department of Dermatology, School of Medicine, Wakayama Medical University, Wakayama 641-0012, Japan; (M.N.); (H.-j.L.); (F.F.)
- Department of Dermatology, School of Medicine, Hyogo College of Medicine, Nishinomiya 663-8501, Japan
- Correspondence:
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28
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Concilio M, Cennamo G, Giordano M, Fossataro F, D'Andrea L, Ciampa N, Naddei R, Orlando F, Tranfa F, Alessio M. Anterior Segment-Optical Coherence Tomography features in Blau syndrome. Photodiagnosis Photodyn Ther 2021; 34:102278. [PMID: 33813016 DOI: 10.1016/j.pdpdt.2021.102278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
Blau syndrome (BS) is a rare granulomatous auto-inflammatory disease, characterized by the classic clinical triad of joints, skin and ocular involvements. Ocular manifestation usually consists in a bilateral insidious chronic anterior uveitis with a potential evolution to panuveitis. We describe the case of two siblings, an 8-years old female and a 5-years old male, with a diagnosis of BS, evaluated by Anterior Segment-Optical Coherence Tomography (AS-OCT). In the female patient, slit-lamp examination revealed bilateral anterior granulomatous uveitis and inflammatory sequelae. AS-OCT revealed high intensity reflective layers in the anterior cornea, hyperreflective dots both in the aqueous humor and in the posterior corneal surface. In the male, no signs of inflammation were detected both on slit-lamp examination and AS-OCT scans. AS-OCT is a valuable, non-invasive tool that could improve the diagnosis of ocular involvement, better characterize and follow-up corneal alterations and anterior segment features in pediatric patients with BS.
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Affiliation(s)
- Marina Concilio
- Eye Clinic, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Gilda Cennamo
- Eye Clinic, Department of Public Health, Federico II University, Naples, Italy.
| | - Mariapaola Giordano
- Eye Clinic, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Federica Fossataro
- Eye Clinic, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Luca D'Andrea
- Eye Clinic, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Nicola Ciampa
- Eye Clinic, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Roberta Naddei
- Pediatric Rheumatology Unit, Department of Mother and Child, Federico II University, Naples, Italy
| | | | - Fausto Tranfa
- Eye Clinic, Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Maria Alessio
- Pediatric Rheumatology Unit, Department of Mother and Child, Federico II University, Naples, Italy
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29
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Su J, Liu D. Blau syndrome with pulmonary nodule in a child. Australas J Dermatol 2021; 62:217-220. [PMID: 33742458 DOI: 10.1111/ajd.13551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 12/07/2020] [Accepted: 12/15/2020] [Indexed: 11/28/2022]
Abstract
Blau syndrome (BS) is a rare monogenic disease caused by mutation of NOD2/CARD15 gene. A case of Blau syndrome in a 4-year-old Chinese boy c.1001G > A(p.R334Q) mutation in the NOD2 genes reported. Imaging revealed a nodule at the tip of the right lung.
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Affiliation(s)
- Jinping Su
- Department of Dermatology/Venerology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Donghua Liu
- Department of Dermatology/Venerology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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30
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Sinharay R, McKeown L, Phillips C, Li A, Duckworth A, Hall F, Griffiths WJH. First report of liver transplantation in Blau syndrome: The challenges faced in this rare granulomatous liver disease. Transpl Immunol 2021; 65:101378. [PMID: 33621644 DOI: 10.1016/j.trim.2021.101378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022]
Abstract
Blau syndrome is a rare autoinflammatory granulomatous disease caused by variants in the NOD2 gene, classically presenting in childhood. Hepatic manifestations are recognized including cholestasis and granulomatous liver disease. We describe a novel NOD2 gene variant c.1471A > C, p.(Met491Leu) in an adult who developed cirrhotic complications despite selective immunotherapy, including recurrent esophageal bleeding and spontaneous bacterial peritonitis which resulted in liver transplantation. He required a second liver transplant as his first graft failed due to ischemic cholangiopathy. Disease recurrence has been observed (hitherto unreported). Of 84 patients with Blau syndrome treated with antibody therapy, five hepatic cases responded to anti-TNF therapy, with promising results if instigated before decompensation occurs. We report the first case of liver transplantation for Blau syndrome in an adult with a novel NOD2 variant. Blau related liver disease can reoccur post transplantation and is an important consideration for any future graft. LAY SUMMARY: Blau syndrome is a rare immune disease which presents in childhood. We describe the first liver transplant for this condition following development of progressive liver disease in adulthood. The patient had a newly described variant in the Blau gene (NOD2). We discuss the effectiveness of antibody therapy currently being used to control the disease, and the role of liver transplantation in Blau syndrome.
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Affiliation(s)
- Ricky Sinharay
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Lorcán McKeown
- University of Cambridge, School of Clinical Medicine, UK
| | | | - Alice Li
- University of Cambridge, School of Clinical Medicine, UK
| | - Adam Duckworth
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Frances Hall
- Department of Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - William J H Griffiths
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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31
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a framework to distinguish Blau syndrome/Early Onset Sarcoidosis and Sarcoidosis clinically. We also discuss relevant differences in genetics, pathogenesis, and management of these diseases. RECENT FINDINGS Blau syndrome and Sarcoidosis share the characteristic histologic finding of noncaseating granulomas as well as some similar clinical characteristics; nevertheless, they are distinct entities with important differences between them. Blau syndrome and Early Onset Sarcoidosis are due to one of numerous possible gain-of-function mutations in NOD2, commonly presenting before age 5 with a triad of skin rash, arthritis, and uveitis. However, as more cases are reported, expanded clinical manifestations have been described. In systemic Sarcoidosis, there are numerous susceptibility genes that have been identified, and disease is thought to result from an environmental exposure in a genetically susceptible host. It most often presents with constitutional symptoms and pulmonary involvement and typically affects adolescents and adults. This paper reviews the similarities and differences between Blau syndrome and Sarcoidosis. We also discuss the importance of distinguishing between them, particularly with regard to prognosis and outcomes.
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Affiliation(s)
- Katherine P Kaufman
- Department of Pediatrics, Division of Rheumatology and Nephrology, Duke University Medical Center, Durham, NC, USA.
- CarolinaEast Internal Medicine, Pollocksville, NC, USA.
| | - Mara L Becker
- Department of Pediatrics, Division of Rheumatology and Nephrology, Duke University Medical Center, Durham, NC, USA
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32
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Arakawa A, Kambe N, Nishikomori R, Tanabe A, Ueda M, Nishigori C, Miyachi Y, Kanazawa N. NOD2 Mutation-Associated Case with Blau Syndrome Triggered by BCG Vaccination. Children (Basel) 2021; 8:children8020117. [PMID: 33562038 PMCID: PMC7915141 DOI: 10.3390/children8020117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/30/2021] [Accepted: 01/31/2021] [Indexed: 11/20/2022]
Abstract
We describe a patient who developed multiple granulomatous skin lesions after Bacille de Calmette et Guérin (BCG) vaccination without significant effect by topical corticosteroid, followed by painless cystic tumors on the bilateral knees and hands and inflammatory changes on ophthalmologic examination. A functional mutation in NOD2 was detected by a genetic analysis, and he was diagnosed as sporadic Blau syndrome. Since NOD2 acts as a sensor for the BCG component, it is possible that BCG vaccination may trigger granuloma formation in Blau syndrome patients with such genetic background.
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Affiliation(s)
- Akiko Arakawa
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan; (A.A.); (N.K.); (Y.M.)
- Department of Dermatology and Allergology, University Hospital, Ludwig-Maximilian-University, D-80337 Munich, Germany
| | - Naotomo Kambe
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan; (A.A.); (N.K.); (Y.M.)
| | - Ryuta Nishikomori
- Department of Pediatrics, Kurume University, Kurume 830-0011, Japan;
| | - Akiyo Tanabe
- Ophthalmology and Visual Science, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan;
| | - Masamichi Ueda
- Institute for Virus Research, Kyoto University Graduate School of Medicine, Kyoto 606-8397, Japan;
| | - Chikako Nishigori
- Department of Dermatology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan;
| | - Yoshiki Miyachi
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan; (A.A.); (N.K.); (Y.M.)
| | - Nobuo Kanazawa
- Department of Dermatology, Hyogo College of Medicine, Mukogawa-cho 1-1, Nishinomiya, Hyogo 663-8501, Japan
- Correspondence: ; Tel.: +81-798-45-6653; Fax: +81-798-45-6651
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Ekundayo TC, Okoh AI. Systematic Assessment of Mycobacterium avium Subspecies Paratuberculosis Infections from 1911-2019: A Growth Analysis of Association with Human Autoimmune Diseases. Microorganisms 2020; 8:E1212. [PMID: 32784941 DOI: 10.3390/microorganisms8081212] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 02/06/2023] Open
Abstract
Mycobacterium avium subsp. paratuberculosis (MAP) is an understudied pathogen worldwide with continuous implications in human autoimmune diseases (ADs). The awareness of MAP appears to be low in many places and its research is at infant stage in many countries. The lack of worldwide coverage of the MAP research landscape calls for urgent research attention and prioritization. This present study aimed to assess MAP global research productivity with an emphasis on its implications in ADs via bibliometric and growth analytic frameworks from authors, countries, institutions, international, disciplines and collaboration network perspectives. MAP primary articles were retrieved from the Scopus database and the Web of Science from 1911 to 2019 via title-specific algorithm. Analytic results of dataset yielded a total of 3889 articles from 581 journals and 20.65 average citations per documents. The annual growth rate of MAP research for the period was 6.31%. Based on a country’s productivity (articles (%), freq. of publication (%)), the USA (887 (22.81%), 26.72%), and Australia (236 (6.07%), 6.07%) ranked the top 2 countries but Egypt and Germany had the highest average growth rate (AGR, 170%) in the last 3 years. MAP studies are generally limited to Europe, Australia, Asia, South America and few nations in Africa. It had positive growth rate (30%–100%) in relation to type 1 diabetes mellitus and rheumatoid arthritis ADs; food science and technology, immunology, agriculture, pathology, and research and experimental medicine, wildlife, environments, virulence, disease resistance, meat and meat products, osteopontin, waste milk and slurry/sludge digestion subjects; but negative growth (−130% to −30%) in ulcerative colitis and Parkinson’s disease and no growth in multiple sclerosis, sarcoidosis, thyroid disorders, psoriasis, and lupus. The mapping revealed a gross lack of collaboration networking in terms of authorship, (intra- and inter-) nationally and institutionally with a generalized collaboration index of 1.82. In conclusion, inadequate resources-, knowledge- and scientific-networking hampered growth and awareness of MAP research globally. The study recommends further research to strengthen evidence of MAP’s epidemiologic prevalence in ADs and proffer practical solution(s) for drug development and point-of-care diagnostics amongst other extended themes.
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Córdova-Fletes C, Rangel-Sosa MM, Martínez-Jacobo LA, Becerra-Solano LE, Arellano-Valdés CA, Tlacuilo-Parra JA, Galán-Huerta KA, Rivas-Estilla AM, Hernandez-Orozco AA, García-Ortiz JE. Whole-exome sequencing in three children with sporadic Blau syndrome, one of them co-presenting with recurrent polyserositis. Autoimmunity 2020; 53:344-352. [PMID: 32597225 DOI: 10.1080/08916934.2020.1786068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Blau syndrome (BS) is a rare, chronic autoinflammatory disease with onset before age 4 and mainly characterised by granulomatous arthritis, recurrent uveitis, and skin rash. Sporadic (also known as early-onset sarcoidosis) or familial BS is caused by gain-of-function mutations in the NOD2 gene, which encodes for a multi-task protein that plays a crucial role in the innate immune defense. We report on three Mexican patients clinically diagnosed with BS who exhibited a likely pathogenic variant in NOD2 as revealed by whole-exome sequencing (WES) and Sanger sequencing: two variants (c.1000 C > T/p.Arg334Trp and c.1538 T > C/p.Met513Thr) lie in the ATP/Mg2+ binding site, whereas the other (c.3019dupC/p.Leu1007ProfsTer2) introduces a premature stop codon disrupting the last LRR domain (LRR9) formation; all three variants are consistent with gain-of-function changes. Interestingly, all these patients presented concomitant likely pathogenic variants in other inflammatory disease-related genes, i.e. TLR10, PRR12, MEFV and/or SLC22A5. Although the clinical presentation in these patients included the BS diagnostic triad, overall it was rather heterogeneous. It is plausible that this clinical variability depends partly on the patients' genetic background as suggested by our WES results. After this molecular diagnosis and given the absence of NOD2 mutations (demonstrated in two trios) and related symptoms in the respective parents (confirmed in all trios), patients 1 and 2 were considered to have sporadic BS, while patient 3, a sporadic BS-recurrent polyserositis compound phenotype. Altogether, our observations and findings underscore the overlapping among inflammatory diseases and the importance of determining the underlying genetic cause by high-throughput methods. Likewise, this study further reinforces a pathogenic link between the here found NOD2 variants and BS and envisages potential additive effects from other loci in these, and probably other patients.
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Affiliation(s)
- Carlos Córdova-Fletes
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Martha M Rangel-Sosa
- Vicerrectoría de Ciencias de la Salud, Departamento de Ciencias Básicas, Universidad de Monterrey, San Pedro Garza García, México
| | - Lizeth A Martínez-Jacobo
- Vicerrectoría de Ciencias de la Salud, Departamento de Ciencias Básicas, Universidad de Monterrey, San Pedro Garza García, México
| | - Luis Eduardo Becerra-Solano
- Unidad de Investigación Médica en Medicina Reproductiva, Hospital de Gineco-Obstetricia No. 4 Luis Castelazo Ayala, IMSS, Ciudad de México, México
| | | | | | - Kame Alberto Galán-Huerta
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Ana María Rivas-Estilla
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México
| | | | - José Elías García-Ortiz
- División de Genética, Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social.,Dirección de Educación e Investigación en Salud, UMAE Hospital de Gineco-Obstretricia, CMNO-IMSS, Guadalajara, México
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Brown W, Bonar SF, McGuigan L, Soper J, Boyle R. Blau syndrome: a rare cause of exuberant granulomatous synovitis of the knee. Skeletal Radiol 2020; 49:1161-1166. [PMID: 31960075 DOI: 10.1007/s00256-020-03376-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 02/02/2023]
Abstract
Blau syndrome (BS) is a rare autosomal dominant familial granulomatous inflammatory disease presenting in early childhood with dermatitis, arthritis and uveitis. Early-onset sarcoidosis represents the sporadic form, and both are characterised by mutations in the CARD15/NOD2 gene on chromosome 16. We describe a 38-year-old man with known BS who presented for orthopaedic review following right-sided patellar dislocation. MRI of the injured knee demonstrated diffuse synovitis and prominent fatty tissue resembling lipoma arborescens with evidence of recent patellar dislocation. Synovectomy was performed and confirmed granulomatous synovitis. Knee imaging findings are described for the first time. Combining distinct morphological bone changes with synovitis which resembles lipoma arborescens and histology which includes sarcoidal-type granulomatous synovitis should lead the radiologist and pathologist to consider the diagnosis of BS.
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Affiliation(s)
- Wendy Brown
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia.
| | - S Fiona Bonar
- Douglass Hanly Moir Pathology, 14 Giffnock Avenue, Macquarie Park, NSW, 2113, Australia
| | | | - Judy Soper
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Richard Boyle
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
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Affiliation(s)
- Julie Poline
- Department of General Pediatrics, Paediatric Internal Medicine, Rheumatology and Infectious Diseases, National Reference Centre for Rare Paediatric Inflammatory Rheumatisms and Systemic Auto-immune diseases RAISE, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris; Université Paris Diderot-Sorbonne Paris-Cité, INSERM, UMR1149; Biology and Genetics of Bacterial Cell Wall Unit, Pasteur Institute, Paris, France
| | - Emmanuelle Bourrat
- Department of General Pediatrics, Paediatric Internal Medicine, Rheumatology and Infectious Diseases, National Reference Centre for Rare Paediatric Inflammatory Rheumatisms and Systemic Auto-immune diseases RAISE, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris; Department of Dermatology, Saint Louis University Hospital, Assistance Publique-Hôpitaux de Paris
| | - Ulrich Meinzer
- Department of General Pediatrics, Paediatric Internal Medicine, Rheumatology and Infectious Diseases, National Reference Centre for Rare Paediatric Inflammatory Rheumatisms and Systemic Auto-immune diseases RAISE, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris; Université Paris Diderot-Sorbonne Paris-Cité, INSERM, UMR1149; Biology and Genetics of Bacterial Cell Wall Unit, Pasteur Institute, Paris, France
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Marín-Noriega MA, Muñoz-Ortiz J, Mosquera C, de-la-Torre A. Ophthalmological treatment of early-onset sarcoidosis/ Blau syndrome in a Colombian child: A case report. Am J Ophthalmol Case Rep 2020; 18:100714. [PMID: 32346654 PMCID: PMC7178324 DOI: 10.1016/j.ajoc.2020.100714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/21/2020] [Accepted: 04/13/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose To report the ophthalmological approach of a patient with Blau syndrome (BS) in Colombia. Observations We describe a 9-year-old Colombian boy with sporadic BS due to a de novo nucleotide-binding oligomerization domain containing 2 (NOD2) mutation, who presented with joint and dermatologic symptoms. He was referred to the uveitis service with a single functional eye, due to retinal detachment in the other eye. Despite treatment with corticosteroids, methotrexate, and adalimumab, the patient continued to exhibit progressive disease. Conclusion BS-related uveitis is characterized by severe ocular morbidity. Appropriate interdisciplinary treatment is necessary for the correct identification and management of the disease, considering the inherent difficulty in its diagnosis due to its diverse clinical manifestations. The severity of BS-related uveitis in this report highlights the need for more effective therapies.
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Affiliation(s)
- María Alejandra Marín-Noriega
- NeURos Research Group. Escuela de Medicina y Ciencias de La Salud, Universidad Del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia
| | - Juliana Muñoz-Ortiz
- NeURos Research Group. Escuela de Medicina y Ciencias de La Salud, Universidad Del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia.,Escuela Barraquer Research Group. Escuela Superior de Oftalmología del Instituto Barraquer de América, Avenida Calle 100 # 18A - 51, Bogotá, Colombia
| | - Catalina Mosquera
- Programa de Reumatología Pediátrica. Universidad Del Bosque, Calle 131A #9-2, Bogotá, Colombia
| | - Alejandra de-la-Torre
- NeURos Research Group. Escuela de Medicina y Ciencias de La Salud, Universidad Del Rosario, Carrera 24 # 63 C 69, Bogotá, Colombia
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Abstract
Purpose: To report the clinical profile of genetically proven Blau syndrome in seven cases from a single center in South India.Materials & Methods: Retrospective case seriesResults: There were four females and three males. All cases had a history of skin and joint involvement of varying severity. Flexion contractures of the proximal interphalangeal joints were seen in all cases except Case 2. Ocular involvement was bilateral and included keratoconjunctivitis sicca (six cases), granulomatous panuveitis (three cases), granulomatous anterior uveitis (three cases), conjunctival granulomas (three cases), subepithelial corneal opacities (one case), and subretinal granuloma (one case). Other ocular findings included band-shaped keratopathy (five cases) and cataract (three cases). All cases received oral steroids and methotrexate with an addition of mycophenolate mofetil in one case. Visual prognosis was good in all cases.Conclusions: Blau syndrome is underreported in India. This is the largest case series of genetically proven Blau syndrome from South India and highlights the clinical profile of Blau syndrome seen in India.
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Affiliation(s)
- Kalpana Babu
- Department of Uveitis & Ocular Inflammation, Vittala International Institute of Ophthalmology & Prabha Eye Clinic and Research Center, Bangalore, India
| | - Anand P Rao
- Department of Pediatric Rheumatology, Manipal Hospitals; Indira Gandhi Institute of Child Health Sciences, Bengaluru, India
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Parackova Z, Bloomfield M, Vrabcova P, Zentsova I, Klocperk A, Milota T, Svaton M, Casanova JL, Bustamante J, Fronkova E, Sediva A. Mutual alteration of NOD2-associated Blau syndrome and IFNγR1 deficiency. J Clin Immunol 2020; 40:165-178. [PMID: 31760574 DOI: 10.1007/s10875-019-00720-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
Blau syndrome (BS) is an auto-inflammatory granulomatous disease that possibly involves abnormal response to interferon gamma (IFNγ) due to exaggerated nucleotide-binding oligomerization domain containing 2 (NOD2) activity. Mendelian susceptibility to mycobacterial diseases (MSMD) is an infectious granulomatous disease that is caused by impaired production of or response to IFNγ. We report a mother and daughter who are both heterozygous for NOD2c.2264C˃T variant and dominant-negative IFNGR1818del4 mutation. The 17-year-old patient displayed an altered form of BS and milder form of MSMD, whereas the 44-year-old mother was completely asymptomatic. This experiment of nature supports the notion that IFNγ is an important driver of at least some BS manifestations and that elucidation of its involvement in the disease immunopathogenesis may identify novel therapeutic targets.
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Affiliation(s)
- Zuzana Parackova
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic.
| | - Marketa Bloomfield
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic
- Department of Pediatrics, 1st Faculty of Medicine Charles University and Thomayer's Hospital, Prague, Czech Republic
| | - Petra Vrabcova
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic
| | - Irena Zentsova
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic
| | - Adam Klocperk
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic
| | - Tomas Milota
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic
| | - Michael Svaton
- CLIP - Childhood Leukaemia Investigation Prague, Department of Paediatric Haematology and Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France
- Imagine Institute, Paris Descartes University, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
- Howard Hughes Medical Institute, New York, NY, USA
- Pediatric Hematology-Immunology Unit, Necker Hospital for Sick Children, AP-HP, Paris, France
| | - Jacinta Bustamante
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France
- Imagine Institute, Paris Descartes University, Paris, France
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY, USA
- Study Center for Primary Immunodeficiencies, AP-HP, Necker Children Hospital, Paris, France
| | - Eva Fronkova
- CLIP - Childhood Leukaemia Investigation Prague, Department of Paediatric Haematology and Oncology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic
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Chen J, Luo Y, Zhao M, Wu D, Yang Y, Zhang W, Shen M. Effective treatment of TNFα inhibitors in Chinese patients with Blau syndrome. Arthritis Res Ther 2019; 21:236. [PMID: 31718710 PMCID: PMC6852754 DOI: 10.1186/s13075-019-2017-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Objectives Blau syndrome (BS) is a rare dominantly inherited autoinflammatory disorder associated with mutations in the nucleotide-binding oligomerization domain containing 2 (NOD2) gene. Biologic therapy of BS yielded diverse results. We aimed to evaluate clinical features and outcomes of Chinese patients with BS who were treated with tumor necrosis factor (TNF)α inhibitors. Methods A total of four patients with BS were diagnosed and treated with infliximab (IFX) at the Peking Union Medical College Hospital during 2015 to 2018 and were followed up for 18 months. All patients were systematically studied for treatment outcomes including the clinical manifestations and inflammatory markers. We also conducted a comprehensive literature review about TNFα inhibitor therapy in BS. Results Four BS patients were all Chinese Han, and three were women. The mean age of disease onset was 4 ± 3.5 years, and the mean time of diagnosis delay was 19 ± 11 years. All patients received IFX plus methotrexate, and all achieved clinical remission of skin lesions and polyarthritis rapidly, as well as normalization of erythrocyte sedimentation rate and C-reactive protein and improvements in inflammatory cytokines, patient visual analogue scale, physician global assessment, and Short Form (SF)-36, at the first follow-up of 6 months. The disease relapsed in two patients after they lengthened the interval of IFX and discontinued methotrexate. According to the 38 English-language publications, 62 patients with BS were reported who underwent TNFα inhibitor therapy, including IFX used in 31, adalimumab in 24, and etanercept in 7. IFX was well tolerated in 27 patients, while 2 still had uveitis, and the other 2 experienced an adverse drug reaction. Conclusions Early recognition and effective treatment of BS are very important to avoid irreversible organ damage. TNFα inhibitors such as IFX may be a promising approach for BS patients who have unsatisfactory response to corticosteroids and traditional disease-modifying antirheumatic drugs.
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Affiliation(s)
- Jing Chen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.,Present Address: Department of Rheumatology, Chongqing Three Gorges Central Hospital, Chongqing, 404000, China
| | - Yi Luo
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Mengzhu Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Di Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yunjiao Yang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China. .,Department of Rheumatology, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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PaÇ Kisaarslan A, SÖzerİ B, Şahİn N, Özdemİr ÇİÇek S, GÜndÜz Z, Demİrkaya E, Berdelİ A, Sadet Özcan S, PorazoĞlu H, DÜŞÜnsel R. Blau Syndrome and Early-Onset Sarcoidosis: A Six Case Series and Review of the Literature. Arch Rheumatol 2020; 35:117-27. [PMID: 32637927 DOI: 10.5606/ArchRheumatol.2020.7060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 06/03/2019] [Indexed: 12/27/2022] Open
Abstract
Objectives This study aims to discuss the clinical, laboratory and genetic findings, and treatment options for six patients who were diagnosed with Blau syndrome (BS)/early-onset sarcoidosis (EOS). Patients and methods The study included four patients (2 males,2 females; mean age 7 years; range 4 to 10 years) with EOS and two siblings (1 male, 1 female; mean age 10 years; range, 9 to 11 years) with BS. Age, age of initial symptoms, age of diagnosis; articular involvement, presence of uveitis, dermatitis, or fever, other organ involvement, laboratory findings, results of metabolic tests for mucopolysaccharidosis and mucolipidosis, results of genetic, pathologic, and immunologic tests, radiologic findings to evaluate skeletal dysplasia, and treatment options were collected. Results The median age at diagnosis of all patients was 6 years (range, 1 to 10 years). Five patients had camptodactyly and bilateral boggy synovitis in the wrists and ankles, one had granulomatous inflammatory changes in the liver and kidney biopsy, and one had attacks of fever and granulomatous dermatitis. None had uveitis. The detected mutations in nucleotide-binding oligomerization domain containing 2 (NOD2) were P268S (rs2066842), M513T (rs104895473), R702W (rs2066844), V955I (rs5743291), H343Y (rs199858111), and M491L (16:50745293). The treatments of patients included corticosteroids, non-steroid anti-inflammatory drugs, methotrexate, infliximab, adalimumab, anakinra, and canacinumab. Conclusion Camptodactyly and boggy synovitis are important signs of BS/EOS. Methotrexate and tumor necrosis factor blockers are more effective in patients with predominantly articular symptoms. In patients 5 and 6 and their mother, we determined a novel M491L mutation in the NOD2 gene. Currently, this work is in progress towards identifying the pathogenesis and treatment options for this disease.
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Affiliation(s)
- Angela Cropley
- Nepean Hospital, Derby St, Kingswood, Sydney, Australia.
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Chiu B, Chan J, Das S, Alshamma Z, Sergi C. Pediatric Sarcoidosis: A Review with Emphasis on Early Onset and High-Risk Sarcoidosis and Diagnostic Challenges. Diagnostics (Basel) 2019; 9:E160. [PMID: 31731423 DOI: 10.3390/diagnostics9040160] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/14/2022] Open
Abstract
Sarcoidosis is a non-necrotizing granulomatous inflammatory syndrome with multisystemic manifestations. We performed a systematic review of sarcoidosis in the pediatric population with particular emphases on early onset sarcoidosis, high-risk sarcoidosis, and newly reported or unusual sarcoid-related diseases. Blau Syndrome and early onset sarcoidosis/ BS-EOS are seen in children younger than five years old presenting with extra-thoracic manifestations but usually without lymphadenopathy and/or pulmonary involvement. The prevalence of high-risk sarcoidosis is very low in children and is further limited by the difficulty of diagnosis in symptomatic children and underdiagnosis in subclinical or asymptomatic patients. Reports of sarcoidal syndromes in users of E-cigarette/marijuana/other flavorings and their induction in cancer immunotherapies are of interests and may be challenging to differentiate from metastatic malignancy. The diagnostic considerations in pediatric sarcoidosis are to support a compatible clinicoradiographic presentation and the pathologic findings of non-necrotizing granulomas by ruling out granulomas of infective etiology. There is no absolutely reliable diagnostic test for sarcoidosis at present. The use of endoscopic bronchial ultrasound (EBUS) and transbronchial fine needle aspiration (TBNA) sampling of intrathoracic lymph nodes and lung, and for superficially accessible lesions, with cytopathological assessment and pathological confirmations provide fair diagnostic yield and excellent patient safety profile in children.
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Abstract
Increasingly, Johne's disease of ruminants and human Crohn's disease are regarded as the same infectious disease: paratuberculosis. Mycobacterium avium ss. paratuberculosis (MAP) is the cause of Johne's and is the most commonly linked infectious cause of Crohn's disease. Humans are broadly exposed to MAP in dairy products and in the environment. MAP has been found within granulomas such as Crohn's disease and can stimulate autoantibodies in diseases such as type 1 diabetes (T1D) and Hashimoto's thyroiditis. Moreover, beyond Crohn's and T1D, MAP is increasingly associated with a host of autoimmune diseases. This article suggests near equivalency between paucibacillary Johne's disease of ruminant animals and human Crohn's disease and implicates MAP zoonosis beyond Crohn's disease to include T1D.
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Affiliation(s)
- Coad Thomas Dow
- McPherson Eye Research Institute, University of Wisconsin, 9431 WIMR, 1111 Highland Avenue, Madison, WI 53705, USA.
| | - Leonardo A Sechi
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43b, 07100 Sassari, Italy.
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Abstract
Blau syndrome is an autosomal dominant rare disease caused by mutations in NOD2 gene. Less than 200 patients published with Blau Syndrome Worldwide. We reported a 41-year old female Turkish patient diagnosed as Blau syndrome. Granulomatous dermatitis and severe headache, as well as recurrent chest and pelvic pain have been present since she was 8 years old. Arthritis started when she was teenage, hypertension diagnosed when she was 20 and other symptoms also occurred during the lifetime (severe preeclampsia, ischemic stroke, recurrent hemiparesis, recurrent-transient-vision-loss and renal-artery-stenosis). Genomic DNA was isolated from peripheral blood and 12 genes sequenced in Autoinflammatory panel on IonTorrent-S5-NGS platform with Parseq-VariFind™AIPassay. NGS analysis showed 107 variants in in the index case, mainly benign with no strong association with Blau syndrome. Additionally, we identified one very rare missense mutation in NOD2 gene (c2803G>A, p.Val935Met) and in silico assessment of the mutation indicated possible pathogenic significance and strong association with Blau syndrome. In addition, we analyzed family members of the index case and identified the same mutation in NOD2 gene. The segregation analysis shows the presence of the same mutant allele in NOD2 gene in the index case affected sister, as well as in her son with arthralgia, while in her non affecter brother we didn't detect the Val935Met mutation in NOD2 gene. Blau Syndrome is known as a very rare disease, mainly caused by mutations in NOD2 gene. Missense mutation diagnosed in our case could be responsible for the phenotype of the index case. Our results indicate the importance of NGS testing and its major role in the detection of rare mutations that may responsible for the onset of autoinflammatory disorders.
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Affiliation(s)
- Jelena Velickovic
- Faculty of Medicine, Institute of Forensic Medicine, University of Belgrade, Belgrade, Serbia
| | - Fatma Silan
- Faculty of Medicine, Department of Medical Genetic, COMU University, Canakkale, Turkey
| | - Firdevs Dincsoy Bir
- Faculty of Medicine, Department of Medical Genetic, COMU University, Canakkale, Turkey
| | - Coskun Silan
- Faculty of Medicine, Department of Pharmacology, COMU University, Canakkale, Turkey
| | - Burcu Albuz
- Faculty of Medicine, Department of Medical Genetic, COMU University, Canakkale, Turkey
| | - Ozturk Ozdemir
- Faculty of Medicine, Department of Medical Genetic, COMU University, Canakkale, Turkey
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Leong KF, Sato R, Oh GGK, Surana U, Pramono ZAD. Blau Syndrome Associated with Nucleotide-binding Oligomerization Domain Containing 2 Mutation in a Baby from Malaysia. Indian J Dermatol 2019; 64:400-403. [PMID: 31543536 PMCID: PMC6749758 DOI: 10.4103/ijd.ijd_44_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Blau syndrome (BS) is a very rare autosomal dominant juvenile inflammatory disorder caused by mutation in nucleotide-binding oligomerization domain containing 2 (NOD2). Usually, dermatitis is the first symptom that appears in the 1st year of life. About 220 BS cases with confirmed NOD2 mutation have been reported. However, the rarity and lack of awareness of the disease, especially in the regions where genetic tests are very limited, often result in late diagnosis and misdiagnosis. Here, we report a de novo BS case from Malaysia, which may be the first report from southeast Asia. PCR and DNA sequencing of peripheral blood mononuclear cells were performed to screen the entire coding region of NOD2 gene. A heterozygous c.1000C>T transition in exon 4, p. R334W, of the NOD2 gene was identified in the patient. This report further reaffirms the ubiquitousness of the disease and recurrency of p. R334W mutation.
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Affiliation(s)
- Kin Fon Leong
- Department of Pediatrics, Institute of Pediatric, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur 50586, Malaysia
| | - Reiko Sato
- Department of Research, National Skin Center, Singapore 308205, Singapore
| | | | - Uttam Surana
- Institute of Molecular and Cell Biology, AStar, Proteos, Singapore 138673, Singapore.,Singapore Bioprocessing Technology Institute, Singapore 138668, Singapore.,Department of Pharmacology, National University of Singapore, Singapore 117660, Singapore
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Abstract
Blau syndrome (BS) is a rare autoinflammatory disorder characterized by the clinical triad of arthritis, uveitis, and dermatitis due to heterozygous gain-of-function mutations in the NOD2 gene. BS can mimic juvenile idiopathic arthritis (JIA)-associated uveitis, rheumatoid arthritis, and ocular tuberculosis. We report a family comprising a mother and her two children, all presenting with uveitis and arthritis. A NOD2 mutation was confirmed in all the three patients - the first such molecularly proven case report of familial BS from India.
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Affiliation(s)
- Mahesh Janarthanan
- Division of Pediatric Rheumatology, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu, India
| | - Chanchal Poddar
- Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - S Sudharshan
- Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Luis Seabra
- INSERM UMR1163, Laboratory of Neurogenetics and Neuroinflammation, Paris Descartes University, Sorbonne-Paris-Cité, Institut Imagine, Paris, France
| | - Yanick J Crow
- INSERM UMR1163, Laboratory of Neurogenetics and Neuroinflammation, Paris Descartes University, Sorbonne-Paris-Cité, Institut Imagine, Paris, France; Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
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DeSouza PJ, Shah R. Characterization of Blau syndrome panuveitis with wide-field fluorescein angiography. Am J Ophthalmol Case Rep 2019; 14:92-94. [PMID: 30989150 PMCID: PMC6447728 DOI: 10.1016/j.ajoc.2019.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose To describe a case of Blau panuveitis, characterized on both portable and tabletop wide-field fluorescein angiography, which resolved on systemic immunosuppression. Observations A 5-year-old female presented with bilateral eye pain, redness, and decreased visual acuity due to panuveitis and had a history of arthritis, tenosynovitis, and dermatitis. Similar ocular and systemic findings in the patient's mother and maternal half-brother prompted genetic testing that confirmed the diagnosis of the rare Blau syndrome. Portable Retcam and tabletop Optos wide-field fluorescein angiography congruently demonstrated retinal vascular and peripapillary leakage. The uveitis dramatically resolved after the addition of adalimumab to methotrexate. Quiescence was maintained with the substitution of infliximab for adalimumab. Conclusions and Importance To our knowledge, we are first to characterize Blau panuveitis retinal findings on wide-field fluorescein angiography and with the use of two different photography systems. Additionally, this report underscores the salient clinical findings of a rare disorder and suggests that robust systemic immunosuppression can effectively treat refractory ocular inflammation.
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Affiliation(s)
- Philip J DeSouza
- Department of Ophthalmology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rajiv Shah
- Department of Ophthalmology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Zheng S, Lee PY, Huang Y, Wang A, Li T. Giant Cell Tumor of Tendon Sheath and Tendinopathy as Early Features of Early Onset Sarcoidosis. Front Pediatr 2019; 7:480. [PMID: 31803699 PMCID: PMC6873213 DOI: 10.3389/fped.2019.00480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/31/2019] [Indexed: 11/23/2022] Open
Abstract
Giant cell tumor of tendon sheath (GCTTS) is characterized by diffuse proliferation of synovial-like cells and multinucleated giant cells along tendon sheaths. This benign tumor typically presents in the third to fourth decade of life and is exceeding rare in children. Here we describe a case of a 10-years-old girl with a history of soft tissue swelling involving the third digit of left hand, bilateral wrists and ankles. Pathology of the finger mass revealed abundant multinucleated giant cells consistent with GCTTS. Resection of the tendinous masses from the ankles also showed multinucleated giant cells along with chronic bursitis. She began to show features of polyarticular arthritis by age 7. Due to progression of arthritis, whole exome sequencing was performed and found a de novo heterozygous mutation in NOD2 (p. R334Q). This variant is the most common mutation responsible for early onset sarcoidosis (EOS)/Blau syndrome, an autoinflammatory disease characterized by granulomatous inflammation of joints, skin and eyes. The early onset of symptoms and presence of multinucleated giant cells and granuloma in this case are in keeping with a diagnosis of EOS/Blau syndrome. The patient responded well to treatment with methotrexate and etanercept. This case extends the clinical spectrum of EOS/Blau syndrome, which should be considered for GCTTS and other unusual presentations of tendon inflammation in children, even in the absence of the characteristic triad of arthritis, dermatitis and uveitis.
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Affiliation(s)
- Shaoling Zheng
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Pui Y Lee
- Division of Allergy, Immunology and Rheumatology, Boston Children's Hospital, Boston, MA, United States
| | - Yukai Huang
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Aiwu Wang
- Department of Pathology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Tianwang Li
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
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Naik AU, Annamalai R, Biswas J. Uveitis in sporadic Blau syndrome: Long-term follow-up of a refractory case treated successfully with adalimumab. Indian J Ophthalmol 2018; 66:1483-1485. [PMID: 30249847 PMCID: PMC6173012 DOI: 10.4103/ijo.ijo_629_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The classic entity of autosomal dominant Blau syndrome (BS) consists of arthritis, dermatitis, and uveitis, occurring as a result of mutations in the NOD2 gene pattern recognition receptor. Sporadic cases are those in which no known gene mutation is identifiable. Uveitis in BS can be refractory to conventional therapy. We report a case of sporadic Blau uveitis managed with adalimumab monotherapy after failing to respond to topical steroids, systemic steroids, methotrexate, and infliximab therapy sequentially. Uveitis resolved completely with adalimumab and the patient has had a disease-free period over a 2-year follow-up with bi-monthly injections for arthritis control.
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Affiliation(s)
- Anmol U Naik
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Medical Research Foundation, Porur, Tamil Nadu, India
| | - Radha Annamalai
- Department of Ophthalmology, Sri Ramachandra Medical Centre, Sri Ramachandra University, Porur, Tamil Nadu, India
| | - Jyotirmay Biswas
- Department of Uvea and Ocular Pathology, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
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