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Blank N, Kötter I, Schmalzing M, Rech J, Krause K, Köhler B, Kaudewitz D, Nitschke M, Haas CS, Lorenz HM, Krusche M. Clinical presentation and genetic variants in patients with autoinflammatory diseases: results from the German GARROD registry. Rheumatol Int 2024; 44:263-271. [PMID: 37747561 PMCID: PMC10796580 DOI: 10.1007/s00296-023-05443-x] [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: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023]
Abstract
To investigate clinical symptoms and genetic variants in patients from the German anti-IL-1 registry for autoinflammatory orphan diseases (GARROD) between 2013 and 2022. Multicentre, retrospective analysis of demographic, clinical and genetic data of patients with autoinflammatory diseases (AID) who received anti-IL-1 targeted therapy. The cohort comprised 152 patients with familial Mediterranean fever (FMF; n = 71), cryopyrin-associated periodic syndromes (CAPS; n = 43), TNF-receptor associated periodic syndrome (TRAPS; n = 19), mevalonate kinase deficiency (MKD; n = 3) and unclassified AID (uAID; n = 16). Inflammatory attacks started in 61.2% of the patients before the age of 18 years. The delay between the first AID attack and anti-IL-1 therapy was 17.8 years. Monogenetic AIDs were diagnosed by clinical symptoms. Genetic analyses confirmed the diagnosis in 87.3% of patients with FMF, 65.2% with CAPS and 94.8% with TRAPS. Among this group, heterozygous MEFV variants and variants of unknown significance (VUS) were detected in 22.5% of patients with FMF, 51.2% with CAPS and 47.4% with TRAPS. Patients with VUS were older at disease onset which is consistent with a milder phenotype. Twenty-four patients had secondary AA amyloidosis (AA) at initiation of anti-IL-1 therapy. The mean age of these patients was 16.4 years at their first attack and 44.9 years at the time of AA diagnosis. Turkish-Armenian ancestry correlated with MEFV variants and higher FMF disease activity compared to German ancestry. Molecular genetic analyses should substantiate the clinical diagnosis of a monogenetic AID. Our data support the concept of variable penetrance of VUS which can be associated with late-onset AID.
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Affiliation(s)
- Norbert Blank
- Department of Internal Medicine V, Division of Rheumatology and Amyloidosis Center, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Zentrum Für Seltene Erkrankungen Heidelberg (ZSE HD), Heidelberg, Germany.
- Internal Medicine 5, Amyloidosis Center and Division of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Ina Kötter
- Department of Rheumatology, University Hospital Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
- Clinic for Rheumatology and Immunology, Bad Bramstedt, Germany
| | - Marc Schmalzing
- Department of Internal Medicine II, Rheumatology and Clinical Immunology, University of Würzburg, Oberdürrbacherstraße 6, 97080, Würzburg, Germany
| | - Jürgen Rech
- Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Department of Internal Medicine 3-Rheumatology and Immunology, Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054, Erlangen, Germany
- Zentrum Für Seltene Erkrankungen Erlangen (ZSE ER), Erlangen, Germany
| | - Karoline Krause
- Department of Dermatology, Charité-Campus Mitte, Luisenstraße 2, 10117, Berlin, Germany
| | - Birgit Köhler
- Städtisches Klinikum Karlsruhe, Department of Internal Medicine I, Nephrology and Rheumatology, Moltkestraße 90, 76133, Karlsruhe, Germany
| | - Dorothee Kaudewitz
- Department of Internal Medicine V, Division of Rheumatology and Amyloidosis Center, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Zentrum Für Seltene Erkrankungen Heidelberg (ZSE HD), Heidelberg, Germany
| | - Martin Nitschke
- Division of Nephrology, Internal Medicine I, Universityhospital S.-H. Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany
| | - Christian S Haas
- University of Marburg, Department of Internal Medicine, Nephrology and Intensive Care Medicine, Baldingerstrasse 1, 35033, Marburg, Germany
| | - Hanns-Martin Lorenz
- Department of Internal Medicine V, Division of Rheumatology and Amyloidosis Center, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Zentrum Für Seltene Erkrankungen Heidelberg (ZSE HD), Heidelberg, Germany
| | - Martin Krusche
- Department of Rheumatology, University Hospital Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Charitéplatz 1, 10117, Berlin, Germany
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Yun M, Deng Z, Navetta-Modrov B, Xin B, Yang J, Nomani H, Aroniadis O, Gorevic PD, Yao Q. Genetic variations in NLRP3 and NLRP12 genes in adult-onset patients with autoinflammatory diseases: a comparative study. Front Immunol 2024; 14:1321370. [PMID: 38343435 PMCID: PMC10853347 DOI: 10.3389/fimmu.2023.1321370] [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: 10/14/2023] [Accepted: 12/26/2023] [Indexed: 02/15/2024] Open
Abstract
Objectives Cryopyrin-associated periodic syndrome or NLRP3-associated autoinflammatory disease (NLRP3-AID) and NLRP12-AID are both Mendelian disorders with autosomal dominant inheritance. Both diseases are rare, primarily reported in the pediatric population, and are thought to be phenotypically indistinguishable. We provide the largest cohort of adult-onset patients and compared these diseases and the gene variant frequency to population controls. Methods A cohort of adult patients with AIDs were retrospectively studied. All underwent molecular testing for periodic fever syndrome gene panels after extensive and negative workups for systemic autoimmune and other related diseases. Patients were divided into Group 1- NLRP3-AID patients with NLRP3 variants (N=15), Group 2- NLRP12-AID with NLRP12 variants (N=14) and Group 3- both NLRP3 and NLRP12 (N=9) variants. Exome sequence data of two large control populations including the ARIC study were used to compare gene variant distribution and frequency. Results All 38 patients were Caucasian with women accounting for 82%. Median age at diagnosis was 41 ± 23 years and the disease duration at diagnosis was 14 ± 13 years. We identified statistically significant differences between the groups, notably that gastrointestinal symptoms as well as evaluations for same were significantly more frequent in patients with NLRP12 variants, and headaches/dizziness were less common among the NLRP12 patients. Livedo reticularis was noted in four patients, exclusively among NLRP12 carriers. Over 50% of patients in Groups 1 and 2 carry low-frequency disease-associated variants, while the remaining carry rare variants. We unprecedently identified digenic variants, i.e., the coexistence of NLRP3 and NLRP12, which were either both low frequency or low frequency/rare. Allele frequencies of all variants identified in our cohort were either absent or significantly lower in the control populations, further strengthening the evidence of susceptibility of these variants to SAID phenotypes. Conclusion Our comparative study shows that both NLRP3-AID and NLRP12-AID share similar clinical phenotypes, yet there are significant differences between them with regard to gastrointestinal and neurological symptoms. A spectrum of high to low genetic variations in both genes can contribute to SAID individually or in combination.
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Affiliation(s)
- Mark Yun
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, United States
| | - Zuoming Deng
- Biodata Mining and Discovery Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, United States
| | - Brianne Navetta-Modrov
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, United States
| | - Baozhong Xin
- Molecular Diagnostics Laboratory, DDC Clinic for Special Needs Children, Middlefield, OH, United States
| | - Jie Yang
- Department of Family, Population and Preventive Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, United States
| | - Hafsa Nomani
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, United States
| | - Olga Aroniadis
- Division of Gastroenterology and Hepatology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, United States
| | - Peter D. Gorevic
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, United States
| | - Qingping Yao
- Division of Rheumatology, Allergy and Immunology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, United States
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Ando T, Abe Y, Yamaji K, Nishikomori R, Tamura N. A case of cryopyrin-associated periodic syndrome due to somatic mosaic mutation complicated with recurrent circinate erythematous psoriasis. Mod Rheumatol Case Rep 2023:rxad067. [PMID: 38036300 DOI: 10.1093/mrcr/rxad067] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/13/2023] [Accepted: 11/30/2023] [Indexed: 12/02/2023]
Abstract
Cryopyrin-associated periotic syndrome (CAPS) is a rare autoinflammatory disease (AID) caused by genetic variants in innate immunity genes. AIDs, including CAPS, mediate proinflammatory cytokines such as interleukin (IL)-1 and IL-18 and result in severe systemic inflammation. A gain-of-function mutation in the NLRP3 gene, which encodes the protein cryopyrin, was identified to be responsible for CAPS in 2001, and since then several additional pathogenic mutations have been found. Moreover, other phenotypes have been identified based on severity and symptomatology, including familial cold autoinflammatory syndrome, Muckle-Wells syndrome (MWS), and neonatal-onset multisystem inflammatory disease (NOMID)/chronic neurologic cutaneous articular syndrome (CINCA). Prompt diagnosis of CAPS remains challenging, however, due to unspecific, extensive clinical signs, and delayed diagnosis and treatment targeting IL-1 lead to multiorgan damage. Another factor complicating diagnosis is the existence of somatic mosaic mutations in the NLRP3 gene in some cases, resulting in symptoms and clinical courses that are atypical. The frequency of somatic mosaic mutations in CAPS was estimated to be 19% in a systematic review. Psoriasis is a chronic inflammatory skin disease that affects about 3% of the global population. Although no reports have shown complication between CAPS and psoriasis, these diseases have several similarities and potential relationships, for instance activation of Th17 cells in the dermis and increased NLRP3 gene expression in psoriatic skin compared with normal skin. Here we report a case of CAPS due to a somatic mosaic mutation with recurrent circinate erythematous psoriasis.
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Affiliation(s)
- Taiki Ando
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ryuta Nishikomori
- The Department of Pediatrics and Child Health, Kurume University School of Medicine
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
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Ducharme-Bénard S, Roberge G, Chapdelaine H. A unique presentation of NLRP3-associated autoinflammatory disease: case report. BMC Rheumatol 2022; 6:91. [PMID: 36510304 PMCID: PMC9743682 DOI: 10.1186/s41927-022-00321-8] [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] [Received: 05/02/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND NLRP3-associated autoinflammatory diseases (NLRP3-AID) are rare genetic autoinflammatory diseases characterized by chronic inflammation and an urticaria-like rash. We report an unusual presentation of severe NLRP3-AID resulting in a significant diagnostic delay of more than three decades. CASE PRESENTATION The patient presented with early-onset serositis as well as prominent peripheral eosinophilia with organ infiltration, in the absence of the classic urticaria-like rash. DNA analysis by next generation sequencing revealed a sporadic class 4 mutation c.1991T > C (p.Met662Thr) in the NLRP3 gene, confirming a diagnosis of NLRP3-AID at 36 years old. Although treatment with anti-interleukin 1 agent led to clinical remission, irreversible sequelae, namely intellectual disability and deafness, remained. CONCLUSION This case highlights unique manifestations of NLRP3-AID, namely the absence of urticaria-like rash, eosinophilic organ infiltration, and pseudoseptic serositis. In order to avoid diagnostic delay and its dire consequences, NLRP3-AID should be suspected in patients displaying autoinflammatory features combined with serum and tissue eosinophilia and/or marked serositis, regardless of skin involvement.
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Affiliation(s)
- Stéphanie Ducharme-Bénard
- grid.14848.310000 0001 2292 3357Department of General Internal Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 Boulevard Gouin Ouest, Montreal, H4J 1C5 QC Canada
| | - Guillaume Roberge
- grid.411172.00000 0001 0081 2808Centre d’excellence en maladies vasculaires, Hôpital St-François d’Assise, Centre Hospitalier Universitaire de Québec–Université Laval, 10 rue de l’Espinay, Quebec, QC G1L 3L5 Canada
| | - Hugo Chapdelaine
- grid.410559.c0000 0001 0743 2111Department of Allergy and Immunology, Centre Hospitalier Universitaire de Montréal, Montreal, QC Canada ,grid.511547.30000 0001 2106 1695Institut de Recherches Cliniques de Montréal, 110, Avenue des Pins Ouest, Montreal, QC H2W 1R7 Canada
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Teshima R, Nishimura A, Hara A, Ubukata Y, Chizuwa S, Wakatsuki M, Iijima T. Anesthesia Management of a Patient With Familial Cold Autoinflammatory Syndrome: A Case Report. Anesth Prog 2022; 69:38-39. [PMID: 36223190 PMCID: PMC9552617 DOI: 10.2344/anpr-69-02-04] [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: 11/01/2021] [Accepted: 02/04/2022] [Indexed: 03/03/2023] Open
Abstract
Familial cold autoinflammatory syndrome (FCAS) is a rare phenotype of cryopyrin-associated periodic syndrome (CAPS) and is characterized by repetitive systemic inflammation triggered by cold stimulation. Recently, we treated a 13-year-old female with FCAS/CAPS scheduled to undergo removal of an impacted tooth. To minimize perioperative heat loss, a forced-air warming system was utilized to prewarm the patient for 10 minutes before induction of general anesthesia. The patient's core and peripheral temperatures were monitored with axillary, superficial temporal artery, and rectal thermometers. The difference in temperatures at these 3 locations decreased to 0.4° C within 60 minutes as a result of the forced-air warming system before induction. Perioperative use of the warming system successfully prevented the occurrence any significant redistribution hypothermia and any symptoms of FCAS/CAPS.
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Affiliation(s)
- Ruri Teshima
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University School of Dentistry, Tokyo, Japan
| | - Akiko Nishimura
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University School of Dentistry, Tokyo, Japan
| | - Akira Hara
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University School of Dentistry, Tokyo, Japan
| | - Yuhei Ubukata
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University School of Dentistry, Tokyo, Japan
| | - Sayaka Chizuwa
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University School of Dentistry, Tokyo, Japan
| | - Mone Wakatsuki
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University School of Dentistry, Tokyo, Japan
| | - Takehiko Iijima
- Department of Perioperative Medicine, Division of Anesthesiology, Showa University School of Dentistry, Tokyo, Japan
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Zayaeva AA, Sokolova LV, Shaduro DV, Petrov AV, Kulanthaivel S, Kaliberdenko VB. Rare Clinical Case of Cryopyrin-Associated Periodic Syndrome Presented with Ankylosing Spondylitis: A Case Report. Curr Rheumatol Rev 2021; 18:373-379. [PMID: 34784874 DOI: 10.2174/1573397117666211116110833] [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: 04/15/2021] [Revised: 09/11/2021] [Accepted: 09/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cryopyrin-Associated Periodic Syndrome (CAPS) is a variety of clinical variants of autoinflammatory diseases. The pathology is based on a mutation in the NLRP3 gene encoding the cryopyrin protein, which leads to the uncontrolled production of interleukin-1β. Particular attention should be paid to the rarity of this disease and the lack of clinical knowledge about it in therapeutic and rheumatological practice, which leads to an erroneous diagnosis and the appointment of ineffective treatment for a long time, leading to the progression of the disease and disability of the patient. CASE PRESENTATION This article describes a clinical case of this disease. The first manifestations of the disease in a woman appeared from the age of 2 years, in the form of a rash and fever. Since school age, there have been signs of arthritis. By the age of 24, sensorineural hearing loss and pain in the spine were evident. The disease occurred under the clinical manifestations of spondyloarthritis. Its treatment with anti-inflammatory therapy did not give a stable result. CONCLUSION From the analysis, we can conclude that patient M. from early childhood suffers from a severe Neonatal-onset Multisystem Inflammatory Disease of a genetic nature. For a long time, the patient was diagnosed with ankylosing spondylitis, and appropriate treatment was carried out without significant success. The correct diagnosis of CAPS was made only in 2018. This patient has conditions of both CAPS and AS together, which is a very rare association in rheumatological practice. The only treatment method that could stop the manifestations of the disease and prevent life-threatening kidney damage (amyloidosis) is the use of genetically engineered biological drugs, i.e., IL-1β inhibitors. The only drug of this group registered in Russia is canakinumab (Ilaris ®). From the moment of diagnosis to the present day, the patient is treated with the genetically engineered drug canakinumab (Ilaris ®) at a dose of 150 mg once every 8 weeks. 6 months after taking the drug, the patient went into complete clinical and laboratory remission.
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Affiliation(s)
- Anna A Zayaeva
- Rheumatologist, Department of Internal Medicine No.2, V.I. Vernadsky Crimean Federal University, Simferopol. Russian Federation
| | - Lyudmila V Sokolova
- Immunologist, Department of Internal Medicine No.2, V.I. Vernadsky Crimean Federal University, Simferopol. Russian Federation
| | - Denis V Shaduro
- Department of Internal Medicine No.2, V.I. Vernadsky Crimean Federal University, Simferopol. Russian Federation
| | - Andrey V Petrov
- Rheumatologist, Head of the Department of Immunology and Biological Therapy, Department of Internal Medicine No.2, V.I. Vernadsky Crimean Federal University, Simferopol. Russian Federation
| | - Shanmugaraj Kulanthaivel
- Science and Research Department, Naarayani Multi Speciality Hospital, Kavindapadi, Erode, Tamilnadu. India
| | - Vitalii B Kaliberdenko
- Onco-Hematologist, Department of Internal Medicine No.2, V.I. Vernadsky Crimean Federal University, Simferopol. Russian Federation
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Papagoras C, Lampropoulou V, Mavraki E, Chrysanthopoulou A, Deftereos S, Aróstegui JI, Skendros P, Ritis K. Multiple sclerosis in a patient with cryopyrin-associated autoinflammatory syndrome: Evidence that autoinflammation is the common link. Clin Immunol 2021; 227:108750. [PMID: 33945870 DOI: 10.1016/j.clim.2021.108750] [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: 03/31/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 01/08/2023]
Abstract
The co-existence of an autoinflammatory syndrome with a demyelinating disorder is a very rare occurrence raising the question whether there is a pathophysiological connection between them. We describe the case of a man with symptoms of cryopyrin-associated periodic syndrome (CAPS) since infancy who later developed multiple sclerosis (MS). As CAPS was genetically confirmed, the inhibition of interleukin-1 (IL-1) with anakinra led to a swift resolution of the CAPS symptoms and also, in combination with teriflunomide, to a clinical and imaging improvement of MS. In vitro studies showed that, upon a CAPS flare, the patient's peripheral neutrophils released neutrophil extracellular traps (NETs) decorated with IL-1β, while NET release was markedly decreased following anakinra-induced remission of CAPS. Taking into account the growing evidence on the involvement of IL-1β in experimental models of MS, this rare patient case suggests that the role of neutrophils/NETs and IL-1β in MS should be further studied.
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Affiliation(s)
- Charalampos Papagoras
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Laboratory of Molecular Hematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vasiliki Lampropoulou
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Eleni Mavraki
- Department of Neurology, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Akrivi Chrysanthopoulou
- Laboratory of Molecular Hematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Savas Deftereos
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Juan I Aróstegui
- Department of Immunology, Hospital Clinic, Barcelona, Spain; Institut d' Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Panagiotis Skendros
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Laboratory of Molecular Hematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Konstantinos Ritis
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; Laboratory of Molecular Hematology, Democritus University of Thrace, Alexandroupolis, Greece.
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Kilic H, Sahin S, Duman C, Adrovic A, Barut K, Turanli ET, Yildirim SR, Kizilkilic O, Kasapcopur O, Saltik S. Spectrum of the neurologic manifestations in childhood-onset cryopyrin-associated periodic syndrome. Eur J Paediatr Neurol 2019; 23:466-472. [PMID: 30967326 DOI: 10.1016/j.ejpn.2019.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 12/21/2018] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Neurologic complications of chronic infantile neurologic, cutaneous and articular syndrome (CINCA) are well-known, whereas there are scarce data regarding neurologic features of milder cryopyrin-associated periodic syndrome (CAPS) phenotypes. We aimed to review the neurologic features in detail and summarize the other CAPS-related manifestations in 12 children. METHODS All children with CAPS that have been followed-up from pediatric rheumatology outpatient clinic, were enrolled to the study. In addition to the neurologic examination, magnetic resonance imaging (MRI) of brain, electroencephalography, eye examination, hearing test and intellectual assessment were done. Demographic, clinical features, genetic analysis and laboratory tests were noted from patient records and hospital database. RESULTS The median age of the subjects was 7 years (range 2-19 years), with a female-to-male ratio 2/1. The phenotype was consistent with familial cold autoinflammatory syndrome in 7 patients, Muckle-Wells syndrome in 3 patients and chronic infantile neurologic, cutaneous and articular syndrome in 2 patients. Most frequently noted neurologic clinical manifestation during the entire disease course was headache (n = 4/12) followed by seizures (n = 3/12), papilledema (n = 3/12), intellectual disability (n = 2/12), aseptic meningitis (n = 2/12), hearing loss (n = 2/12) and optic atrophy (n = 1/12). MRI of the brain revealed abnormal lesions in two patients. Uveitis or conjunctivitis were seen in two children. Overall, neurological involvement was detected in 6/12 of our cohort, of which half (n = 3) was in severe form. CONCLUSION Half of the children with CAPS exhibited neurologic manifestations with varying degrees of severity. Increased understanding and awareness of this rare but treatable syndrome among neurologists is essential. If remains untreated and unrecognized, this autoinflammatory syndrome could lead to significant morbidity and mortality. Besides complete resolution of systemic symptoms, anti-interleukin-1 treatment may also prevent progression of neurologic findings when initiated in the early stage of the disease.
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Affiliation(s)
- Huseyin Kilic
- Department of Pediatric Neurology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey.
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Cisem Duman
- Department of Pediatric Neurology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Eda Tahir Turanli
- Department of Molecular Biology and Genetics, Istanbul Technical University, Istanbul, Turkey
| | - Senihe Rengin Yildirim
- Departments of Ophthalmology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Radiology, Division of Neuroradiology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Sema Saltik
- Department of Pediatric Neurology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
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Hui A, Johnson LB, Greemberg R, Penney L, Ramsey SE. Severe cryopyrin-associated periodic syndrome first characterized by early childhood-onset sensorineural hearing loss - Case report and literature review. Int J Pediatr Otorhinolaryngol 2019; 120:68-72. [PMID: 30772614 DOI: 10.1016/j.ijporl.2019.01.037] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/22/2018] [Accepted: 01/23/2019] [Indexed: 12/24/2022]
Abstract
Infant-onset bilateral sensorineural hearing loss is a key presenting symptom of the autoinflammatory cryopyrin-associated periodic syndrome. Other symptoms include periodic fever, cold-induced urticaria-like rash, chronic aseptic meningitis, polyarticular arthralgias, and renal AA amyloidosis. Early recognition and treatment with interleukin-1 blockade are critical for preventing disabling or fatal complications. We describe a patient with severe cryopyrin-associated periodic syndrome who presented at age 18 months with macrocephaly and moderate sensorineural hearing loss, later developing systemic sequelae. The pathogenic nature of the de novo NLRP3 gene variant identified was supported by a markedly elevated serum amyloid A level and sustained clinical response to anti-IL-1 therapy.
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Affiliation(s)
- Amaris Hui
- Division of Pediatric Otolaryngology, Department of Surgery, IWK Health Centre, 5850/5980 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada.
| | - Liane B Johnson
- Division of Pediatric Otolaryngology, Department of Surgery, IWK Health Centre, 5850/5980 University Avenue, PO Box 9700, Halifax, NS, B3K 6R8, Canada.
| | - Rony Greemberg
- Allergy and Clinical Immunology, Department of Pediatrics, Chaleur Regional Hospital, 1750 Sunset Ave, Bathurst, NB, E2A 4L7, Canada.
| | - Lynette Penney
- Division of Medical Genetics, Department of Pediatrics, IWK Health Centre, 5850/5980 University Ave, PO Box 9700, Halifax, NS, B3K 6R8, Canada.
| | - Suzanne E Ramsey
- Division of Pediatric Rheumatology, Department of Pediatrics, IWK Health Centre, 5850/5980 University Ave, PO Box 9700, Halifax, NS, B3K 6R8, Canada.
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10
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Mulders-Manders CM, Kanters TA, van Daele PLA, Hoppenreijs E, Legger GE, van Laar JAM, Simon A, Hakkaart-van Roijen L. Decreased quality of life and societal impact of cryopyrin-associated periodic syndrome treated with canakinumab: a questionnaire based cohort study. Orphanet J Rare Dis 2018; 13:59. [PMID: 29678136 PMCID: PMC5910566 DOI: 10.1186/s13023-018-0799-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 11/21/2017] [Accepted: 04/04/2018] [Indexed: 01/01/2023] Open
Abstract
Background Cryopyrin-associated periodic syndrome (CAPS) is a rare disease. Knowledge on the quality of life (QoL) and the disease’s societal impact is limited. Canakinumab is used in increasing frequency for the treatment of CAPS. Methods Observational study in Dutch CAPS patients. Patients completed questionnaires regarding treatment with canakinumab at baseline and retrospectively. Quality of life was assessed using the EQ-5D-5L in adults and CHQ-PF50 in children. Impact on work and school was assessed. Caregivers' quality of life was assessed using the CarerQol. Results Mean quality of life scores during treatment with canakinumab were 0.769 (EQ-5D-5L), 51.1 (CHQ-P) and 57–1 (CHQ-M). Most patients experienced problems on the pain/discomfort dimension. Higher disease activity and the presence of complications negatively influenced QoL. Half of the patients with a paid job reported absenteeism from work due to CAPS, for an average of 8.7 days in a 4-week period. All schoolgoing patients (N = 5) reported absence from school due to CAPS, for an average of 2.9 days. Caregivers reported gaining a lot fulfillment from providing care for their family members. Conclusion QoL during treatment is lower than in the general Dutch population. CAPS leads to productivity loss and absenteeism from school, and impacts the quality of life in informal caregivers. Electronic supplementary material The online version of this article (10.1186/s13023-018-0799-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catharina M Mulders-Manders
- Department of Internal Medicine, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands. .,Expertise Center for Immunodeficiency and Autoinflammation, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Tim A Kanters
- Erasmus University Rotterdam, Institute for Medical Technology Assessment, Bayle Building - Campus Woudestein, PO box 1738, 3000, DR, Rotterdam, The Netherlands
| | - Paul L A van Daele
- Department of Internal Medicine and Immunology, Erasmus MC, Front Service Immunology, room: Nb-1218, PO box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Esther Hoppenreijs
- Department of Paediatric Rheumatology, Radboud university medical center, Amalia Children's Hospital, 804, PO box 9101, 6500, HB, Nijmegen, the Netherlands
| | - G Elizabeth Legger
- Department of Pediatrics, University Medical Center Groningen, PO box 30.001, 9700, RB, Groningen, the Netherlands
| | - Jan A M van Laar
- Department of Internal Medicine and Immunology, Erasmus MC, Front Service Immunology, room: Nb-1218, PO box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Anna Simon
- Department of Internal Medicine, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands.,Expertise Center for Immunodeficiency and Autoinflammation, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Leona Hakkaart-van Roijen
- Erasmus University Rotterdam, Institute for Medical Technology Assessment, Bayle Building - Campus Woudestein, PO box 1738, 3000, DR, Rotterdam, The Netherlands
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11
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Eskola V, Pohjankoski H, Kröger L, Aalto K, Latva K, Korppi M. Cryopyrin-associated periodic syndrome in early childhood can be successfully treated with interleukin-1 blockades. Acta Paediatr 2018; 107:577-580. [PMID: 29331074 DOI: 10.1111/apa.14217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 09/06/2017] [Accepted: 01/08/2018] [Indexed: 12/19/2022]
Abstract
Cryopyrin-associated periodic syndrome (CAPS) is caused by a mutation in the NLRP3 gene encoding cryopyrin production. Overproduction of interleukin-1 (IL-1) leads to symptoms that are associated with elevated inflammatory markers, including periodic fever and a rash. We provide a clinical overview of CAPS in children, including three Finnish case studies. CONCLUSION When CAPS has been diagnosed, an IL-1 blockade with biological should be introduced to lessen the symptoms and to prevent the progression of organ damage.
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Affiliation(s)
- Vesa Eskola
- Department of Pediatrics; Tampere University Hospital; Tampere Finland
| | - Heini Pohjankoski
- Department of Pediatrics; Päijät-Häme District Central Hospital; Lahti Finland
| | - Liisa Kröger
- Department of Pediatrics; Kuopio University Hospital; Kuopio Finland
| | - Kristiina Aalto
- Department of Pediatrics; Helsinki University Hospital; Helsinki Finland
| | - Katariina Latva
- Department of Pediatrics; Päijät-Häme District Central Hospital; Lahti Finland
| | - Matti Korppi
- Department of Pediatrics; Tampere University Hospital; Tampere Finland
- Pediatric Research Centre University of Tampere; Tampere Finland
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12
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Abstract
Muckle-Wells syndrome (MWS) is a rare autoinflammatory disease. This study aimed to report the clinical features and gene variations of the first case series of MWS patients in Chinese population. Four Han Chinese patients were diagnosed with MWS and followed up at our adult clinic for autoinflammatory diseases. All relevant phenotypes and genotypes were collected. All patients were adult male. The median age of disease onset was 4.5 years, and one patient had adult-onset disease. No positive family history was observed. All patients had a remittent disease course. The duration of fever attacks ranged from 0.5 to 7 days. Skin rashes were present in all patients. The other manifestations included polyarthralgia/arthritis (n = 3), oral ulcers (n = 2), conjunctivitis (n = 2), myalgia (n = 2), headache (n = 2), pharyngitis (n = 1), abdominal pain (n = 1), severe sensorineural hearing loss (n = 1), and chronic meningitis with communicating hydrocephalus (n = 1). None of the patients showed evidence of renal amyloidosis. Each patient carried a heterozygous mutation in an NLRP3 gene, including D29V, V70M, T348M, and Q703K, respectively. D29V and V70M variants were novel mutations in exon 1 of NLRP3. All patients had good response to corticosteroids. Our study suggests that MWS could be identified in Chinese population. Our finding of novel mutations in NLRP3 may expand the diversity of MWS.
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Affiliation(s)
- Di Wu
- Peking Union Medical College Hospital, Beijing, 100730, China
| | - Min Shen
- Peking Union Medical College Hospital, Beijing, 100730, China.
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13
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Shen M, Tang L, Shi X, Zeng X, Yao Q. NLRP12 autoinflammatory disease: a Chinese case series and literature review. Clin Rheumatol 2016; 36:1661-1667. [PMID: 27633793 DOI: 10.1007/s10067-016-3410-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [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: 09/02/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 12/19/2022]
Abstract
As one of the systemic autoinflammatory diseases (SAIDs), the nucleotide-binding oligomerization domain-like receptor protein (NLRP)12 autoinflammatory disease (NLRP12-AD) is an autosomal dominant disorder associated with NLRP12 mutation. SAIDs have been hardly reported in the Chinese population, and NLRP12-AD has been reported only in Caucasians. We report the first case series of NLRP12-AD in the Chinese population coupled with literature review. Three Han Chinese adult patients with clinical phenotype suggestive of NLRP12-AD carrying NLRP12 variants were treated by the authors in 2015. Their phenotype and genotype were carefully studied. A PubMed search for SAIDs was conducted between January, 1990 and January, 2016, and we focused on NLRP12-AD. All three adult patients developed periodic disease in adulthood. They presented with recurrent fever (n = 3), polyarthralgia (n = 3), myalgia (n = 3), urticaria (n = 2), lymphadenopathy (n = 2), and erythema nodosa (n = 1). All patients carry the NLRP12 mutation F402L. Based upon our analysis of a total of 26 patients with NLRP12-AD in the literature, both familial and sporadic cases were equally reported and late-onset cases accounted for 28 %. NLRP12-AD patients typically present with periodic fever, urticaria-like rash, arthralgia/arthritis, myalgia, and lymphadenopathy. Genotyping identifies the NLRP12 gene mutations, notably F402L (55 %). Relative to the literature reports, our patients had the similar phenotypic and genotypic features. Patients with NLRP12-AD usually respond to glucocorticoid therapy. Our report is the first to confirm the presence of NLRP12-AD in the Chinese population. It highlights the importance of screening NLRP12 in patients with unexplained periodic fever syndrome.
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Affiliation(s)
- 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, 1 Shuaifuyuan, Dongcheng District, Beijing, NO, 100730, China.
| | - Lin Tang
- Department of Rheumatology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochun Shi
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaofeng Zeng
- 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, 1 Shuaifuyuan, Dongcheng District, Beijing, NO, 100730, China
| | - Qingping Yao
- Division of Rheumatology, Allergy, and Immunology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Hirano M, Seguchi J, Yamamura M, Narita A, Okanobu H, Nishikomori R, Heike T, Hosokawa M, Morizane Y, Shiraga F. Successful resolution of stromal keratitis and uveitis using canakinumab in a patient with chronic infantile neurologic, cutaneous, and articular syndrome: a case study. J Ophthalmic Inflamm Infect 2015; 5:34. [PMID: 26590045 PMCID: PMC4654730 DOI: 10.1186/s12348-015-0065-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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: 08/27/2015] [Accepted: 11/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cryopyrin-associated periodic syndrome (CAPS) is a group of rare autoinflammatory diseases, and of these, chronic infantile neurologic, cutaneous, and articular/neonatal-onset multisystem inflammatory disease (CINCA/NOMID) syndrome has the most severe phenotype. Canakinumab, a monoclonal antibody that targets interleukin-1β, has been shown to be an effective treatment for resolving systemic inflammation. However, its efficacy for treating ophthalmic symptoms of this disorder remains unclear. FINDINGS A 64-year-old female reported episodes of nonpruritic urticaria, fever, aseptic meningitis, and bilateral sensorineural deafness. Her son had experienced similar symptoms. She was initially referred for ophthalmologic treatment for an infectious corneal ulcer. Examination of her right eye by slit lamp biomicroscopy showed diffuse conjunctival injection, corneal infiltrates, a corneal ulcer, and hypopyon. She was therefore treated aggressively with topical and systemic antibiotics in addition to antifungal medications. However, this was ineffective. Genetic analysis detected the heterozygous germline p.Asp303Asn mutation in the NLRP3 gene in both our patient and her son. She was therefore diagnosed with CINCA/NOMID syndrome based on her clinical manifestations. All of the patient's physical and ophthalmic symptoms were resolved within a few days after the initiation of canakinumab treatment. During an 18-month follow-up period, no adverse events or severe infections were observed. CONCLUSIONS Our case report indicates that canakinumab is effective not only for the treatment of systemic inflammation but also for treating ophthalmic involvement, such as recurrent stromal keratitis and anterior uveitis.
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Affiliation(s)
- Masayuki Hirano
- Department of Ophthalmology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Jiro Seguchi
- Department of Ophthalmology, Okayama Saiseikai General Hospital, Okayama, Japan.
| | - Masahiro Yamamura
- Center for Rheumatology, Okayama Saiseikai General Hospital, Okayama, Japan.
| | - Akiko Narita
- Department of Ophthalmology, Okayama Saiseikai General Hospital, Okayama, Japan.
| | - Hirotaka Okanobu
- Department of Ophthalmology, Kurashiki Medical Center, Kurashiki, Japan.
| | - Ryuta Nishikomori
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Toshio Heike
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Mio Hosokawa
- Department of Ophthalmology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Yuki Morizane
- Department of Ophthalmology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Fumio Shiraga
- Department of Ophthalmology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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15
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Imaizumi R, Ishii Y, Miki K, Kudo S, Murakami T, Koyama I, Nakajima I, Fuchinoue S, Kawaguchi Y, Taniguchi A, Teraoka S. A case of cryopyrin-associated periodic syndrome with kidney transplant failure. CEN Case Rep 2014; 4:1-5. [PMID: 28509262 DOI: 10.1007/s13730-014-0129-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 08/31/2013] [Accepted: 05/27/2014] [Indexed: 12/26/2022] Open
Abstract
The cryopyrin-associated periodic syndrome (CAPS) is an autosomal dominant autoinflammatory disease characterized by fever, skin rash, and joint involvement with acute inflammatory response. The genetic defect involves the NLRP3 gene that encodes cryopyrin and leads to an abnormal production of interleukin-1 (IL-1). Therefore, anti-IL-1 treatment represents an effective therapy. One of the most severe manifestations of the disease is secondary amyloidosis that causes renal failure. We present a patient with CAPS who underwent renal transplantation for renal insufficiency caused by amyloidosis. The function of the transplanted kidney deteriorated because of the late administration of IL-1 receptor antagonist, anakinra. This case may indicate the importance of early initiation of anti-IL-1 treatment in CAPS patients who have undergone kidney transplantation.
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Affiliation(s)
- Rie Imaizumi
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yasuo Ishii
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Katsuyuki Miki
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shinji Kudo
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Toru Murakami
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Ichiro Koyama
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Ichiro Nakajima
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shohei Fuchinoue
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Atsuo Taniguchi
- Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan.
| | - Satoshi Teraoka
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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