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Pillai J, Pillai K. Accuracy of generative artificial intelligence models in differential diagnoses of familial Mediterranean fever and deficiency of Interleukin-1 receptor antagonist. J Transl Autoimmun 2023; 7:100213. [PMID: 37927888 PMCID: PMC10622681 DOI: 10.1016/j.jtauto.2023.100213] [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: 08/14/2023] [Revised: 09/18/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
With the increasing development of artificial intelligence, large language models (LLMs) have been utilized to solve problems in natural language processing tasks. More recently, LLMs have shown unique potential in numerous applications within medicine but have been particularly investigated for their ability in clinical reasoning. Although the diagnostic accuracy of LLMs in forming differential diagnoses has been reviewed in general internal medicine applications, much is unknown in autoinflammatory disorders. From the nature of autoinflammatory diseases, forming a differential diagnosis is challenging due to the overlapping symptoms between disorders and even more difficult without genetic screening. In this work, the diagnostic accuracy of the Generative Pre-Trained Transformer Model-4 (GPT-4), GPT-3.5, and Large Language Model Meta AI (LLaMa) were evaluated in clinical vignettes of Deficiency of Interleukin-1 Receptor Antagonist (DIRA) and Familial Mediterranean Fever (FMF). We then compared these models to a control group including one internal medicine physician. It was found that GPT-4 did not significantly differ in correctly identifying DIRA and FMF patients compared to the internist. However, the physician maintained a significantly higher accuracy than GPT-3.5 and LLaMa 2 for either disease. Overall, we explore and discuss the unique potential of LLMs in diagnostics for autoimmune diseases.
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Affiliation(s)
- Joshua Pillai
- Department of Biological Sciences, Irvine Unified School District. 5050 Barranca Parkway, Irvine, 92604, CA, USA
| | - Kathryn Pillai
- Department of Medical Education, California University of Science and Medicine, School of Medicine. 1501 Violet St, Colton, CA, USA
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Koryllou A, Mejbri M, Theodoropoulou K, Hofer M, Carlomagno R. Chronic Nonbacterial Osteomyelitis in Children. Children (Basel) 2021; 8:551. [PMID: 34202154 DOI: 10.3390/children8070551] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 12/26/2022]
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an auto-inflammatory bone disorder with a wide spectrum of clinical manifestations, from unifocal to multifocal lesions. When it manifests with multifocal lesions, it is also referred to as chronic recurrent multifocal osteomyelitis (CRMO). CNO/CRMO can affect all age groups, with the pediatric population being the most common. Patients may present with systemic inflammation, but there is no pathognomonic laboratory finding. Magnetic resonance imaging (MRI) is the gold standard radiological tool for diagnosis. In the absence of validated diagnostic criteria, CNO/CRMO remains an exclusion diagnosis. Bone biopsy does not show a specific disease pattern, but it may be necessary in unifocal or atypical cases to differentiate it from malignancy or infection. First-line treatments are non-steroidal anti-inflammatory drugs (NSAIDs), while bisphosphonates or TNF-α blockers can be used in refractory cases. The disease course is unpredictable, and uncontrolled lesions can complicate with bone fractures and deformations, underlying the importance of long-term follow-up in these patients.
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Kuemmerle-Deschner JB, Welzel T, Hoertnagel K, Tsiflikas I, Hospach A, Liu X, Schlipf S, Hansmann S, Samba SD, Griesinger A, Benseler SM, Weber AN. New variant in the IL1RN-gene ( DIRA) associated with late-onset, CRMO-like presentation. Rheumatology (Oxford) 2021; 59:3259-3263. [PMID: 32259833 DOI: 10.1093/rheumatology/keaa119] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 10/21/2019] [Revised: 02/19/2020] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To report a chronic recurrent multifocal osteomyelitis (CRMO)-like clinical phenotype with multisystem inflammation associated with a novel gene variant in the spectrum of IL-1-mediated diseases. METHODS A 3-year-old boy presented with recurrent episodes of fever, serositis, pancreatitis and high inflammatory markers with onset at age 13 months. At age 3 years, he started limping. Imaging revealed multifocal pelvic bone inflammation suggestive of CRMO. Autoinflammation panel testing was non-contributory. Whole exome sequencing (WES) and advanced IL-1 pathway analysis was conducted. RESULTS WES identified a novel homozygous interleukin receptor 1 (IL1RN) variant (c.62C>G; p. Ser21*) (NM_173842.2). Functional analysis of IL1RN mRNA and IL-1 receptor antagonist (IL-1RA) protein confirmed the diagnosis of a deficiency of the IL-1 receptor antagonist (DIRA). Treatment with the nonselective IL-1 inhibitor anakinra resulting in rapid remission; switch to the selective IL-1β antagonist canakinumab led to a flare within 6 weeks. Re-start of anakinra recaptured remission, last documented at the recent 19-month follow-up. CONCLUSION This is the first report of a novel late-onset DIRA confirmed by advanced diagnostic testing. In patients with systemic inflammation and CRMO-like bone lesions, IL1RN testing should be considered; even in the absence of skin manifestations. Non-selective IL-1 inhibition is an effective therapy.
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Affiliation(s)
- Jasmin B Kuemmerle-Deschner
- Autoinflammation Reference Center Tuebingen (arcT), Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Tatjana Welzel
- Autoinflammation Reference Center Tuebingen (arcT), Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tuebingen, Germany.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital of Basel, University of Basel, Basel, Switzerland
| | - Konstanze Hoertnagel
- Center for Human Genetics and Laboratory Diagnostics (AHC) Martinsried, Martinsried
| | - Ilias Tsiflikas
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen
| | - Anton Hospach
- Pediatric Rheumatology, Klinikum Stuttgart, Olgahospital, Stuttgart
| | - Xiao Liu
- Department of Immunology, University of Tuebingen, Tuebingen
| | - Susanne Schlipf
- Pediatric private practice Dr. Lakner, Schwaebisch Gmünd, Germany
| | - Sandra Hansmann
- Autoinflammation Reference Center Tuebingen (arcT), Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Samuel D Samba
- Autoinflammation Reference Center Tuebingen (arcT), Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Andreas Griesinger
- Autoinflammation Reference Center Tuebingen (arcT), Rheumatology, Department of Pediatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Susanne M Benseler
- Rheumatology, Department of Pediatrics, Alberta Children's Hospital (ACH), ACH Research Institute, University of Calgary, Alberta, Canada
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Mendonça LO, Grossi A, Caroli F, de Oliveira RA, Kalil J, Castro FFM, Pontillo A, Ceccherini I, Barros MAMT, Gattorno M. A case report of a novel compound heterozygous mutation in a Brazilian patient with deficiency of Interleukin-1 receptor antagonist ( DIRA). Pediatr Rheumatol Online J 2020; 18:67. [PMID: 32819369 PMCID: PMC7439677 DOI: 10.1186/s12969-020-00454-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 08/03/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Deficiency of the natural antagonist of interleukin-1 was first described in 2009 and so far 20 patients has been reported. In Brazil just two cases have been reported both carrying the same homozygous 15 bp deletion. Blocking interleukin-1 has changed rate survival for DIRA patients. The use of anakinra and rilonacept has been reported safe and efficient, whereas the selective blockade of interleukin-1 beta, using the monoclonal antibody canakinumab has been reported in a single case only. CASE PRESENTATION Here we report a case of a 7 years old Brazilian boy that presented with recurrent episodes of systemic inflammation with severe disabling osteomyelitis with mild pustular skin rash. A Next Generation Sequencing gene panel allowed to detect two pathogenic mutations in the IL1RN gene, described in compound heterozygosity. Corticosteroids was effective in controlling inflammation and anti-IL1 beta blocker triggered disease flare. Complete clinical control could be achieved using IL-1 receptor antagonist. CONCLUSIONS DIRA is a severe, life threatening autoinflammatory condition with low numbers of patients described all over the world. The mutation p.Asp72_Ile76del in IL1RN is presented in all Brazilian DIRA patients already described and p.Q45* (rs1019766125) is a new mutation affecting the IL1RN gene. Following the pathogenesis of DIRA, blocking both subunits of interleukin one as well as antagonizing the receptor using anakinra or rilonacept seems to be effective. There is just one report using canakinumab for the treatment of DIRA and this is the first report of disease flare using this drug.
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Affiliation(s)
- Leonardo Oliveira Mendonça
- Autoimmune and Autoinflammatory Unit; Clinical Immunology and Allergy Department, School of Medicine, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255 - 8 Andar, Sao Paulo, Brazil.
- UOSD Genetics and Genomics of Rare Diseases, Istituto Giannina Gaslini, Genoa, Italy.
- Immunogenetic Laboratory, Department of Immunology, Biomedical Science Insitute, University of Sao Paulo, Sao Paulo, Brazil.
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Giannina Gaslini, Genoa, Italy.
| | - Alice Grossi
- UOSD Genetics and Genomics of Rare Diseases, Istituto Giannina Gaslini, Genoa, Italy
| | - Francesco Caroli
- UOSD Genetics and Genomics of Rare Diseases, Istituto Giannina Gaslini, Genoa, Italy
| | - Robson Aguiar de Oliveira
- Autoimmune and Autoinflammatory Unit; Clinical Immunology and Allergy Department, School of Medicine, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255 - 8 Andar, Sao Paulo, Brazil
| | - Jorge Kalil
- Autoimmune and Autoinflammatory Unit; Clinical Immunology and Allergy Department, School of Medicine, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255 - 8 Andar, Sao Paulo, Brazil
| | - Fabio Fernandes Morato Castro
- Autoimmune and Autoinflammatory Unit; Clinical Immunology and Allergy Department, School of Medicine, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255 - 8 Andar, Sao Paulo, Brazil
| | - Alessandra Pontillo
- Immunogenetic Laboratory, Department of Immunology, Biomedical Science Insitute, University of Sao Paulo, Sao Paulo, Brazil
| | - Isabella Ceccherini
- UOSD Genetics and Genomics of Rare Diseases, Istituto Giannina Gaslini, Genoa, Italy
| | - Myrthes Anna Maragna Toledo Barros
- Autoimmune and Autoinflammatory Unit; Clinical Immunology and Allergy Department, School of Medicine, University of São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 255 - 8 Andar, Sao Paulo, Brazil
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Giannina Gaslini, Genoa, Italy
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Sözeri B, Gerçeker-Türk B, Yıldız-Atıkan B, Mir S, Berdeli A. A novel mutation of interleukin-1 receptor antagonist (IL1RN) in a DIRA patient from Turkey: Diagnosis and treatment. Turk J Pediatr 2019; 60:588-592. [PMID: 30968643 DOI: 10.24953/turkjped.2018.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Sözeri B, Gerçeker-Türk B, Yıldız-Atıkan B, Mir S, Berdeli A. A novel mutation of interleukin-1 receptor antagonist (IL1RN) in a DIRA patient from Turkey: Diagnosis and treatment. Turk J Pediatr 2018; 60: 588-592. Autoinflammatory diseases can cause severe inflammation in bone and skin such as neonatal-onset multisystem inflammatory disease (NOMID), Majeed syndrome, interleukin-36 receptor antagonist deficiency (DITRA) and deficiency of interleukin-1 (IL-1) receptor antagonist (DIRA) syndrome. Here we report a five-year old boy who was admitted to the hospital with pustular skin lesions and fever in the first month of his life. Molecular analysis of IL1RN gene revealed a single homozygous C nucleotide deletion at nucleotide position 396 (p.Thr133Profs*118). The novel p.Thr133Profs*118 mutation found in our study caused frameshift mutation and as a result, the respective protein is most likely non-functional. The patient, who received a variety of treatments for various preliminary diagnoses until the final diagnosis (DIRA), was treated with recombinant IL-1Ra, anakinra, and experienced significant clinical improvement.
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Affiliation(s)
- Betül Sözeri
- 1Division Pediatric Rheumatology, Health Sciences University, Istanbul Umraniye Education and Research Hospital Istanbul, Turkey
| | - Bengü Gerçeker-Türk
- Departments of Dermatology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Başak Yıldız-Atıkan
- Departments of Pediatric Infectious Diseases, Ege University Faculty of Medicine, Izmir, Turkey
| | - Sevgi Mir
- Departments of Pediatric Rheumatology, Ege University Faculty of Medicine, Izmir, Turkey
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Abstract
Chronic nonbacterial osteomyelitis (CNO) is an innate immune system disorder that predominantly affects children. It can present as part of a syndrome or in isolation. It presents as bone pain with or without fever or objective swelling at the site. It is difficult to diagnose. Laboratory studies can be normal, whereas a biopsy reveals sterile osteomyelitis. Osteolytic or sclerotic bone changes may be seen on radiographs. However, MRI is more sensitive for detecting CNO and is considered the gold standard for monitoring the disease. Treatment depends on disease severity and includes nonsteroidal antiinflammatory drugs, bisphosphonates, and cytokine inhibitors.
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Affiliation(s)
- Yongdong Zhao
- Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, MA 7.110, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
| | - Polly J Ferguson
- Department of Pediatrics, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 4038 Boyd Tower, Iowa City, IA 52242, USA.
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Mendonca LO, Malle L, Donovan FX, Chandrasekharappa SC, Montealegre Sanchez GA, Garg M, Tedgard U, Castells M, Saini SS, Dutta S, Goldbach-Mansky R, Suri D, Jesus AA. Deficiency of Interleukin-1 Receptor Antagonist ( DIRA): Report of the First Indian Patient and a Novel Deletion Affecting IL1RN. J Clin Immunol 2017; 37:445-451. [PMID: 28503715 DOI: 10.1007/s10875-017-0399-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 04/03/2017] [Accepted: 04/27/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Deficiency of interleukin-1 receptor antagonist (DIRA) is a rare life-threatening autoinflammatory disease caused by autosomal recessive mutations in IL1RN. DIRA presents clinically with early onset generalized pustulosis, multifocal osteomyelitis, and elevation of acute phase reactants. We evaluated and treated an antibiotic-unresponsive patient with presumed DIRA with recombinant IL-1Ra (anakinra). The patient developed anaphylaxis to anakinra and was subsequently desensitized. METHODS Genetic analysis of IL1RN was undertaken and treatment with anakinra was initiated. RESULTS A 5-month-old Indian girl born to healthy non-consanguineous parents presented at the third week of life with irritability, sterile multifocal osteomyelitis including ribs and clavicles, a mild pustular rash, and elevated acute phase reactants. SNP array of the patient's genomic DNA revealed a previously unrecognized homozygous deletion of approximately 22.5 Kb. PCR and Sanger sequencing of the borders of the deleted area allowed identification of the breakpoints of the deletion, thus confirming a homozygous 22,216 bp deletion that spans the first four exons of IL1RN. Due to a clinical suspicion of DIRA, anakinra was initiated which resulted in an anaphylactic reaction that triggered desensitization with subsequent marked and sustained clinical and laboratory improvement. CONCLUSION We report a novel DIRA-causing homozygous deletion affecting IL1RN in an Indian patient. The mutation likely is a founder mutation; the design of breakpoint-specific primers will enable genetic screening in Indian patients suspected of DIRA. The patient developed anaphylaxis to anakinra, was desensitized, and is in clinical remission on continued treatment.
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Affiliation(s)
| | - Louise Malle
- Translational Autoinflammatory Diseases Studies, NIAID, NIH, Bethesda, MD, USA
| | - Frank X Donovan
- Cancer Genetics and Comparative Genomics Branch, NHGRI, NIH, Bethesda, MD, USA
| | | | | | - Megha Garg
- Translational Autoinflammatory Diseases Studies, NIAID, NIH, Bethesda, MD, USA
- Rheumatology Fellowship Program, NIAMS, NIH, Bethesda, MD, USA
| | - Ulf Tedgard
- Department of Pediatric Hematology Oncology, Skåne University Hospital, Lund, Sweden
| | - Mariana Castells
- Hypersensitiviy and Desensitization Center, Mastocytosis Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Shiv S Saini
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Deepti Suri
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Adriana A Jesus
- Translational Autoinflammatory Diseases Studies, NIAID, NIH, Bethesda, MD, USA.
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Abstract
IL-1 is a master cytokine of local and systemic inflammation. With the availability of specific IL-1 targeting therapies, a broadening list of diseases has revealed the pathologic role of IL-1-mediated inflammation. Although IL-1, either IL-1α or IL-1β, was administered to patients in order to improve bone marrow function or increase host immune responses to cancer, these patients experienced unacceptable toxicity with fever, anorexia, myalgias, arthralgias, fatigue, gastrointestinal upset and sleep disturbances; frank hypotension occurred. Thus it was not unexpected that specific pharmacological blockade of IL-1 activity in inflammatory diseases would be beneficial. Monotherapy blocking IL-1 activity in a broad spectrum of inflammatory syndromes results in a rapid and sustained reduction in disease severity. In common conditions such as heart failure and gout arthritis, IL-1 blockade can be effective therapy. Three IL-1blockers have been approved: the IL-1 receptor antagonist, anakinra, blocks the IL-1 receptor and therefore reduces the activity of IL-1α and IL-1β. A soluble decoy receptor, rilonacept, and a neutralizing monoclonal anti-interleukin-1β antibody, canakinumab, are also approved. A monoclonal antibody directed against the IL-1 receptor and a neutralizing anti-IL-1α are in clinical trials. By specifically blocking IL-1, we have learned a great deal about the role of this cytokine in inflammation but equally important, reducing IL-1 activity has lifted the burden of disease for many patients.
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Key Words
- AOSD
- Autoimmune
- Autoinflammatory
- C-reactive protein
- CAPS
- CRP
- DIRA
- FCAS
- FMF
- HIDS
- Inflammation
- NLRP12
- NLRP3
- NOMID
- PAPA
- PASH
- PFAPA
- SAPHO
- SJIA
- TNF receptor associated periodic syndrome
- TRAPS
- adult onset Still's disease
- cryopyrin autoinflammatory periodic syndromes
- deficiency of IL-1Ra
- familial Mediterranean fever
- familial cold autoinflammatory syndrome
- hyper IgD syndrome
- neonatal onset multi-inflammatory diseases
- nucleotide-binding domain and leucine-rich repeat pyrin containing 12
- nucleotide-binding domain and leucine-rich repeat pyrin containing 3
- periodic fever, aphthous stomatitis, pharyngitis, and adenitis
- pyoderma-gangrenosum, acne, and suppurativa hidradenitis
- pyogenic arthritis, pyoderma gangrenosum, and acne
- synovitis, acne, pustulosis, hyperostosis and osteitis
- systemic-onset juvenile idiopathic arthritis
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Affiliation(s)
- Charles A Dinarello
- Department of Medicine, University of Colorado Denver, Aurora, CO, United States; Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jos W M van der Meer
- Department of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
Autoinflammatory bone disease is a new branch of autoinflammatory diseases caused by seemingly unprovoked activation of the innate immune system leading to an osseous inflammatory process. The inflammatory bone lesions in these disorders are characterized by chronic inflammation that is typically culture negative with no demonstrable organism on histopathology. The most common autoinflammatory bone diseases in childhood include chronic nonbacterial osteomyelitis (CNO), synovitis, acne, pustulosis, hyperostosis, osteitis syndrome, Majeed syndrome, deficiency of interleukin-1 receptor antagonist, and cherubism. In this article, the authors focus on CNO and summarize the distinct genetic autoinflammatory bone syndromes.
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Affiliation(s)
- Sara M Stern
- Division of Immunology, Rheumatology, and Allergy, Department of Pediatrics, University of Utah, PO Box 581289, Salt Lake City, UT 84158, USA.
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