Preexisting autoantibodies to type I IFNs underlie critical COVID-19 pneumonia in patients with APS-1

Patients with biallelic loss-of-function variants of AIRE suffer from autoimmune polyendocrine syndrome type-1 (APS-1) and produce a broad range of autoantibodies (auto-Abs), including circulating auto-Abs neutralizing most type I interferons (IFNs). These auto-Abs were recently reported to account for at least 10% of cases of life-threatening COVID-19 pneumonia in the general population. We report 22 APS-1 patients from 21 kindreds in seven countries, aged between 8 and 48 yr and infected with SARS-CoV-2 since February 2020. The 21 patients tested had auto-Abs neutralizing IFN-α subtypes and/or IFN-ω; one had anti-IFN-β and another anti-IFN-ε, but none had anti-IFN-κ. Strikingly, 19 patients (86%) were hospitalized for COVID-19 pneumonia, including 15 (68%) admitted to an intensive care unit, 11 (50%) who required mechanical ventilation, and four (18%) who died. Ambulatory disease in three patients (14%) was possibly accounted for by prior or early specific interventions. Preexisting auto-Abs neutralizing type I IFNs in APS-1 patients confer a very high risk of life-threatening COVID-19 pneumonia at any age.

[The challenge for dermatologists of early APECED diagnosis]

BACKGROUND

Polyglandular auto-immune syndrome type 1 (PAS-1) or auto-immune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disorder linked to auto-immune regulator (AIRE) gene mutations. Herein, we report the case of a 3-year-old boy with APECED emphasizing the wide phenotypic variability and the extent of skin lesions.

PATIENTS AND METHODS

A 3-year-old boy with a history of auto-immune hepatitis was referred for a generalized pruriginous urticaria-like eruption present for one month. He was born to non-consanguineous parents. Cutaneous examination revealed twenty-nail dystrophy, which had been present since the age of 2 years. Both direct microscopy and culture of nail samples were negative for Candida albicans. Esophagogastroduodenoscopy revealed esophageal candidiasis. A diagnosis of APECED was suspected and subsequently confirmed by molecular analysis of the AIRE gene, which showed two mutations. No other auto-immune endocrinopathies were found.

DISCUSSION

Our case report illustrates the phenotypic variability of APECED with the absence of typical manifestations such as Addison's disease and hypoparathyroidism. APECED should thus be systematically suspected in young children presenting with cutaneous lesions associated with mucocutaneous candidiasis or auto-immune disease, even in the absence of known endocrinopathies.

CONCLUSION

Dermatologists should be aware of this association since early diagnosis of APECED is critical in preventing life-threatening endocrinological crises.

High-performance thin-layer chromatographic determination of 5-methoxypsoralen in serum from patients

A simple and rapid high-performance thin-layer chromatographic (HPTLC) determination of 5-methoxypsoralen in serum is necessary for the therapeutic survey of patients treated with Puvatherapy (psoralen+UVA). The assay for this biological fluid involves an extraction with heptane-dichloromethane (4:1, v/v). The analytical method is linear from 50 to 250 ng/ml. This assay range is adequate for analysing human serum, as it corresponds to psoralen concentrations measured in serum from patients treated with psoralen and UVA against psoriasis and vitiligo. The limit of detection is 15 ng/ml. The coefficient of variation was less than 7%.

[Cerebral cavernoma: a rare vascular malformation]

The authors have observed 7 cases of intracranial cavernous haemangioma. A review of the literature shows that the diagnosis is suggested by the occurrence of epileptic seizures, signs of expansive process or meningeal haemorrhage. Computerized tomography displays an area of hyperdensity enhanced by injections of a contrast medium. Surgical excision is mandatory. The post-operative mortality varies with the site of the malformation.

[Occlusive arteriopathy of the circle of Willis with outlined "Moya-Moya" network in a woman with migraine under oral contraception. Regressive course]

A 19-year-old woman with migraine under contraceptive therapy had transient right hemiparesis due to a minor lesion in the left hemisphere, which was probably hemorrhagic rather than ischemic. On the left side, angiography showed nearly complete obstruction of the terminal portion of the internal carotid artery, extending to the initial portion of its terminal branches, with an outlined "Moya-Moya" network. On the right side, moderate annular stenosis of the cervical portion of the internal carotid was visible. On subsequent angiographies, done 7 and 19 months later, blood flow was reestablished in the left internal carotid artery as well as in its terminal branches, but with persistent segmental stenosis. Since the stroke, the symptomatology of migrainous attacks has been altered, pointing to a left hemispheric spreading.

[Parkinson disease and depression (author's transl)]

Depression and Parkinson disease, two very different conditions at first sight, have much more intricate connections than is usually believed. Depression may be the patient's reaction to Parkinson disease, a condition that is anticipated with anxiety, with good reason as it is often very disabling and has not been significantly prolonged by dopamine therapy. Depression may precede the first signs of Parkinson disease. Pseudoparkinsonian melancholia may be difficult to distinguish from the akinetic form of Parkinson disease. Most of the symptoms of the latter have been encountered in the former. The following features do not occur in depression: astasia with trepidation, festination, monotonous tachyphemia and palilalia, sebaceous hypersecretion, and of course unilateral or frankly asymmetric signs. Parkinson syndrome secondary to depression can be classified with those parkinsonian syndromes that are different from parkinson disease and secondary to a clearcut etiology. In some instances, diagnosis is established by the response to therapy. In the present state of our knowledge, the treatment of depression relies on chemotherapy and sismotherapy and not on dopamine therapy. The management of Parkinson disease rests on dopamine which may be associated with tricylic antidepressants.

[Unilateral dysplasia of the circle of Willis with multiple distal stenoses (author's transl)]

Neurological and clinical examinations were found to be normal in a woman aged 40 years who had had a single generalized epileptic seizure. Rediological examinations demonstrated a spiral-shaped calcification above and laterally to the left sella turcica. This corresponded to changes in the C 1 segment of the left carotid sinus, which was partly stenosed distally, with left unilateral abnormalities of the circle of Willis and multiple distal stenoses of the left sylvian and vertebro-basilar arteries. Scanning demonstrated that these had been present for a long time, but it is not possible to establish the diagnosis on an etiological basis as no similar radiological findings have been published.

[Long term administration of oral prednisone or prednisolone in treatment of myasthenia gravis. Report of five cases (author's transl)]

Five patients, four of them with severe or severe generalized myasthenia gravis, were treated by long term orally administrated prednisolone, with following results: one complete remission and two almost complete remissions (in three aged fernale patients), two substantial improvements (one in a male patient, one in a young adult female patient, both thymectomized). The least favourable result was observed in the male patient. Positive results of such treatment were similarly reported by several authors (with an average of 70% complete or almost complete remission, 20% substantial improvement, 7% moderate improvement). These results appear qualitatively superior to those obtained with ACTH, and may be long-lasting. Treatment with prednisolone may be applied to any form of myasthenia gravis, particularly those which do not react to anticholinesterasic agents in moderate dosages. At onset of treatment, patients should be under care of a reanimation unit. Dosage is initially high (60--100 mg daily, secondarily on alternate days), and should be reduced very slowly, once a definite improvement is achieved. The duration of this treatment depends upon the results obtained: it should not last under one year. Associated treatment with anticholinesterasic agents remains disputable, whereas associated thymectomy seems to provide best results.

[Plexus lesions following radiation therapy. Report of nineteen cases (author's transl)]

Nineteen patients with plexus lesions following radiation therapy were investigated: fifteen with brachial plexus, 4 with lumbar or sacral plexus involvement. Symptoms at onset are usually sensory. Motor disturbances occur either simultaneously or after some delay, their course is generally gradual and unfavourable. Areflexia appears early and was present in every case. Important cutaneous lesions (radiodermitis) and considerable induration of soft tissues were observed in every patient. Diagnosis is a relapse of the mitotic process. Severity of prognosis makes imperative a definite technique of radiation therapy. In all the patients included in this study, dosage had exceded 1,600 rets. Patients were tentatively treated with D-penicillamine, an inhibitor of collagen synthesis.

[Cisterno-medullary anomalies. Diagnostic problems, surgical treatment (author's transl)]

Under the term cisterno-medullary anomalies are included several disorders: bony and nervous malformations, arachnoiditis of the posterior fossa. As they are frequently associated, a thorough investigation, both anatomical and dynamic, is a prerequisite to any therapeutic attempt. Along with causing damage to the neuraxis, these anomalies interfere with the dynamics of the CSF and may lead to the development of a communicating syringomyelia, whatever the theory proposed. The presenting symptoms are varied, and diagnosis should be accordingly suspected. Of fundamental importance are instrumental investigations. A complete evaluation is in most of the cases obtainable with: bone X-rays, air-myelography (or "bulle"), intrathecal ou ventricular radio-isotope scan. Surgery is the only treatment. The aim is both decompression of the neural structures and restoration of a normal CSF dynamic flow. Opening of the posterior fossa is successful in the case of developmental abnormalities, But it seems to prove a failure when the chief anomaly is arachnoiditis. In such cases, ventricular drainage alone may be followed by improvement. It appears from this that the problem is twofold: the technical problem of the drainage, and the pre-operatory diagnosis of a posterior fossa arachnoiditis.

[Reversible humoral alterations paralleling the course of a recurring meningioma with metastases (author's transl)]

Case report of a recurring meningioma of the posterior fossa, with pulmonary metastases. Humoral alterations (sedimentation rate, fibrinemia, alkalin phosphatases, sideremia, prothrombin, blood proteins and BSP) paralleled the course of the tumor and may be considered as a para-tumoral syndrome. Pathogenesis is unknown.

[Recurrent polyneuropathy with a 19-year course, associated with a benign IgG monoclonal gammapathy]

A case of recurrent polyradiculoneuritis in a 54-year-old man is described. It is exceptional because of its lengthy development over a period of 19 years and by its association with a paraprotein of the IgE type without anyother anomal. Corticotherapy had a favourable effect on the clinical symptoms but did not affect the amount of monoclonal immunoglobulin in the serum. The nosological position of this neuropathy and the type of gammapathy are discussed. An immune mechanism seems likely, but no proof of a link between the neuropathy and the gammapathy could be found.

[Circulatory disorders induced by amantidine]

Amantadine has been used since 1969 in the treatment of Parkinson's disease. In 1970, were described the special symptoms noted in the lower limbs due to this drug. The authors, after a review of the various disturbances, have studied 10 cases by Capillaroscopy. They emphasize the interest of the study of this abnormality of the micro-circulation, producing vaso-constriction of the arterioles and venules.