Oral presentations
Molecular determinants of innate immunity
O01 New MVK mutant mouse avatars of mevalonate kinase deficiency mimic the underlying
defect in protein prenylation in patients
Marcia A. Munoz1, Oliver P. Skinner1, Julie Jurczyluk1, Kristen Perry1, Robert Brink2,
David Zahra2, Rob J. Arts3, Anna Simon3, Michael J. Rogers1
1Bone Biology; 2Immunology, Garvan Institute of Medical Research, Sydney, Australia;
3Medical Centre, Radboud University, Nijmegen, Netherlands
Correspondence: Marcia A. Munoz
Introduction: Mevalonate Kinase Deficiency (MKD) is a periodic fever syndrome characterised
by recurrent bouts of high fever and systemic inflammation. MKD is caused by recessive,
hypomorphic mutations in the mevalonate kinase gene (MVK) encoding a key enzyme in
the mevalonate pathway. This pathway is responsible for cholesterol synthesis and
the production of isoprenoid lipid tags required for post-translational prenylation
of proteins. It is believed that inflammation in MKD is triggered by shortage of isoprenoid
lipids and defective prenylation of small GTPases. We have found that protein prenylation
is indeed compromised in PBMCs from patients and this defect distinguishes MKD from
other periodic fever syndromes. However, the link between protein prenylation and
inflammation in MKD is still far from understood, largely due to the lack of suitable
genetic mouse models.
Objectives: To generate new Mvkmutant mouse models of MKD that mimic the human disease.
Methods: CRISPR/Cas9 gene editing was used to generate different heterozygous mouse
lines with hypomorphic mutations in exon 11 of theMvkgene: a V377I substitution (the
most frequent mutation in MKD), and 8, 13 or 91 base pair deletions. These lines were
then crossed to generate homozygous Mvk
V377I/V377I
or Mvk
V377I/deI
compound heterozygous mice. To assess the effect of the mutations on the mevalonate
pathway, we measured the accumulation of unprenylated Rab GTPases and Rap1A using
an in vitroprenylation assay and western blotting. For quantification of inflammatory
cytokines in serum, as well as in culture supernatants from LPS-stimulated PBMCs and
bone marrow macrophages, we used ELISA and multiplex cytokine bead arrays.
Results: Homozygous mice carrying complete loss of function deletion mutations were
not viable and, as expected, wildtype and heterozygous Mvkmutant mice had normal protein
prenylation. However, in a similar pattern to patient PBMCs, Mvk
V377I/deI
immune cells from blood, spleen and bone marrow had a dramatic accumulation of unprenylated
Rab and Rap1A GTPases, with a much milder defect in Mvk
V377I/V377I
cells. This is consistent with reportedly less severe clinical disease associated
with the homozygous V377I mutation. Furthermore, Mvk
V377I/deI
mice had slightly elevated levels of inflammatory serum cytokines, including IL-6
and G-CSF, and cultures of PBMCs and bone marrow macrophages responded more robustly
to LPS stimulation than cells from control mice. Interestingly, like patient-derived
cell lines, the prenylation defect was dramatically enhanced in bone marrow cells
from Mvkmutant mice after briefly culturing at higher temperature (39-40oC). Importantly,
addition of the missing isoprenoid lipid geranylgeraniol could rescue the prenylation
defect in primary cell cultures in vitroand in peritoneal macrophages in vivo.
Conclusion: To our knowledge, we have generated the first genetic mouse avatars of
MKD. These mice, like MKD patients, have defective protein prenylation and an exaggerated
inflammatory response. Furthermore, as with patient-derived cell lines, Mvkmutant
mouse cells are temperature-sensitive, suggesting that elevations in body temperature
(e.g. caused by mild infections) could quickly precipitate devastating defects in
protein prenylation that lead to systemic inflammatory flares. These mice are exciting
new tools to study the pathophysiology of MKD and can be used to develop new therapeutic
approaches, such as supplementation with isoprenoid lipids.
Disclosure of Interest
None Declared
O02 Generation and analysis of mice carrying a novel heterozygous missense mutation
of a proteasome subunit, PSMB9, in patients with autoinflammation and immunodeficiency
Hiroaki Hemmi1, Nobuo Kanazawa2, Noriko Kinjo3, Satoru Hamada3, Hidenori Ohnishi4,
Tsunehiro Mizushima5, Akira Kinoshita6, Koh-Ichiro Yoshiura6, Tsuneyasu Kaisho1
1Department of Immunology, Wakayama Medical University Institute of Advanced Medicine;
2Department of Dermatology, Wakayama Medical University, Wakayama; 3Department of
Child Health and Welfare (Pediatrics), University of the Ryukyus Graduate School of
Medicine, Nishihara; 4Department of Pediatrics, Gifu University Graduate School of
Medicine, Gifu; 5Picobiology Institute, University of Hyogo Graduate School of Life
Science, Kamigori; 6Department of Human Genetics, Nagasaki University Atomic Bomb
Disease Institute, Nagasaki, Japan
Correspondence: Tsuneyasu Kaisho
Introduction: The proteasome is a large protein complex involved in degradation of
unnecessary or useless proteins. Homozygous, compound heterozygous or digenic mutations
of proteasome subunits cause autoinflammatory diseases, termed proteasome-associated
autoinflammatory syndromes (PRAAS). De novo, heterozygous missense mutation in the
proteasome subunit PSMB9 (encodes β1i) gene (hereafter, PSMB9 X mutation), was commonly
found in two unrelated patients showing PRAAS-like but distinct manifestations, on
which two other posters are presented in this meeting. The PSMB9 X mutation is novel
and causes a substitution of an amino acid conserved among multiple species.
Objectives: It is unclear whether and how the PSMB9 X mutation contributes to the
manifestations of the patients. In order to clarify this issue, we have generated
and analyzed mutant mice carrying the mutation.
Methods: The mice carrying the Psmb9 X mutation were generated with CRISPR/Cas9 technology.
Homozygous Psmb9 X mutant mice died within 6 months old. Therefore, the heterozygous Psmb9
X mutant mice were mainly analyzed. Not only biochemical but also immunological analyses
including histological and flow cytometry analyses were performed.
Results: Heterozygous Psmb9 X mutant mice appeared healthy at glance. The β1i subunit
becomes mature after processing by the proteasome, but this maturation process was
impaired in splenocytes of the heterozygous Psmb9 X mutant mice. In the mutant mice,
thymus was small and the cortico-medullary junction was unclear. All thymocytes such
as CD4+, CD8+, double positive and double negative cells were decreased. In the spleen,
B cells as well as CD4+ and CD8+ T cells were decreased. Furthermore, serum levels
of immunoglobulins, including IgM, IgGs and IgA, were severely decreased. Dendritic
cells (DCs) and all DC subsets were also decreased, although the conventional DC1
subset, defined as CD8α+CD11b- cells, was most severely decreased. Meanwhile, CD11b+
cells consisting mainly of neutrophils and monocytes were increased in the bone marrow.
These phenotype of the heterozygous Psmb9 X mutant mice were not identical to, but
overlapping significantly with the manifestations of the two patients.
Conclusion: We here generated mutant mice carrying a novel heterozygous missense mutation
in the proteasome subunit Psmb9 gene, which was identified in two unrelated PRAAS-like patients.
Multiple defects in both innate and adaptive immune cells were observed in the heterozygous
Psmb9 X mutant mice and some, although not all, defects were also observed in the
two patients. These results indicate that the heterozygous Psmb9 X mutation can be
the cause of the PRAAS-like phenotypes in the two patients. The findings that the
mutation causes not only autoinflammation but also combined immunodeficiency prompt
us to propose a novel category of autoinflammatory diseases distinct from PRAAS as
“proteasome-associated autoinflammation and immunodeficiency disease (PRAID)”. The
mutant mice are unique and quite useful for clarifying how the proteasome dysfunction
leads to various manifestations of PRAID.
Disclosure of Interest
None Declared
Mechanisms of inflammasome activation
O03 Cofilin-1 is an essential redox sensor for NLRP3 inflammasome activation
Wonyong Lee, Yong Hwan Park, Daniel L. Kastner, Jae Jin Chae
NHGRI, Bethesda, United States
Correspondence: Wonyong Lee
Introduction: NLRP3 has a pivotal role in nucleating the inflammasome, a cytoplasmic
multiprotein complex that mediates the maturation of the proinflammatory cytokine
interleukin-1β (IL-1β) by activating caspase-1. Mutations in the gene encoding NLRP3
cause a spectrum of autoinflammatory diseases, the cryopyrin-associated periodic syndromes
(CAPS). The generation of reactive oxygen species (ROS) is one of the major NLRP3
inflammasome activating factors. However, the molecular basis of the relationship
between change of cellular redox state and NLRP3 inflammasome activation has not been
elucidated.
Methods: We utilized mouse bone marrow-derived macrophage (BMDM) to analyze interaction
of cofilin-1 and NLRP3 by co-immunoprecipitation (co-IP). Mouse BMDMs were used to
ectopically express wild-type (WT) or mutant cofilin-1 proteins, and to transfect
siRNA for knockdown assay. Cofilin-1 knock-in (KI) mice (C39A or C39S) were generated
by microinjection of sgRNA and Cas9 ribonucleoprotein (RNP) complex.
Results: To identify an ROS-mediated regulator for NLRP3 inflammasome activation,
the immune complexes precipitated by NLRP3 specific antibody from BMDMs of WT or NLRP3-KO
mice were analyzed by mass spectrometry. We found cofilin-1, the actin severing protein,
as a negative regulator for the NLRP3 inflammasome. Cofilin-1 interacted with the
nucleotide-binding domain (NBD) of NLRP3 and dissociated from NLRP3 when the cells
were stimulated with known NLRP3 inflammasome activators, such as ATP or nigericin.
The NLRP3 inflammasome activators generate ROS that leads to cofilin-1 oxidation,
which is intramolecular disulfide bond formation between two cysteine residues at
amino acids 39 and 80. This oxidation induces conformational change of cofilin-1 and
dissociation from NLRP3, which results in the activation of the NLRP3 inflammasome.
Indeed, the assembly of NLRP3 inflammasome components is impaired and the IL-1β release
was significantly suppressed in BMDMs ectopically expressing oxidation-resistant mutant
cofilin-1 (C39A or C80A). In addition, knockdown of cofilin-1 in LPS-primed BMDMs
induced NLRP3 inflammasome activation without activator treatment. We also observed
that the interaction of cofilin-1 with the CAPS-associated mutant NLRP3 proteins was
substantially diminished relative to WT NLRP3, which resulted in constitutive activation
of the NLRP3 inflammasome. To examine the role of cofilin as a redox sensor for NLRP3
inflammasome activation in vivo, we have generated KI mice expressing oxidation-resistant
mutant cofilin-1 (C39A or C39S). Unexpectedly, the IL-1β release from the BMDMs of
the KI mice was higher than WT BMDMs when the cells were stimulated with ATP after
LPS priming. Consistently, IL-1β levels in the serum of KI mice after injection of
lipopolysaccharide (LPS) intraperitoneally was significantly higher than WT mice.
This inconsistent result may be due to the low level of mutant cofilin-1 in KI mice.
Indeed, similarly to the result of cofilin-1 knockdown, LPS-primed KI BMDMs release
substantial IL-1β without activators.
Conclusion: Taken together, these findings suggest that cofilin-1 is a key component
in regulating the NLRP3 inflammasome in response to ROS. In addition, our data suggest
cofilin-1 as a potential therapeutic target for the inflammatory conditions involving
the NLRP3 inflammasome, including gout, type 2 diabetes mellitus, atherosclerosis,
and Alzheimer’s disease.
Disclosure of Interest
None Declared
O04 Autoinflammatory mutation in NLRC4 reveals an LRR-LRR oligomerization interface
Fiona Moghaddas1,2,3, Ping Zeng4, Yuxia Zhang5, Heike Schuetzle6, Sebastian Brenner6,
Sigrun Hofmann6, Reinhard Berner6, Yuanbo Zhao5,7, Bingtai Lu5, Xiaoyun Chen5, Li
Zhang5, Suyun Cheng4, Stefan Winkler6, Kai Lehmberg8, Scott W. Canna9, Peter E. Czabotar10,11,
Ian P. Wicks2,11,12, Dominic De Nardo2,11, Christian Hendrich6,13,14, Huasong Zeng4,
Seth L. Masters2,11
1Clinical Immunology and Allergy, The Royal Melbourne Hospital, Melbourne; 2Inflammation
Division, The Walter and Eliza Hall Institute of Medical Research; 3Department of
Medical Biology, The University of Melbourne, Parkville, Australia; 4Department of
Rheumatology; 5Immunology Laboratory, Guangzhou Women and Children’s Medical Centre,
Guangzhou, China; 6Department of Pediatrics, University Hospital and Faculty of Medicine
Carl Gustav Carus, Dresden, Germany; 7Department of Chemical Biology, Guizhou Medical
University, Guiyang, China; 8Division of Pediatric Stem Cell Transplantation and Immunology,
University Medical Center Hamburg Eppendorf, Hamburg, Germany; 9Pediatric Rheumatology/RK
Mellon Institute, Children’s Hospital of Pittsburgh ofUPMC, Pittsburgh, United States;
10Structural Biology Division, The Walter and Eliza Hall Institute of Medical Research,
Parkville; 11Department of Medical Biology, The University of Melbourne, Melbourne;
12Rheumatology Department, The Royal Melbourne Hospital, Parkville, Australia; 13Department
of Women’s & Children’s Health, nstitute of Translational Medicine, University of
Liverpool; 14Department of Pediatrics Rheumatology, Alder Hey Children's NHS Foundation
Trust Hospital, Liverpool, United Kingdom
Correspondence: Fiona Moghaddas
Introduction: Monogenic autoinflammatory disorders are characterised by dysregulation
of the innate immune system. A significant number of this broadening group of disorders
are caused by gain-of-function mutations in inflammasome forming proteins, such as
NLRC4. A number of mutations in NLRC4 have been described, leading to a spectrum of
NLRC4-associated autoinflammatory disorders (NLRC4-AID).
Objectives: We studied two patients with early onset macrophage activation syndrome
caused by the same de novo mutation in NLRC4 (c.G1965C, p.W655C). Unlike other mutations
in NLRC4 described to date, p.W655 is located within the leucine rich repeat (LRR)
domain. For this reason, we investigated mechanisms by which this mutation contributes
to the pathogenesis of autoinflammatory disease.
Methods: Next generation and Sanger sequencing techniques were used for genetic analysis.
ELISA was performed to quantify serum cytokine levels. In vitro, inflammasome complex
formation was quantified using flow cytometric analysis of Apoptosis-associated Speck-like
protein containing a Caspase recruitment domain (ASC) specks.Monocyte-like cell lines
were generated by genetic deletion of NLRC4 from THP-1 cells using CRISPR/Cas9 techniques
followed by lentiviral transduction of wild type (WT) or mutant NLRC4 cDNA. Cell death
and release of IL-1b/IL-18 were quantified using flow cytometry and ELISA respectively.
Results: Both reported patients succumbed to macrophage activation syndrome early
in life, associated with increased IL-18 serum levels. The NLRC4 mutation identified,
c.G1965C/p.W655C, caused increased ASC speck formation in vitro. In THP-1 cells, introduction
of c.G1965C/p.W655C NLRC4 resulted in increased cell death, IL-1b and IL-18 production.
The enhanced response was independent of NLRP3 and caspase-8. ASC contributed to p.W655C
NLRC4 mediated cytokine release, but not cell death. p.W655 is located at the interface
between adjacent LRR domains in the oligomeric inflammasome structure. Mutation of
p.W655 activates the NLRC4 inflammasome complex by engaging with two interfaces on
the opposing LRR domain. One key set of residues (p.D1010, p.D1011, p.L1012 and p.I1015)
participates in LRR-LRR oligomerization when it is triggered by NLRC4-AID mutations
or T3SS effector (PrgI) stimulation of the NLRC4 inflammasome complex.
Conclusion: This is the first report of a mutation in the LRR domain of NLRC4 causing
NLRC4-AID. c.G1965C/p.W655C NLRC4 increases inflammasome activation, leading to constitutive
IL-18 production and increased IL-1b release upon priming, where ASC contributes to
the cytokine response, but not to cell death. Data generated from various NLRC4 mutations
suggests that the tryptophan at p.W655 does not tolerate substitution, and provides
evidence that the LRR-LRR interface has an important, previously unrecognized role
in oligomerization of the NLRC4 inflammasome complex.
Disclosure of Interest
None Declared
Multifactorial vs monogenic autoinflammatory diseases
O05 Canakinumab, on a reduced dose or a prolonged dose interval without concomitant
corticosteroids and methotrexate, maintains efficacy in systemic juvenile idiopathic
arthritis patients in clinical remission
Pierre Quartier1, Ekaterina Alexeeva2, Carine Wouters3, Inmaculada Calvo4, Tilmann
Kallinich5, Bo Magnusson6, Nico Wulffraat7, Xiaoling Wei8, Alan Slade9, Ken Abrams9,
Alberto Martini10
1AP-HP, Institut des Maladies Génétiques (IMAGINE), and Université Paris-Descartes,
Necker-Enfants Malades Hospital, Paris, France; 2National Medical Research Center
of Children's Health and Sechenov First Moscow State Medical University of the Ministry
of Health of the Russian Federation, Moscow, Russian Federation; 3Gasthuisberg University
Hospital,Leuven, Belgium; 4Hospital Universitario La Fe, Valencia, Spain; 5Charité
Berlin Campus Virchow, Berlin, Germany; 6Karolinska University Hospital, Stockholm,
Sweden; 7University Medical Center Utrecht, Utrecht, Netherlands; 8China Novartis
Institutes for Biomedical Research Co., Ltd, Beijing, China; 9Novartis Pharmaceuticals
Corporation, East Hanover, United States; 10Universita di Genova Pediatria II, Genova,
Italy
Correspondence: Ekaterina Alexeeva
Introduction: Treatment with canakinumab (CAN), a selective, human anti-IL-1β monoclonal
antibody, has shown sustained therapeutic effect along with corticosteroid dose reduction/discontinuation
in patients with systemic juvenile idiopathic arthritis (SJIA), in a long-term extension
study (NCT00891046).1
Objectives: To evaluate the efficacy and safety results from a study evaluating 2
different canakinumab tapering regimens in SJIA patients who were in clinical remission
(NCT02296424).
Methods: This Phase 3b/4 study had two parts. In Part I, 182 patients with inactive
disease from the extension study1 (cohort 1) and CAN-naïve patients (cohort 2) with
active disease were administered subcutaneous CAN 4 mg/kg q4w. Per protocol titration
off corticosteroids and/or methotrexate was attempted during Part I. Eligible patients
(inactive disease for 24 consecutive weeks and being corticosteroid- and methotrexate-free
for at least 4 weeks) advanced to Part II. Patients were randomised to either a 3-step
CAN dose reduction regimen (2mg/kg/q4w, followed by tapering to 1 mg/kg/q4w and then
discontinuation) or dose interval prolongation regimen (4mg/kg q8w, followed by tapering
to 4 mg/kg/q12w and then discontinuation); patients advanced to the next tapering
step if inactive disease was maintained for 24 weeks. The primary objective was to
evaluate if at least 40% of patients were able to maintain inactive disease status
for at least 24 consecutive weeks on either 2mg/kg q4w or 4mg/kg q8w.
Results: In Part II, a total of 75 patients were randomised to a dose reduction (n=38)
or dose interval prolongation (n=37) in CAN tapering regimen. The proportion of patients
who maintained inactive disease for 24 consecutive weeks exceeded the predefined threshold
of 40% for Step 1 of: the reduced CAN dose (71%; 2 mg/kg q4w) and prolonged dose interval
(84%; 4 mg/kg q8w) treatment arms. A total of 68% (26/38) and 79% (30/37) of the dose
reduction and interval prolongation arms, respectively were successful in Step 2,
while only 33% (25/75) of patients successfully discontinued CAN and maintained inactive
disease for 24 consecutive weeks. Adverse events (AEs) and serious AEs observed within
the 2 treatment cohorts and across Parts I and II were similar without any specific
pattern or relationship to patients’ disease status at baseline or treatment regimen.
The most frequent AEs were common infections such as nasopharyngitis, upper respiratory
tract infection, and pharyngitis followed by SJIA-related events such as rash, pyrexia
and arthralgia. Clinical laboratory abnormalities were consistent with expected findings
in patients with active SJIA and the known safety profile of CAN.
Conclusion: SJIA patients who are able to maintain inactive disease status on CAN
monotherapy can successfully taper CAN by either reducing the dose or prolonging the
dosing interval. However, only a minority of patients successfully discontinued CAN
treatment for 24 weeks. The safety profile for both CAN titration regimens was similar
and consistent with other CAN SJIA studies. No new safety signals were identified.
Reference
1. Brunner et al. Arthritis Rheumatol.2016; 68 (S10).
Disclosure of Interest
P. Quartier Consultant for: Abbvie, Lilly, Novimmune, Novartis and SOBI,Speaker Bureau
of: AbbVie, Lilly, Novartis and SOBI, E. Alexeeva Grant / Research Support from: Roche,
Abbott, Pfizer, Bristol-Myers Squibb, Centocor, Novartis, C. Wouters Consultant for:
GSK, Roche, Pfizer , I. Calvo: None Declared, T. Kallinich Speaker Bureau of: Novartis,
B. Magnusson: None Declared, N. Wulffraat Consultant for: Novartis, X. Wei Employee
of: Novartis, A. Slade Conflict with: Novartis Pharmaceuticals CorporationShareholder
of: Novartis Pharmaceuticals Corporation,Employee of: Novartis Pharmaceuticals Corporation,
K. Abrams Conflict with: Novartis Pharmaceuticals CorporationShareholder of: Novartis
Pharmaceuticals Corporation,Employee of: Novartis Pharmaceuticals Corporation, A.
Martini: None Declared
O06 IL-18:CXCL9 ratio as a predictor of treatment response in patients with systemic
juvenile idiopathic arthritis treated with canakinumab
Tanja Hinze1, Christoph Kessel1, Claas Hinze1, Julia Seibert2, Hermann Gram2, Dirk
Foell1
1Department of Pediatric Rheumatology and Immunology, Muenster University Hospital,
Muenster, Germany; 2Novartis Pharma, Basel, Switzerland
Correspondence: Tanja Hinze
Introduction: Canakinumab, a monoclonal anti-interleukin (IL)-1β antibody, is highly
effective for treating patients with systemic juvenile idiopathic arthritis (SJIA)
but biomarkers predicting treatment response are desirable.
Objectives: The objective of this study was to analyze the association of various
serum biomarkers with treatment outcomes.
Methods: Serum samples from 54 patients treated with canakinumab in an open-label
long-term extension study were studied by Luminex at different time points during
the study, including days 1 (baseline), 3, 15 and weeks 4, 8, 24, 48. Treatment outcomes
included modified pediatric American College of Rheumatology (pACR) 30/50/70/90/100
responses within 15 days of treatment, clinically inactive disease (CID) according
to the Wallace criteria within 15 days of treatment and sustained complete response,
defined as pACR100or CID within 15 days of treatment plus no disease flare or macrophage
activation syndrome (MAS) during the study. Data were analysed using non-parametric
testing and receiver operating characteristic (ROC) analysis.
Results: Within 15 days of treatment with canakinumab, 79%/77%/68%/49%/34% of the
patients reached a modified pACR 30/50/70/90/100 response and 34% CID. Within a median
follow-up of 23 months, 12 of 54 (22%) patients had a sustained complete response
and 5 (9%) had developed MAS. Biomarkers did not correlate significantly with age,
duration of disease or active joint count. Most biomarkers were elevated when compared
to healthy controls at baseline and some rapidly decreased within 15 days of therapy
(IL-1RA, IL-6, IL-18 and S100A12). A pattern was apparent when comparing responders
and non-responders; responders had higher IL-18 and IFN-γ levels and lower CXCL9 levels
at baseline, most emphasized by the IL-18:CXCL9 and the IFN-γ:CXCL9 ratios (Table
1). As determined via ROC analyses, these ratios had good accuracy in predicting treatment
responses relating to pACR30/50/70/90/100/CID responses at day 15 and sustained complete
response (area under the curve [AUC] for IL-18:CXCL9 ratio 0.79/0.75/0.67/0.72/0.77/0.71
and 0.80, respectively; and for the IFN-γ:CXCL9 ratio 0.79/0.76/0.71/0.75/0.77/0.76
and 0.79). Higher baseline CXCL9 levels predicted future MAS during the course of
the study (ROC analysis AUC = 0.77).
Conclusion: Several serum biomarkers were markedly elevated in patients with SJIA
at baseline. A dysregulation of the IL-18-IFN-γ-CXCL9 axis is present in patients
with SJIA, confirming findings from other investigators. However, our findings indicate
that patients with a lower response to IL-18 and IFN-γ, as measured by CXCL9, an IFN-γ-induced
chemokine, may have a better clinical response to canakinumab treatment. These findings
will have to be confirmed in other cohorts.
Disclosure of Interest
T. Hinze Grant / Research Support from: Study was funded by Novartis Pharma , C. Kessel
Grant / Research Support from: Study was funded by Novartis Pharma, C. Hinze Grant
/ Research Support from: Study was funded by Novartis Pharma, J. Seibert Employee
of: Novartis Pharma, H. Gram Employee of: Novartis Pharma, D. Foell Grant / Research
Support from: Study was funded by Novartis Pharma
Table 1 (abstract O06).
Median (range) IFN-gamma: CXCL9 and IL-18:CXCL9 ratios at baseline
IL-18:CXCL9 ratio at baseline
IFN-γ:CXCL9 ratio at baseline
Responders
Non-Responders
P value*
Responders
Non-Responders
P value*
pACR30 at day 15
2.54 (0.03-557.31)
0.34 (0.01-1.62)
0.004
5.27 (0.19-68.32)
0.82 (0.24-4.85)
0.003
pACR50 at day 15
2.37 (0.03-557.31)
0.36 (0.01-3.76)
0.010
5.23 (0.19-68.32)
1.35 (0.24-5.38)
0.007
pACR70 at day 15
2.54 (0.03-557.31)
0.57 (0.01-42.27)
0.052
5.27 (0.19-68.32)
1.56 (0.24-20.03)
0.015
pACR90 at day 15
3.69 (0.03-557.31)
0.57 (0.01-42.27)
0.006
7.51 (0.19-68.32)
1.88 (0.19-20.03)
0.002
pACR100 at day 15
3.99 (0.05-557.31)
0.57 (0.01-42.27)
0.001
8.35 (0.19-68.32)
1.97 (0.19-43.46)
0.002
CID at day 15
3.84 (0.03-557.31)
0.66 (0.01-42.81)
0.015
8.34 (0.62-68.32)
1.97 (0.19-41.52)
0.002
Sustained complete response
5.52 (0.03-557.31)
0.65 (0.01-277.69)
0.002
8.35 (0.62-68.32)
2.01 (0.19-43.46)
0.002
*Mann-Whitney U test
Update of autoinflammatory diseases
O07 The NIH cohort study of DADA2 patients: novel insights into pathophysiology and
treatment with TNF inhibitors
Qing Zhou1,2, Natalie Deuitch1, Dan Yang3, Natalia Sampaio Moura1, Xiaomin Yu4, Oskar
Schnappauf1, Patrycja Hoffmann1, Deborah Stone1, Amanda Ombrello1, Manfred Boehm3,
Daniel Kastner1, Ivona Aksentijevich1
1NHGRI/NIH, Bethesda, United States; 2Zhejiang University, Hang Zhou, China; 3NHLBI/NIH;
4NIAID/NIH, Bethesda, United States
Correspondence: Qing Zhou
Introduction: Deficiency of Adenosine Deaminase 2 (DADA2) is a recessively inherited
disorder caused by a loss of functional ADA2 protein. A broad spectrum of features,
including systemic inflammation, cutaneous, neurologic, musculoskeletal, and immunological
manifestations have now been associated with DADA2. Given the highly polymorphic nature
of the ADA2 and the complex clinical presentations of DADA2, large cohort studies
are critical to advancing our knowledge of ADA2’s role in disease manifestation and
pathogenesis.
Objectives: To expand on the genetics of patients with DADA2 and explore the pathophysiology
and the underlying mechanisms of TNF inhibitor response in these patients.
Methods: We performed Sanger sequencing of the ADA2 gene (previously known as CECR1)
and measured ADA2 enzyme activity in serum samples of patients and family members.
We used flow cytometry, intracellular cytokine staining, transcriptome analysis, immunohistochemistry
and cell differentiation experiments to define an inflammatory signature in DADA2
patients and studied their response to TNF inhibitor treatment.
Results: We have identified 60 patients with DADA2 and detected 10 pathogenic variants,
which had not previously been associated with DADA2 – p.R9W, p.R34W, p.W204C, p.E244A,
p.D329N, p.L351Q, p.A357T, p.P425A, p.P435A, p.W501*.Patients tested for ADA2 enzymatic
activity had significantly decreased protein activity. Symptoms were highly variable
among patients, even in cases with identical genotypes.
We identified distinct inflammatory signatures. Patients had significantly higher
subsets of CD14+ inflammatory monocytes than healthy controls. Phosphorylation of
STAT1 was upregulated in patients CD4+ cells and monocytes following stimulation.
Additionally, we observed increased gene expression of IP-10 in patients’ monocytes
and macrophages. Furthermore, we observed strong NF-κB signaling in patients. Intracellular
cytokine staining and qPCR for IL-1β, IL-6, and TNF cytokines were elevated in patients’
monocytes.
After TNF inhibitor treatment, IFN and NF-κB inflammatory signatures were normalized.
Analyses of post-treatment skin, lung and brain biopsies showed minimal perivascular
TNF and resolution of inflammatory myeloid cell infiltrates. Immunostaining of skin
biopsies revealed intact blood vessels with normal endothelial layers after treatment.
Together, the data provides evidence that TNF inhibition both reduces systemic inflammation
and improves endothelial integrity in the small vessels.
ADA2 deficiency affects the differentiation of monocytes to anti-inflammatory M2 macrophages.
Treatment with TNF-inhibitors rescued the impairment of M2 differentiation as demonstrated
by improved cell morphology and a higher number of M2 macrophages.
Conclusion: We report 10 novel pathogenic variants in ADA2, which is valuable for
future DADA2 molecular diagnostic. Most important, we showed the cellular mechanism
underlying effective treatment with anti-TNF therapies. DADA2 vasculitis is strongly
related to the presence of activated myeloid cells and is reversible.
Disclosure of Interest
None Declared
O08 Recommendation on colchicine dosing and definition of colchicine resistance/intolerance
in the management of FMF
Seza Ozen1, Erdal Sag1, Eldad Ben-Chetrit2, Marco Gattorno3, Ahmet Gul4, Philip Hashkes5,
Isabelle Kone-Paut6, Helen Lachmann7, Elena Tsitsamis8, Marinka Twilt9, Fabrizio de
Benedetti10, Jasmin B. Kuemmerle-Deschner11
1Pediatric Rheumatology, Hacettepe University, Ankara, Turkey; 2Rheumatology Unit,
Hadassah-Hebrew University Hospital, Jerusalem, Israel; 3Clincal Pediatrics and Rheumatology,
Gaslini Institute, Genova, Italy; 4Department of Internal Medicine, Division of Rheumatology,
Istanbul University, Istanbul, Turkey; 5Pediatric Rheumatology Unit, Department of
Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel; 6Service de rhumatologie
pédiatrique, CHU de Bicêtre, Le Kremlin-Bicêtre, France; 7Royal Free Campus, National
Amyloidosis Centre, London, United Kingdom; 8First Department of Pediatrics, Aghia
Sophia Childrens Hospital, University of Athens Medical School, Athens, Greece; 9Rheumatology,
Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary,
Canada; 10Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, Rome, Italy;
11Department of Pediatrics, Division of Pediatric Rheumatology, University Hospital
Tuebingen, Tuebingen, Germany
Correspondence: Jasmin B. Kuemmerle-Deschner
Introduction: FMF is the most common monogenic autoinflammatory disease and colchicine
is the drug of choice for the treatment. However, about 5-10% of FMF patients do not
respond to colchicine even when they are fully compliant. Anti-IL1 treatments are
used for the patients who are resistant to colchicine. Treatment with IL-1 inhibitors
have been shown to be effective in clinical trials and in several case series.
Objectives: The objective of this report is to produce evidence-based recommendations
to define “colchicine resistance“, as well as compliance and intolerance, to guide
rheumatologists and other health professionals in the treatment and follow-up of patients
with colchicine-resistant FMF.
Methods: A consensus meeting with 12 experts followed a systemic literature review
and Delphi questionnaire. The expert committee consisted of adult and pediatric rheumatologists
with expertise in FMF. Parameters for colchicine resistance/intolerance/compliance
derived from the literature were evaluated by a pre-meeting online questionnaire.
All parameters were discussed with a nominal group technique during the meeting. Recommendations
were accepted if more than 80% agreement was reached. If agreement was below 80% a
second round of discussion was held.
Results: The systematic literature review yielded 264 articles. Of these, 38 were
selected for expert review. After the literature review, Delphi survey, and round
table discussion, recommendations that reached consensus levels were:
Colchicine is the drug of choice for the treatment of FMF and compliance is a critical
issue. For the following statements, it is assumed that the patient is compliant with
colchicine.
When utilizing colchicine to treat FMF, it is recommended to adjust the dose based
on disease activity with the maximal dose in children depending on age (and weight).
The maximum recommended colchicine dose for the treatment of FMF is between 1-3 mg
per day depending on age, limited by signs of toxicity and tolerability.
For a patient receiving the maximum tolerated dose of colchicine, resistance to colchicine
is defined as ongoing disease activity (as reflected by either recurrent clinical
attacks (average one or more attacks per month over a three-month period), or persistently
elevated CRP or SAA in between attacks (depending on which is available locally)),
in the absence of any other plausible explanation.
AA amyloidosis develops as a consequence of persistent inflammation, which may be
a manifestation of colchicine resistance.
Colchicine intolerance, which generally manifests as GI symptoms (such as diarrhea
and nausea), is common and can limit the ability to achieve or maintain the effective
dose. Dose-limiting toxicity is rare and may include elevated LFT, leukopenia, azoospermia
etc.
Active disease and intolerance to colchicine affect quality of life.
Various patient reported outcomes to be used to guide FMF disease management were
outlined.
Conclusion: The suggested recommendations are intended to improve patient care in
FMF, to make a personalized treatment plan.
Disclosure of Interest
S. Ozen Speaker Bureau of: Novartis, SOBI, Pfizer, E. Sag: None Declared, E. Ben-Chetrit:
None Declared, M. Gattorno: None Declared, A. Gul: None Declared, P. Hashkes Grant
/ Research Support from: Novartis,Consultant for: Novartis, I. Kone-Paut: None Declared,
H. Lachmann: None Declared, E. Tsitsamis: None Declared, M. Twilt: None Declared,
F. de Benedetti: None Declared, J. Kuemmerle-Deschner Grant / Research Support from:
Novartis, SOBI,Consultant for: Novartis, SOBI
Oral communications – clinical
O09 The clinical spectrum of the deficiency of adenosine deaminase 2 (DADA2) continues
to expand
Karyl Barron1, Amanda Ombrello2, Debra Stone2, Patrycja Hoffmann2, Tina Romeo2, Anne
Jones2, Natalia Sampaio Moura2, Oskar Schnappauf2, Ivona Aksentijevich2, Jenna Bergerson1,
Ariane Soldatos3, Camilo Toro2, Dan Kastner2
1NIAID; 2NHGRI; 3NINDS, NIH, Bethesda, United States
Correspondence: Karyl Barron
Introduction: The original reports of the deficiency of adenosine deaminase 2 (DADA2)
in 2014 emphasized early-onset lacunar strokes, livedoid rash, intermittent fevers
and early-onset polyarteritis nodosa. Since then, there have been reports of antibody
deficiency, pure red cell aplasia, and cytopenias observed in DADA2 patients.
Objectives: To document the range of clinical manifestations of DADA2.
Methods: 46 patients were enrolled in an IRB approved study at the NIH. Sequencing
of ADA2, the gene encoding ADA2 (adenosine deaminase 2), was performed on all patients.
All underwent extensive clinical, laboratory & radiologic evaluation.
Results: We evaluated 46 patients with DADA2 (24 F/22 M) including 6 sibling pairs
& 2 families with 3 affected individuals. All patients had biallelic germline mutations
in ADA2. Serum ADA2 enzyme activity levels were obtained in 32 patients and revealed
absent to low levels compared to age-matched controls.
The 46thpatient, seen 5 years after bone marrow transplantation for presumed GATA2
deficiency, was not included in our summary calculations.
32 patients (71%) reported a history of recurrent fevers. 6 patients (13%) had diffuse
lymphadenopathy.
Skin involvement was seen in 38 patients (84%) including livedo in 34 (76%), cutaneous
polyarteritis nodosa in 27 (60%), and Raynaud’s in 9 (20%).
22 patients (49%) had a history of at least one stroke.Brain MRI showed evidence of
ischemic infarcts in l6/22 (73%), 5 had both ischemic & hemorrhagic strokes (23%)
and 1 had a hemorrhagic stroke (5%). There were 55 strokes in the 22 patients, the
majority occurring in the brain stem and cerebellum (38%) and deep brain nuclei (36%).
The average age at the time of the first stroke was 5.6 years (range 5 months-20 years). Stroke
patients had an average of 3 strokes (range of 1-11). 3 patients manifest severe sequelae
of hemorrhagic strokes.
Abdominal ultrasound revealed hepatomegaly in 20 patients (44%) & splenomegaly in
26 (58%). Portal hypertension was observed in 7 patients (16%). Liver biopsies revealed
hepatoportal sclerosis in 5 patients and focal nodular regenerative hyperplasia in
2. Abdominal MRA was abnormal in 7/13 patients, revealing arteritis and aneurysms.
Significant peripheral vasculopathy was seen in 4 patients, one requiring multiple
amputations of gangrenous digits. Systemic hypertension was observed in 11 patients
(24%).
Laboratory evaluation revealed hypogammaglobulinemia in 26 patients (58%). Immunoglobulin
replacement was required in 10 patients. Lymphocyte phenotyping revealed arrested
B cell class switching in 24/34 patients (71%) and decreased memory T cells in 11/34
(32%). Severe hematologic abnormalities, including anemia, leukopenia, lymphopenia
and/or thrombocytopenia in 18 patients (40%), with 6 developing pancytopenia and 3
pure red cell aplasia. Immune mediated neutropenia was observed in 12 patients. ESR
and C-reactive protein were elevated in 73% & 86%, respectively.
6 patients underwent bone marrow transplantation with 4 patients successfully engrafted
(2 requiring a second transplant), and 2 recently transplanted.
Conclusion: The spectrum of DADA2 continues to expand to include ischemic and hemorrhagic
strokes, cutaneous findings, portal and systemic hypertension, hematologic abnormalities,
vascular pathology, immune deficiency and bone marrow failure. As the phenotypic presentation
is likely to continue to expand, it is important to investigate any new complaints.
Disclosure of Interest
None Declared
O10 Serum S100A8/A9 (calprotectin) in familial mediterranean fever and carriers of
MEFV mutations does not correlate with disease activity
Ruth Pepper1, Mathew Hutchinson2, Scott R. Henderson3, Sarah K. Todd3, Alan D. Salama3,
Philip N. Hawkins4, Dorota Rowczenio4, Helen J. Lachmann4
1Centre for Nephrology, UCL; 2Rheumatology, University College Hospital; 3Centre for
Nephrology; 4National Amyloidosis Centre, UCL Division of Medicine and Royal Free
Hospital NHS Foundation Trust, London, United Kingdom
Correspondence: Ruth Pepper
Introduction: Familial Mediterranean Fever (FMF) is caused by mutations in MEFV. The
protein product pyrin is expressed in monocytes, neutrophils and eosinophils. Acute
inflammatory attacks are accompanied by a dramatic hepatic acute phase response. S100A8/A9
is damage associated molecular pattern and a TLR4 ligand expressed in neutrophils,
monocytes and early infiltrating macrophages.
Objectives: We aimed to investigate S100A8/A9 in 39 patients with FMF, 45 healthy
carriers and 16 wild type controls.
Methods: All patients were genotyped. Patients and healthy controls (HC) serum S100A8/A9
levels, cell surface expression on monocytes and neutrophils as well as intracellular
peripheral blood mononuclear cells (PBMC) expression were measured by flow cytometry
(FACS). CD14 cells were isolated and following overnight incubation with or without
LPS, S100A8/A9 was measured in the supernatants by ELISA. Patient and HC monocyte
apoptosis was compared.
Results: Serum levels were measures in 84 samples from 31 patients with homozygous
or compound mutations (median 9061ng/ml [range 500-38470], 79 samples from 39 symptomatic
patients who were MEFV heterozygotes (median 9394ng/ml [range 1744-38119], 80 samples
from 45 individuals with MEFV variants but without clinical features of FMF (median
10939ng/ml [range 2447->40000]. There was no difference in calprotectin concentrations
between the different mutations and no correlation with levels of the hepatic acute
phase response, CRP or SAA. All the groups described had significantly higher levels
than healthy controls (n=16 median 2836ng/ml [range 1058-6175])(p<0.001). Minimal
monocyte and neutrophil cell surface expression was detectable. Following LPS stimulation
there was significantly more S100A8/A9 detected in the supernatants in patients than
healthy control CD14. There was also a trend to an increased intracellular monocyte
S100A8/A9 expression.
Conclusion: Patients with pyrin mutations both with and without clinical disease have
greatly elevated serum S100A8/A9 levels without detectable cell surface expression
in well-controlled disease with a trend to an increased monocyte intracellular expression.
Upon monocyte stimulation with LPS, increasedS100A8/A9 is secreted. The exact mechanism
by which these patients, especially those with mutations but no clinical disease,
demonstrate sustained elevated serum S100A8/A9 remains to be elucidated but does not
appear to result in a significant clinical sequelae.
Disclosure of Interest
None Declared
O11 PAPA syndrome: novelties from the Eurofever registry
Roberta Caorsi, Daniela Marotto, Antonella Insalaco, Angelo Marzano, Joost Frenkel,
Graciela Espada, Immaculada Calvo Penades, Marijia Jelusic, Maria Cristina Maggio,
Joost Swart, Esther Hoppenreijs, Ozgur Kasapcopur, Fabrizio De Benedetti, Marco Gattorno,
The Pediatric Rheumatology International Trial Organization (PRINTO) and the Eurofever
Project
Center for Autoinflammatory Diseases and Immunodeficiency, Istituto G. Gaslini, Genova,
Italy
Correspondence: Roberta Caorsi
Introduction: PAPA syndrome is a very rare autoinflammatory condition. Few data are
nowadays available about the clinical characteristic, the response to treatment and
the outcome of this disease.
Objectives:To analyse the data of the PAPA patients enrolled to the Eurofever registry.
Methods: the data analysed in the study were extracted from the Eurofever registry,
which is hosted in the PRINTO website (www.printo.it). The patients were included
in the study in the presence of mutations in the PSTPIP1 gene or, in genetically negative
patients, in the presence of at least two of the following clinical manifestation:
recurrent pyogenic arthritis, pyoderma gangrenousm or skin abscess with negative cultural
tests. Demographic data, clinical manifestations and response to treatment were analysed.
Results: In may 2018 baseline and clinical information were available of near 4000
patients in the Eurofever registry. Of the 36 patients classified as PAPA syndrome,
2 were excluded from the study. 34 PAPA patients, from 11 different centers, were
analysed: the genotype was confirmatory in 29 patients, while in 5 was not available.
10 patients were of the same family, in 4 cases one parent was affected (2 included
in the registry), while in other 8 patients the family history was negative. At the
time of enrolment, 15 patients were in the paediatric age, while 19 were adults. The
mutations detected in the PSTPIP1 gene were E250Q (13 pts), E250K (5 pts), A230T (3
pts), G258A (3 pts), E277D (2 pts), E257G (1 pt), G940A (1pts) and R365W (1 pts).
The disease course was recurrent in 24 patients, while the other 10 presented a chronic
disease course with periodic recrudesces. Joint and skin involvement were present
at disease onset in 24 and 9 patients respectively. In other 12 patients skin involvement
appeared over time. 20 out of the 34 patients presented clinical manifestations not
typical of PAPA syndrome (psoriasis, uveitis, osteolytic bone lesions, chronic renal
failure, muscular abscesses, gastrointestinal symptoms anaemia and hepatosplenomegaly).
10 patients were treated with NSAID with partial and poor response in 6 and 4 patients
respectively, while steroids caused a complete or partial control of disease manifestations
in 6 and 10 patients respectively. Five patients were treated with methotrexate with
partial response. Etanercept was used in 6 patient with complete response in 2 and
partial in 4, adalimumab in 4 patients (1 partial and 1 complete responders, 2 failure)
and anakinra in 9 patients (3 partial and 6 complete responders). 2 patients were
treated with Canakinumab with complete response.
Conclusion: This study enlightens the phenotypic variability of PAPA syndrome. The
unusual clinical manifestations and the lack of the clinical triad of the disease
may be responsible for the under recognition of this disease. Between biologic drugs,
IL-1 inhibitors were more effective in the analysed cohort of patients.
Disclosure of Interest
None Declared
O12 New classification criteria for recurrent autoinflammatory diseases applied to
an independent cohort: experience from the JIR cohort database
Glory Dingulu1, Sophie Georgin-Lavialle2, Isabelle Koné-Paut3, Pascal Pillet4, Anne
Pagnier5, Etienne Merlin5, Daniela Kaiser6, Alexandre Belot7, Michael Hofer8, Véronique
Hentgen9
1Centre Hospitalier Versailles, Le Chesnay; 2Service de Médecine Interne-CEREMAIA,
Centre Hospitalier Universitaire Tenon, Paris; 3Service de Rhumatologie Pédiatrique-CEREMAIA,
Centre Hospitalier Universitaire Le Kremlin Bicêtre, Le Kremlin Bicêtre; 4Service
d’Accueil des Urgences Pédiatriques, Centre Hospitalier Universitaire Pellegrin, Bordeaux;
5Service de Pédiatrie Générale, Centre Hospitalier Universitaire Clermont Ferrand,
Clermont Ferrand, France; 6Service de Pédiatrie Générale, Centre Hospitalier Cantonal
Luzern, Luzern, Switzerland; 7Service de Néphrologie-Rhumatologie Pédiatrique, Centre
Hospitalier Universitaire Mère-Enfant, Bron, France; 8Service de Rhumatologie Pédiatrique,
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; 9Service de Pédiatrie
Générale-CEREMAIA, Centre Hospitalier Versailles, Le Chesnay, France
Correspondence: Glory Dingulu
Introduction: New classification criteria for the inherited periodic fever syndromes
Cryopyrin Associated Periodic Syndrom (CAPS), Tumour Necrosis Factor Receptor Associated
Periodic Syndrom (TRAPS), Familial Mediterranean Fever (FMF), Mevalonate Kinase Deficiency
(MKD), have recently been developed during a Consensus Conference held in Genoa in
March 2017.
Objectives: The aim of our study was to compare these new classification criteria
for monogenic recurrent fever syndromes with the diagnoses of clinicians in a real-life
setting.For this purpose we used the JIRcohort database, an international platform
gathering data of patients with pediatric inflammatory disease.
Methods: Patients with recurrent fever syndrome and complete clinical and genetic
data were enrolled to the study from the auto-inflammatory module of the JIRcohort
database. Patients genotype were characterized with HRF pathogenicity classification.
A score from 0 to 2, 0 (no mutation), 1 (non-confirmatory genotype) and 2 (confirmatory
genotype) was attributed to each gene screened in one patient. The new Genoa classification
criteria were applied to all the patients and then compared to the diagnosis of the
treating physician. The treating physician diagnosis was considered as standard reference.
If the treating physician hesitated between two or more diagnoses, patients were redefined
as Syndrome of Unexplained Recurrent Fever (SURF). SURF and PFAPA patients were pooled
together. Finally, for each criteria sensitivity and specificity were determined before
an analytical study, describing true positive, false positive and false positive patients.
Results: 455 patients were included:10 CAPS, 11 MKD, 27 TRAPS, 122 FMF and 285 SURF/PFAPA
patients.
CAPS classification criteria showed a 60 % sensitivity and 98% specificity. 6 patients
were true positive patients with confirmatory and non-confirmatory NLRP3 genotype.
4 were false negative patients with non-confirmatory genotype or no mutation in NLRP3.
8 were false positive with no mutation in NLRP3.
TRAPS classification criteria showed a 100 % sensitivity and 98% specificity. 22 were
true positive patients with confirmatory and non-confirmatory TNFRSF1A genotype. 5
patients were false positive with non-confirmatory genotype or no mutation in TNFRSF1A.
FMF classification criteria showed a 96 % sensitivity and 88% specificity. 117 patients
were true positive with confirmatory, non-confirmatory and non mutated MEFV genotype.
5 were false negative with non-confirmatory and non mutated genotype. 37 werefalse
positive patients with patients with non-confirmatory genotype or non mutated genotype
or no MEFV screening.
MKD classification criteria showed a 64 % sensitivity and 66% specificity. 7 patients
were true positive patients with confirmatory MVK genotype.4 were false negative patientswith
non-confirmatory genotype or non mutated MVK genotype. 148 were false positive patients
with non mutated MVK genotype.
Conclusion: This work is the first to study Genoa criteria, in real-life setting,
in a cohort of patients seen with recurrent fever. Genoa criteria showed tremendous
performance for patients with confirmatory genotype and helped classifying patients
with non-confirmatory genotype.
Genoa classification criteria were less effective when patients did not display at
least one genetic variant. Implementation of biological criteria in MKD might improve
MKD criteria performance.
The major limit of our study is the lack of a proper gold standard when genotype is
not confirmatory. Nevertheless our study shows that the new classification criteria
are of a high risk of misclassification in patients displaying a recurrent fever syndrome
without genetic test.
Disclosure of Interest
None Declared
O13 Impaired platelet functions in patients treated with colchicine
Özlem Çimen1, Selcan Demir2, Erdal Sağ2, Armağan Keskin1, Yelda Bilginer2, Şule Ünal
Cangül3, Seza Özen2
1Department of Pediatrics; 2Department of Pediatric Rheumatology; 3Department of Pediatric
Hematology, Hacettepe University Medical Faculty, Ankara, Turkey
Correspondence: Selcan Demir
Introduction: Colchicine has been used in the treatment of Familial Mediterranean
Fever (FMF) since 1972. Apart from the inhibiting mitosis in all cells, colchicine
has an anti-inflammatory effect by inhibiting activation and migration of neutrophils.
Colchicine is a safe drug at recommended doses, but it can cause rare side effects
including hematological findings such as lymphopenia, thrombocytopenia and neutropenia.
Objectives: In this study we aimed to define the adverse effect of colchicine on platelet
function and its clinical relevance.
Methods: A total of 220 FMF patients between June 2016-2017, followed at Hacettepe
University Pediatric Rheumatology Department and were on colchicine treatment for
at least one year, were included to the study.
Results: Among the selected 220 FMF patients, 100 of them (54% female) described hematological
symptoms when questioned in detail. The mean age of these patients was 11.74 ± 4.86
years. The mean cumulative colchicine exposure was 5.7±3.8 years.
The most common referral symptom was frequent epistaxis (79%) followed by easy bruising
(69%), and menstrual disorder including prolonged or heavy menstrual bleeding (21.8%
among female patients). Among these 100 patients, 36 of them had prolonged bleeding
time and impaired platelet aggregation test. Patients who had abnormal platelet function
tests (the group with abnormal bleeding time) were receiving higher colchicine doses
(median 0.05 vs 0.03 mg/kg/day; p:0.001) compared to the patients who had normal platelet
function tests (bleeding time normal group) However there were no significant difference
in terms of cumulative colchicine exposure (median 6.5 vs 4.5 years; p:0.07) and total
platelet counts (median 288500 vs 279000/mm3; p:0.61). Patients with abnormal platelet
function tests (bleeding time abnormal group) also had more epistaxis (47% vs 7%;
p<0.001), bruising (51% vs 3%; p<0.001) and dysmenorrhea (among female patients 100%
vs 26%; p<0.001) (Figure 1 and 2). Colchicine was not reduced in these patients and
no life-threatening event was observed.
Conclusion: In our study, we have shown prolonged bleeding time for the first time
in the literature. Colchicine may cause microtubule inhibition in platelets as well
as in other cells and impair platelet function. Further prospective studies are needed
to clarify the significance of this side effect.
Disclosure of Interest
None Declared
O14 Autoinflammatory disorders in patients with myelodysplastic syndrome: the role
of distinctive karyotypes and somatic mutations
Mark Kacar1, Abdulla Watad2, Nicola Bragazzi3, Qiao Zhou2, Catherine Cargo4, Dennis
McGonagle2, Sinisa Savic2
1Department of Clinical Immunology and Allergy, St James University Hospital; 2LIRMM,
University of Leeds, Leeds, United Kingdom; 3Department of Health Sciences, University
of Genoa, Genoa, Italy; 4Department of Haematology, St James University Hospital,
Leeds, United Kingdom
Correspondence: Mark Kacar
Introduction: A higher prevalence of autoimmune and autoinflammatory complications
has been reported in patients with myelodysplastic syndrome (MDS). The exact cause
of this remains to be elucidated.
Objectives: To determine the correlation between patients’ demographic, clinical and
molecular (karyotype, somatic genetic mutation status) features of MDS with specific
autoinflammatory complications and long-term outcome.
Methods: This was a retrospective study of 140 MDS patients referred to the Haematological
Malignancy Diagnostic Service (HMDS) in Leeds, UK, between 2012-2018. As part of their
diagnostic workup, all patients had karyotype assessment and targeted genetic sequencing
performed. Patients’ medical records were examined to collect demographic and clinical
information, and to identify patients with autoinflammatory complications. Patients
were classified as having ‘non-specific autoinflammatory features’ if CRP was found
to be elevated (>10.0 mg/L) on 5 or more separate occasions and this elevation could
not be explained by infection, malignancy or autoimmunity. Chi-squared test, Student
t-test, analysis of variance (ANOVA), univariate and multivariate logistic regression
analyses were performed.
Results: The average age was 77.08±11 years (median 79 years), with a male (n=91,
65.0%) preponderance. The 72 patients who had non-specific autoinflammatory features
(51%) tended to be younger (75.15±11.23 years versus 79.15±11.92, p=0.0395), and more
frequently had arthritis (n=25, 34.7%, versus n=12, 17.6%, p=0.0225), arthralgia (n=32,
44.4%, versus n=18, 26.5%, p=0.0271), skin rash (n=22, 30.6%, versus n=10, 14.7%,
p=0.0261), and pleuritis (16, 22.2%, versus n=3, 4.4%, p=0.0022). 26.4% of MDS patients
had a well-defined diagnosis of autoinflammatory disorder, with neutrophilic dermatosis
and polymyalgia rheumatic occurring most commonly. Mutations affecting the transcription
factor pathway (NPM1, RUNX1, BCOR, WTI, TP53, MYD88) (OR 3.15 [95%CI 1.04-9.56], p=0.0426)
and deletion of chromosome 5 (OR 3.37 [95%CI 1.01-11.22], p=0.0479) were associated
with autoinflammatory complications in general. Stratifying the patients into a “well-defined”
and “non-specific” autoinflammatory disease group showed that deletion of chromosome
7 was associated with well-defined conditions, whilst deletion of chromosome 5 was
linked with a non-specific autoinflammatory status. Furthermore, a higher rate of
acute leukaemia transformation was reported in MDS patients with autoinflammatory
status (n=25, 34.7%, versus n=8, 11.8%, p=0.0002).
Conclusion: Autoinflammatory conditions were found to be more prevalent than expected
in patients with MDS and were linked to a worse prognosis. Transcription factor pathway
gene mutations and an abnormal karyotype were also associated with autoinflammation.
Autoinflammatory features were associated with malignant transformation, hinting at
the possibility that treatment of the autoinflammation might play a role in preventing
disease progression. Further studies are required to replicate our findings and study
the effect of anti-inflammatory therapy on disease progression.
Disclosure of Interest
None Declared
Table 1 (abstract O14).
See text for description
Predictor
OR [95%CI]
Statistical significance
Overall autoinflammation
Transcription factor pathway
3.15 [95%CI 1.04 to 9.56]
0.0426
Deletion of chromosome 5
3.37 [95%CI 1.01 to 11.22]
0.0479
Well-defined autoinflammatory disease
Transcription factor pathway
4.50 [95%CI 1.04 to 19.47]
0.0441
Deletion of chromosome 7
6.13 [95%CI 1.16 to 32.33]
0.0325
Number of mutations
3.39 [95%CI 1.08 to 10.66]
0.0441
Unspecified inflammatory state
Deletionof chromosome 5
3.57 [95%CI 1.02 to 12.48]
0.0465
O15 A novel MEFV mutation associated with an autosomal dominant FMF complicated by
AA amyloidosis in a large British kindred
Dorota Rowczenio, Taryn Youngstein, Hadija Trojer, Charalampia Papadopoulou, Tamer
Rezk, Philip Hawkins, Helen Lachmann
National Amyloidosis Centre, UCL, London, United Kingdom
Correspondence: Dorota Rowczenio
Introduction: Hereditary systemic autoinflammatory diseases (SAIDs) are rare genetic
disorders characterised by recurrent, spontaneously resolving episodes of fever and
systemic inflammation that predominantly involves serosal surfaces. AA amyloidosis
is the most serious complication of SAIDs and is associated with proteinuric renal
dysfunction that progresses to end stage renal failure and premature death.
Objectives: To find a genetic cause in a large British family with a dominantly inherited
autoinflammatory syndrome complicated by AA amyloidosis.
Methods: Initially the Next Generation Sequencing (NGS) targeting 20 autoinflammatory
genes was performed in the index patient and his sister, both of whom have been diagnosed
with AA amyloidosis. There was a clear autosomal dominant inheritance affecting three
generations. Upon finding a genetic cause the DNA obtained from other affected family
members were analysed by Sanger sequencing.
Results: The index case was diagnosed with sJIA aged 7 and developed end stage renal
failure in his early twenties. He had haemodialysis for four years and underwent renal
transplantation at the age of 32. He was referred to the National Amyloidosis Centre
(NAC) with a suspicion of AA amyloid deposits in the transplanted kidneys. He reported
suffering with fever accompanied by severe abdominal and chest pain, arthritis, erythema
and night sweats from early life. Interestingly having been started on colchicine
for post-transplant gout he felt significantly better. Subsequently his sister developed
nephrotic syndrome due to AA amyloidosis. She describes similar symptoms throughout
most of her life. Their parents were of white British origin from a non-consanguineous
kindred. Their father had died aged 52 years from complications immediately following
a cadaveric renal transplantation. The post-mortem examination of his renal biopsy
revealed deposition of AA amyloid fibrils. The index case grandmother also suffered
with cyclical episodic abdominal cramping and had a history of osteoarthritis. The
index case’s two paternal cousins and two of their children described similar symptoms.
NGS revealed a single MEFV allele to be affected in both the index case and his sister,
resulting in the p.P373L variant in exon 3. Subsequently this variant was confirmed
by Sanger sequencing in all living affected members. The mutant allele was not identified
in the unaffected cases. All symptomatic individuals were treated with colchicine
which suppressed their FMF related inflammation. We sequenced SAA1 gene, as homozygosity
for the SAA1.1 allele is a known susceptibility factor for AA amyloidosis, but all
cases were heterozygous.
Conclusion: In the Northern Caucasian population FMF is extremely rare in comparison
to the Mediterranean region. Typically FMF is an autosomal recessive disorder, nonetheless
very rare cases of dominantly inherited disease have previously been reported, namely
caused by the deletion of methionine residue at position 694 identified in British
patients and three substitutions affecting threonine 577: p.T577N, p.T577S and p.T577A
found in British, Turkish and Dutch patients respectively.
Here we report a novel MEFV variant p.P373L causing dominant FMF in three generations
of a large British family and in three cases this was complicated by AA amyloidosis
indicating a severe pathogenicity of this variant.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Oral communications – Immunology
O16 PYRIN inflammasome dysregulation in FMF patients: implication for a fast diagnostic
test
Thomas Henry, Flora Magnotti, Alexandre Belot, Yvan Jamilloux
Inserm U1111, CNRS UMR5308, Univ. Lyon, ENS Lyon, CIRI, Lyon, France
Correspondence: Thomas Henry
Introduction: Familial Mediterranean Fever (FMF) is usually associated with bi-allelic
mutations in the MEFV gene. MEFV encodes Pyrin, an inflammasome sensor leading to
IL-1β release and a fast cell death termed pyroptosis. The relationship between MEFV
mutations and Pyrin inflammasome regulations is still poorly understood. Furthermore,
due to the large number of MEFV variants and a substantial proportions of FMF patients
presenting mutations in a single MEFV allele, the genetic confirmation of the FMF
diagnosis is often unconclusive.
Objectives: The objective of the study were:
to understand at the molecular levels the Pyrin inflammasome dysregulation in monocytes
from FMF patients
to assess whether monitoring Pyrin inflammasome activation could lead to a novel functional
diagnostic test for FMF
Methods: Monocytes from healthy donors (HD) or FMF patients were isolated and treated
with a kinase inhibitor targeting the PKC superfamily, which includes PKN1/2 known
to regulate Pyrin inflammasome activation. IL-1β release andcell death kinetics were
monitored.
In parallel, a human monocyte cell line was engineered to modelize FMF and HD monocytes
and assess the role of Pyrin phosphorylation and inflammasome components in cell death
and cytokine release.
Results: Dephosphorylation of Pyrin was sufficient to trigger Pyrin inflammasome activation
in monocytes from FMF patients while no inflammasome activation was observed in monocytes
from healthy controls.
Using a human monocyte cell line, we demonstrated that dephosphorylation of Pyrin
was similar in cells expressing wild-type or mutated MEFV but that a mutated MEFV
was necessary and sufficient to progress to active inflammasome upon PKC superfamily
inhibition.
Finally, thanks to a cohort of FMF patients, we demonstrate that FMF patients can
be efficiently and specifically diagnosed based on the response of their monocytes
to PKC superfamily inhibitors.
Conclusion: Our results demonstrate that Pyrin dephosphorylation is sufficient to
trigger inflammasome activation in monocytes from FMF patients but not from healthy
donors. This indicates that in healthy donors, the progression to an active Pyrin
inflammasome requires two independently-controlled steps and that the second mechanism
of control is deficient in monocytes from FMF patients.
Our study also demonstrates that monitoring inflammasome activation upon PKC superfamily
inhibition in monocytes can discriminate FMF patients from patients with other inflammatory
conditions opening the way to a fast functional test to diagnose FMF.
Disclosure of Interest
None Declared
O17 Unraveling the molecular pathogenesis of proteasome-associated autoinflammatory
syndromes
Frédéric Ebstein1, Anja Brehm2, Sébastien Küry3, Thomas Besnard3, Bertrand Isidor3,
Stéphane Bézieau3, Pawel Stankiewicz4, Elke Krüger1
1Institut für Medizinische Biochemie und Molekularbiologie (IMBM), Universitätsmedizin
Greifswald, Greifswald; 2Institut für Biochemie, Charité Universitätsmedizin Berlin,
Berlin, Germany; 3Service de Génétique Médicale, CHU de Nantes, Nantes, France; 4Dept
of Molecular and Human Genetics, Baylor College of Medicine, Houston, United States
Correspondence: Frédéric Ebstein
Introduction: In most eukaryotic cells, the degradation of abnormal and/or regulatory
proteins is ensured by large multi-subunit ATP-dependent proteases known as proteasomes
which consist in two distinct sub-complexes, a 20S core particle and a 19S regulatory
particle. Since the early 2010s, an increasing number of loss-of-function mutations
have been identified in genes encoding proteasome subunits including PSMB8, PSMB9,
PSMB4, PSMA3 and PSMD12 and/or the proteasome maturation protein POMP. Fascinatingly,
depending on the subunit affected, such genomic alterations result in the development
of two seemingly distinct phenotypes, namely: (i) systemic autoinflammation or (ii)
cognitive impairment. Herein, mutations of the 20S core particle subunits (i.e. PSMB8,
PSMB9, PSMB4 and PSMA3) and/or POMP are typically associated with a group of autoinflammatory
syndromes sharing the same constellation of clinical signs and frequently referred
to as chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature
(CANDLE) and/or proteasome-associated autoinflammatory syndromes (PRAAS). By contrast,
genetic disruption of the subunits of the 19S regulatory particle (i.e. PSMD12) leads
to a syndromic form of intellectual disability (ID).
Objectives: Our aim in this study is to determine whether syndromic ID disorders caused
by variants in genes encoding 19S proteasome subunits share similarities with CANDLE/PRAAS
in their etiology and/or pathogenesis particularly regarding inflammation.
Methods: Peripheral blood mononuclear cells (PBMC) from subjects carrying 19S proteasome
loss-of-function mutations diagnosed with syndromic ID as well as related control
were collected and subjected to RNA isolation and protein extraction prior to quantitative
PCR and western-blot analysis, respectively.
Results: Like CANDLE/PRAAS, syndromic ID disorders caused by genomic alterations in
19S proteasome genes were associated with perturbed proteasome function, as evidenced
by increased levels of intracellular ubiquitin-protein conjugates. Most importantly,
our data show that PBMC from patients with syndromic ID exhibit high transcription
levels of various IFN-induced genes (ISG) including CXCL10, CXCL9, IFI44 and IFI44L.
Interestingly, the strength of the IFN signatures in these patients correlated with
the magnitude of the unfolded protein responses (UPR) initiated by proteasome dysfunction,
suggesting a cause-and-effect relationship between endoplasmic reticulum (ER) stress
and inflammation.
Conclusion: In this work, we provide evidence on the association of 19S proteasome
dysfunction with the generation of autoinflammation in subjects diagnosed with syndromic
ID disorders. From these data, we expect to convey a more integrated picture of the
pathophysiology of syndromic ID and identify new therapeutic targets for the treatment
of cognitive impairment.
Disclosure of Interest
None Declared
O18 A novel knock-in mouse model of CAPS that develops amyloidosis: therapeutic efficacy
of proton pump inhibitors
Arinna Bertoni1, Sonia Carta2, Chiara Baldovini3, Federica Penco1, Enrica Balza2,
Silvia Borghini4, Marco Di Duca4, Emanuela Ognio5, Paolo Nozza3, Francesca Schena1,
Patrizia Castellani2, Claudia Pastorino1, Carola Perrone1, Laura Obici6, Alberto Martini7,
Isabella Ceccherini4, Marco Gattorno1, Anna Rubartelli2, Sabrina Chiesa1
1Centro Malattie Autoinfiammatorie ed Immunodeficienze, IRCCS Istituto G. Gaslini;
2Unità di Biologia Cellulare, IRCCS Ospedale Policlinico San Martino; 3Anatomia Patologica;
4Genetica Medica, IRCCS Istituto G. Gaslini; 5S.S Animal Facility, IRCCS Ospedale
Policlinico San Martino, Genova; 6Centro per lo Studio e la Cura delle Amiloidosi
Sistemiche, Fondazione IRCCS Policlinico San Matteo, Pavia; 7Direzione Scientifica,
IRCCS Istituto G. Gaslini, Genova, Italy
Correspondence: Arinna Bertoni
Introduction: Cryopyrin associated periodic syndromes (CAPS) are a group of autoinflammatory
diseases linked to gain-of-function mutations in the NLRP3 gene that cause uncontrolled
IL-1β secretion. CINCA syndrome is the most severe CAPS disease characterized by central
nervous system disabilities with a long-term risk of secondary amyloidosis.
Proton pump inhibitors (PPIs), commonly used as inhibitors of gastric acidproduction,
also display anti-inflammatory properties, making them promising drugs in sepsis and
in inflammatory disorders.
Objectives: To develop a novel NLRP3 knock-in (KI) mouse model of CAPSto evaluate
amyloid deposition and to test alternative therapeutic approaches.
Methods: We generated KI mice by engineering N475K mutation associated with CAPS phenotype
into mouse Nlrp3 gene. KI and Wild Type (WT) mice received PPIs or PBS intraperitoneally
and were analyzed for survival, inflammation, cytokine secretion, and amyloidosis
development. Cytokines secretion from bone marrow derived dendritic cells (BMDCs)
and peritoneal macrophages (PMs) was evaluated by ELISA. Hystological analysis of
all organs was evaluated by hematoxylin and eosin staining. Amyloid deposition was
quantified through Congo Red staining.
Results: Mutant NLRP3 KI mice displayed features that recapitulates the immunological
and clinical phenotype of CAPS. These mice had systemic inflammation, with high levels
of serum pro-inflammatory cytokines compared to WT controls. Hystological analysis
revealed the presence of acute and chronic inflammatory cell infiltrates and amyloid
deposits in spleen, liver and kidneys. As in CAPS monocytes , BMDCs and PM from KI
mice showed a strong increase in IL-1β, IL-18, and IL-1α secretion and decreased levels
in interleukin-1 receptor antagonist (IL-1Ra), the naturally occurring IL-1b inhibitor.
PPIs treatment of KI mice showed a clear clinical impact with improvement of inflammatory
conditions and regression of amyloid deposits. Remarkably, BMDCs and PMs from PPI-treated
mice presentedreduced secretion of pro-inflammatory cytokines and re-established the
levels of IL-1RA.
Conclusion: NLRP3 KI mice display a CAPS phenotype with many characteristics of autoinflammation,
including amyloidosis. The therapeutic effectiveness associated with lack oftoxicity
indicates that PPIs could represent relevant adjuvants to the anti-IL-1 drugs in IL-1
driven diseases.
Disclosure of Interest
None Declared
O19 T cell defects in patients with ARPC1B germline mutations account for combined
immunodeficiency
Immacolata Brigida1, Matteo Zoccolillo1,4, Maria Pia Cicalese1,2,3, Laurène Pfajfer5-9,
Federica Barzaghi2,4, Serena Scala1, Carmen Oleaga-Quintas10,11, Jesus A. Alvarez12,
Lucia Sereni1, Stefania Giannelli1, Claudia Sartirana1, Francesca Dionisio1, Luca
Pavesi13, Marta Benavides-Nieto14,15, Luca Basso-Ricci1, Paola Capasso1, Benedetta
Mazzi16, Jeremie Rosain10,11,28, Nufar Marcus17, Yu Nee Lee18, Raz Somech18, Massimo
Degano19, Giuseppe Raiola20, Roberta Caorsi21, Paolo Picco21, Marcela Moncada Velez12,
Joelle Khourieh11,12, Andrés Augusto Arias12,29, Aziz Bousfiha22, Thomas Issekutz23,
Andrew Issekutz23, Bertrand Boisson11,12,24, Kerry Dobbs25, Anna Villa1,26, Angelo
Lombardo1,3, Benedicte Neven14, Despina Moshous14,15, Jean-Laurent Casanova11,12,14,24,27,
José Luis Franco12, Luigi D Notarangelo25, Cristina Scielzo13, Stefano Volpi21,30,
Loïc Dupré5-9, Jacinta Bustamante11,12,24,28, Marco Gattorno21,31‡, and Alessandro
Aiuti1,2,3‡
1San Raffaele Telethon Institute for Gene Therapy, SR-TIGET; 2Pediatric Immunohematology,
San Raffaele Scientific Institute, Milan; 3Vita-Salute San Raffaele University, Milan,
Italy; 4Department of Systems Medicine, Tor Vergata University, Rome, Italy; 5INSERM,
UMR1043, Centre de Physiopathologie de Toulouse Purpan, Toulouse, France; 6CNRS, UMR5282,
Toulouse, France; 7Université Toulouse III Paul-Sabatier, Toulouse, France; 8Ludwig
Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria; 9CeMM Research
Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria;
10Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163,
75015 Paris, France, EU; 11Paris Descartes University, Imagine Institute, 75015 Paris,
France, EU; 12Group of Primary Immunodeficiencies, Department of Microbiology & Parasitology,
School of Medicine, University of Antioquia UdeA, Medellin, Colombia; 13Division of
Experimental Oncology, Unit of B-cell Neoplasia, San Raffaele Scientific Institute,
Milan; 14Pediatric Hematology-Immunology Unit, Necker Hospital for Sick Children,
AP-HP, 75015 Paris, France, EU; 15Genome Dynamics in the Immune System, Université
Paris Descartes – Sorbonne Paris; 16Immunogenetics Laboratory, HLA & Chimerism, Dept.
of Immunohematology & Blood Transfusion, IRCCS Ospedale San Raffaele, Milano, Italy;
17Kipper Institute for Allergy and Immunology, Schneider Children’s Medical Center
of Israel, Petach Tikva, Israel, affiliated with Sackler School of Medicine, Tel Aviv
University, Tel Aviv, Israel; 18Pediatric Department A and the Immunology Services,
“Edmond and Lily Safra” Children's Hospital, Jeffrey Modell Foundation Center, Sheba
Medical Center, Tel Hashomer affiliated with Sackler School of Medicine, Tel Aviv
University, Tel Aviv, Israel; 19Division of Immunology, Transplantation, and Infectious
Diseases, Biocrystallography Unit. San Raffaele Scientific Institute, Milan; 20Unità
Operativa di Pediatria, Azienda Ospedaliera “Pugliese-Ciaccio” di Catanzaro; 21U.O.
Clinica Pediatrica e Reumatologia, Istituto Giannina Gaslini, Genova, Italy; 22Clinical
Immunology Unit, Department of Pediatrics, King Hassan II University, Ibn-Rochd Hospital,
Casablanca, Morocco; 23Department of Pediatrics & Department of Microbiology-Immunology,
Dalhousie University, Halifax, Nova Scotia, Canada; 24St. Giles Laboratory of Human
Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New
York, NY 10065, USA; 25Laboratory of Clinical Immunology and Microbiology, National
Institute of Allergy and Infectious Diseases, NIH, Bethesda, USA; 26Istituto di Ricerca
Genetica e Biomedica (IRGB), Consiglio Nazionale delle Ricerche (CNR), Milan Unit,
Milan, Italy; 27Howard Hughes Medical Institute, NY, USA; 28Center for the Study of
Primary Immunodeficiencies, Assistance Publique-Hôpitaux de Paris AP-HP, Necker Hospital
for Sick Children, Paris, France, EU; 29School of Microbiology, University of Antioquia
UdeA, Medellin, Colombia; 30Università degli Studi di Genova, Genova, Italy; 31UOSD
Centro Malattie e Autoinfiammatorie e Immunodeficienze, Istituto Giannina Gaslini,
Genova, Italy
Correspondence: Alessandro Aiuti
Introduction: ARPC1B is a key factor for the assembly and maintenance of the ARP2/3
complex, involved in actin branching from an existing filament. Germline mutations
in ARPC1B have been recently described in six unrelated patients, with clinical features
of combined immunodeficiency, whose neutrophils and platelets but not T lymphocytes
were studied.
Objectives: We hypothesized that ARPC1B-deficiency may also lead to cytoskeleton and
functional defects in T cells
Methods: Next-generation sequencing in 6 patients; flow cytometry, proliferation and
migration, confocal and electron microscopy) to characterize defects in T cells; lentiviral-mediated
gene transfer for genetic correction of ARPC1B.
Results: We identified bi-allelic mutations in 6 unrelated patients with severe infections,
autoimmune manifestations and platelet defects showing altered protein structure,
and absent/low expression of the ARPC1B protein. Confocal microscopy showed altered
expression of ARPC1B with actin. T cells displayed impaired TCR-mediated proliferation
and SDF1-α directed migration. Gene transfer of ARPC1B in patient’s T cells using
a lentiviral vector restored ARPC1B expression, leading to improved T-cell proliferation
in vitro. In 2 patients normal ARPC1B levels in a fraction of lymphocytes were associated
with in vivo somatic reversion and improved T cell migration in vitro. In one of the
patient somatic revertant was present only in memory CD8+ T-cells, which showed improved
in vitro T-cell migration.
Conclusion: Inherited ARPC1B deficiency alters T cell cytoskeletal dynamics and functions,
contributing to the clinical features of combined immunodeficiency.
Disclosure of Interest
None Declared
O20 B cell defect in ADA2 deficiency patients
Francesca Schena1, Federica Penco1, Stefano Volpi1,2, Claudia Pastorino1, Roberta
Caorsi1, Arinna Bertoni1, Francesca Kalli3, Daniela Fenoglio3,4,5, Annalisa Salis6,
Ignazia Prigione1, Paola Bocca1, Francesca Antonini7, Antonella Insalaco8, Alice Grossi9,
Gianluca Damonte6, Isabella Ceccherini9, Gilberto Filaci3,4,5, Alberto Martini1,2,
Elisabetta Traggiai10, Marco Gattorno1
1UOSD Centro Malattie Autoinfiammatorie e Immunodeficienze and Clinica Pediatrica
e Reumatologia, IRCCS Istituto Giannina Gaslini; 2Università degli studi di Genova;
3Center of Excellence for Biomedical Research; 4Department of Internal Medicine, Clinical
Immunology Unit, Università di Genova; 5Ospedale Policlinico San Martino; 6Department
of Experimental Medicine and Center of Excellence for Biomedical Research, Università
di Genova; 7Core Facilities Flow-Cytometry and Cell imaging Lab, Istituto Giannina
Gaslini, Genova; 8Division of Rheumatology, Department of Pediatric Medicine, IRCCS,
Bambino Gesù Children’s Hospital, Roma; 9Medical Genetics, IRCCS Istituto Giannina
Gaslini, Genova, Italy; 10Novartis Institutes for Biomedical Research, Basel, Switzerland
Correspondence: Francesca Schena
Introduction: Adenosine Deaminase 2 Deficiency (DADA2) is an autoinflammatory disease
characterized by systemic vasculopathy, strokes and mild immunodeficiency, mainly
affecting B cell compartment. The defect is due to a loss of function mutation of
ADA2 gene, coding for Adenosine Deaminase 2, a protein which regulates the catabolism
of extracellular adenosine.
Objectives: Hypogammaglobulinemia and recurrent infections are associated to DADA2.
We therefore investigated phenotype and in vitro B and T cell responses in DADA2 patients
to address if ADA2 mutation affects B and T cell function and in particular we focused
on B cell-T cell interaction.
Methods: 14 patients carrying loss of function mutations in ADA2 were examined. They
showed clinical history with livedo reticularis, fever, vasculitis and neurological
symptoms. We analyzed peripheral B and T cell phenotype by flow cytometry, in vitro
B-cell proliferation and differentiation to Immunoglobulin secreting cells in response
to TLR9 agonist and T cell help. Moreover B cells isolated from DADA2 patients or
HD have been cultured in co-culture with CD4+ T cells and in vitro B cell proliferation
has been evaluated by CFSE dilution, whereas B cell differentiation and immunoglobulin
secretion in response to TLR9 agonist and T cell help have been evaluated by ELISA
and ELISPOT assay. Simultaneously cytokine production from Tfh cells has been analyzed.
Results: Flow-cytometric analysis of DADA2 peripheral blood showed a significant reduction
of switch memory B cells and an increased frequency of CD21low B cells. Regarding
T cell compartment memory CD4+ and CD8+ T cells are significantly reduced; interestingly
we identified an expansion in frequency of circulating Tfh cells.
Then we investigated a role of ADA2 in B cells: we found that ADA2 is expressed in
all B cell subsets, secreted but its enzymatic activity is strongly impaired in DADA2.
We show that Naïve B cells from DADA2 patients are impaired in their proliferation,
suggesting an intrinsic defect due to the mutation.
We also addressed the interaction between B and helper T cells; DADA2 CD4+ T cells
showed an impairment in the IL21 production and a downregulation of CD40L, suggesting
a functional defect of Tfh cells; then we found that proliferation and differentiation
of patients’ B cells were not sustained from patients’ CD4+ T cells.
Conclusion: Our findings suggest that ADA2 mutations could lead to an intrinsic defect
in B cell function and to a reduced T cell dependent B cell response.
Disclosure of Interest
None Declared
O21 Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome
and obstructive sleep apnea are distinct inflammatory disorders of oropharyngeal lymphoid
tissue
Kalpana Manthiram1, Silvia Preite2, Fatma Dedeoglu3, Maranda Lawton3, Pamela Mudd4,
Hemalatha Srinivasalu4, Greg Licameli3, Kathryn Edwards5, Pamela Schwartzberg2, Daniel
Kastner1
1National Human Genome Research Institute; 2National Institute of Allergy and Infectious
Diseases, NIH, Bethesda; 3Boston Children’s Hospital, Harvard Medical School, Boston;
4Children’s National Medical Center, George Washington University School of Medicine,
Washington; 5Vanderbilt University School of Medicine, Nashville, United States
Correspondence: Kalpana Manthiram
Introduction: Tonsillectomy is one of the most common surgical procedures in children
and is performed typically for recurrent tonsillitis or obstructive sleep apnea (OSA),
and less frequently for periodic fever, aphthous stomatitis pharyngitis, cervical
adenitis (PFAPA) syndrome. The pathogenesis of OSA and PFAPA is unknown.
Objectives: In order to understand the pathogenesis of these two disorders, we studied
the immunologic profile of tonsils removed from children with PFAPA and OSA in comparision
with control tonsils.
Methods: After getting informed consent, we obtained tonsils from children undergoing
tonsillectomy for (1) PFAPA (N=12) and (2) OSA (N=12), and from (3) children undergoing
tonsillectomy during oropharyngeal anatomic correction surgery like pharyngeal flap
preparation (“controls”, N=9).Mononuclear cells from the tonsils were separated by
standard methods and cells were analyzed by flow cytometry and gene expression with
Nanostring. Cytokine production by isolated tonsillar mononuclear cells was measured
by flow cytometry following phorbol 12-myristate 13-acetate (PMA) and ionomycin stimulation
for 4 hours ex vivo.
Results: Tonsils from patients with PFAPA, which were removed during asymptomatic
intervals, had evidence of germinal center suppression with significantly fewer T
follicular helper cells, more T follicular regulatory cells, fewer plasma cells and
reduced IgG class switching compared to tonsils from either OSA patients or controls.
Gene expression analysis revealed downregulation of pro-inflammatory genes in tonsillar
myeloid cells from patients with PFAPA. However, upon stimulation with PMA and ionomycin,
CD4+ T cells from tonsils of patients with PFAPA produced more IFNγ and IL-17 than
that of controls, but less than those of patients with OSA.
On the other hand, tonsils from patients with OSA, had significantly larger germinal
center areas by histology compared to those from patients with PFAPA and controls.
Moreover, in tonsils from OSA patients, we found higher IFNγ production by CD4+ T,
CD8+ T and NK cells, and greater IL-17 production by CD4+ T cells and NK cells upon
stimulation with PMA and ionomycin when compared with tonsils from PFAPA patients
and controls.
Conclusion: We show that tonsils from both patients with PFAPA and OSA exhibit evidence
of immune dysregulation. During asymptomatic periods, PFAPA patients display myeloid
cell and germinal center suppression in the tonsils, suggesting a compensatory response
to inflammatory flares. However, upon stimulation, CD4+ T cells produce high levels
of pro-inflammatory cytokines. We hypothesize that alternating periods of heightened
immune activation and suppression lead to the periodicity of PFAPA. In comparison,
tonsils from patients with OSA display relatively constant germinal center hypertrophy
likely due to unchecked chronic T cell activation. Further studies are necessary to
understand the genetic and environmental risk factors for T cell activation in both
of these disorders and why PFAPA patients may have cycling of inflammatory periods
in the tonsils while OSA patients have chronic tonsillar inflammation.
Disclosure of Interest
None Declared
O22 PFAPA syndrome: NK cells infiltrating tonsils support the crucial role of innate
immunity in the pathogenesis
Sabrina Chiesa1, Roberta Caorsi2, Francesca Bellora3, Mariella Della Chiesa3, Ilaria
Ingrosso1, Federica Penco1, ArinnaBertoni1, Claudia Pastorino1, Ignazia Prigione1,
Alessia Omenetti2, Martina Finetti2, Silvia Borghini4, Angela Sementa5, Roberto D’Agostino6,
LuciaSemino6, Alberto Martini7, Cristina Bottino3, Marco Gattorno1
1Centro Malattie Autoinfiammatorie e Immunodeficienze; 2Clinica Pediatrica e Reumatologica,
IIRCCS G. Gaslini; 3Medicina Sperimentale, University of Genoa; 4Laboratorio di Genetica
Molecolare; 5Anatomia Patologica; 6UO Otorinolaringoiatria, IIRCCS G. Gaslini; 7Clinica
Pediatrica e Reumatologica, University of Genoa, Genova, Italy
Correspondence: Sabrina Chiesa
Introduction: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis
(PFAPA) syndrome is a more frequent cause of recurrent fever in children. The exact
etiology of this pediatric disorder is still unknown. Elevated serum levels of IL-1β,
IL-18, IL-6, and IFNγ suggest innate immunity dysregulation as the key pathomechanism
of PFAPA attacks. Palatine tonsils are sites where innate immunity leads to the onset
of adaptive immunity, mediated by B and T lymphocytes. Natural killer (NK) cells,
the most important effectors of the innate lymphoid cells (ILCs), play a fundamental
role in innate immune responses.
Objectives: Tonsillectomy is one of the therapeutic options for PFAPA patients. We
tested whether specific infiltrating inflammatory cells in pediatric tonsils contribute
to PFAPA pathogenesis.
Methods: Tonsils were collected from 2 groups of pediatric patients undergoing tonsillectomy:
PFAPA patients (n=32) and children with bacterial tonsillitis (control group, CG)
(n=25). Phenotypic analysis of subpopulations of tonsil cell suspensions and tissues
was performedby flow cytometry and immunohistochemistry.
Results: During the asymptomatic phase of disease the number of monocytes did not
differ between the PFAPA and control tonsils. We observed a considerable recruitment
of NK cells in tonsils of PFAPA patients respect to CG. In particular, we detected
a significant expansion of both CD56bright CD16- and CD56dim CD16+ NK cell subsets
in PFAPA samples compared to CG. A fine characterization of activating and inhibitory
NK receptors suggested a crucial role of CD56dim CD16+ cell subset in PFAPA disease.
Specially, activating receptors, as natural cytotoxicity receptors (NCRs) and NKG2D,
were higher in NK cells of PFAPA patients than in NK cells from CG. Remarkably, CD56+
NK cells from PFAPA tonsils werecytotoxic and contained much more perforine and granzyme
than those from CG tonsils. NK cells from PFAPA tonsils exhibited increased IFN-g
production, compared to NK from CG. Accordingly, plasmacytoid dendritic cells, the
main source of type I interferon cytokines, were significantly increased in PFAPA
tonsils. We detected a higher number of naïve and a significantly lower percentage
of effector memory CD4+ and CD8+ T cells in PFAPA tonsils compared to CG. Additionally,
PFAPA tonsils presented a significant decrease of both functional follicular helper
T cells (CXCR5+ICOS+) and T regulatory cells (CD39+Foxp3+). Finally, CD19+CD38+ B
cellswere reduced in this cohort of PFAPA tonsils.
Conclusion: These results suggest aninvolvement of NK cells in the pathogenesis of
PFAPA and support the crucial role ofinnate immunity in the disease. Nonetheless,
the abundant and activated CD56+NK cells might shape adaptive immunity that is impaired
in the tonsils of PFAPA patients.
Disclosure of Interest
None Declared
Novel AID pathways and genes
O23 Identification of rare coding variants in IL-1-related pathways in patients with
adult-onset still’s disease
Giulio Cavalli1,2, Rosanne Van Deuren2, Peer Arts2, Marloes Steerhower2, Paolo Sfriso3,
Paola Galozzi3, Serena Colafrancesco4, Roberta Priori4, Luca Cantarini5, Stefano Rodolfi1,
Elena Baldissera1, Frank van der Veerdonk2, Lorenzo Dagna1, Alexander Hoischen2, Charles
A. Dinarello2,6
1Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UniRAR), Vita-Salute
San Raffaele University, Milan, Italy; 2Department of Medicine, Radboud University
Medical Centre, Nijmegen, Netherlands; 3Rheumatology, University of Padua, Padua;
4Rheumatology, Sapienza University, Rome; 5Rheumatology, University of Siena, Siena;
6Department of Medicine, University of Colorado Denver, Aurora, CO, Italy
Correspondence: Giulio Cavalli
Introduction: Adult-onset Still's disease (AOSD) is a rare autoinflammatory disease
characterized by fever, arthritis, and multi-organ involvement. Inflammation in AOSD
is mediated by interleukin (IL)-1β, as confirmed by the dramatic clinical efficacy of
selective blockers of this cytokine. The genetic predisposition to this rampant IL-1-driven
inflammation remains nevertheless elusive. Previous studies failed to identify associations
between polymorphisms in the genes encoding IL-1 and AOSD, thus pointing at more complex
genetic mechanisms. This ‘missing heritability’ cannot be adequately investigated
with traditional techniques for genetic partitioning, such as GWAS, which only assess
common variants and polymorphisms. Studies focusing on highly penetrant rare variants
or different types of mutations (i.e. small copy-number variations; insertions/deletions)
are warranted.
Objectives: We hypothesized that genetically determined changes in IL-1-related pathways
resulting in excessive IL-1β activity lead to the development of autoinflammation
in AOSD. Scope of this study was to unravel the combined mutational variation of a
network of IL-1-related receptors, pathways, counter-regulators, and cellular processes
possibly involved in the pathogenesis of AOSD and IL-1-mediated inflammation in general.
Methods: We collected clinical, demographic, and genetic data from a large cohort
of 76 AOSD patients and developed an innovative platform based on molecular inversion
probes (MIP) technology for performing highly multiplexed targeted-resequencing. This
allows efficient sequencing of the coding sequence of 48 genes related to the IL-1-pathway,
and allows studying rare and common variants in one assay. We have also screened 500
healthy controls, and 1000s of samples with other disorders using the same assay.
Results: We identified rare and unique (i.e. private variants) in the IL1 pathway
in several individuals with AOSD. Whether any these are involved in a strong predisposition
to AOSD is currently followed-up. Rare genetic variants have been identified in six
IL-1-pathway ‘clusters’:
Deregulated activation of the inflammasome and release of IL‑1β and IL-18.
IL-1 family receptors and intracellular signaling mediators.
Other pro-inflammatory cytokines and receptors.
Regulatory molecules, including IL-1Ra or IL-37.
Cellular processes regulating production of IL-1 and IL-18 (i.e. autophagy).
Production of ROS, which function as markers of cellular damage and trigger inflammation.
Conclusion: Unraveling the genetic bases of inflammation in AOSD deepens our understanding
of the human innate immunome. Of note, this study platform may serve for the genetic
analysis of other IL-1-mediated conditions, including gout and other autoinflammatory
diseases, whose genetic predisposition remains elusive. Equally important, the identification
of pathways amenable to targeting with small molecules or biologics may translate
into remarkable clinical implications.
Disclosure of Interest
None Declared
O24 Trisomy 8-associated autoinflammatory disease (TRIAD) is characterized by increased
monocyte activation
Kalpana Manthiram1, Alina Dulau-Florea2, Deborah Bruns3, Amanda Ombrello1, Karyl Barron4,
Tina Romeo1, Anne Jones1, Karin Weiss1, Sandro Perazzio5, Isabelle Kone-Paut6, Nora
Al-Mutiari7, Troy Torgerson5, Daniel Kastner1
1National Human Genome Research Institute; 2Department of Laboratory Medicine, NIH,
Bethesda; 3Department of Counseling, Quantitative Methods, and Special Education,
Southern Illinois University Carbondale, Carbondale; 4National Institute of Allergy
and Infectious Diseases, NIH, Bethesda; 5Department of Pediatrics, University of Washington
School of Medicine, Seattle, United States; 6Bicêtre University Hospital, APHP, CEREMAIA,
University of Paris Sud, Paris, France; 7Department of Pediatrics, Sabah Hospital,
Kuwait City, Kuwait
Correspondence: Kalpana Manthiram
Introduction: Many adults with acquired trisomy 8 and myelodysplasia have been reported
to have Behçet’s-like inflammatory disease. A few patients with constitutional trisomy
8 mosaicism and ulcerative disease have also been reported. The spectrum of phenotypic
abnormalities, inflammatory profiles, and treatment responses of patients with constitutional
trisomy 8 are not well-characterized.
Objectives: We analyzed the clinical and immunologic features of a cohort of patients
with trisomy 8 mosaicism in order to understand the pathogenesis of the disorder.
Methods: Whole blood gene expression was analyzed with the Nanostring Human Immunology
panel. Copy number of two genes on the p and q arms of chromosome 8 were determined
by digital droplet PCR in sorted CD3+ T cells, CD19+ B cells, and CD14+ monocytes
from peripheral blood to determine the percentage of mosaicism in different cell populations.
Platelet electron microscopy was performed in a clinical laboratory.
Results: Eleven patients with trisomy 8 mosaicism ranging in age from 5 to 37 years
were recruited. Eight-two percent had recurrent fever, 82% had oral ulcerations, and
72% had severe oral ulcerations larger than 1 cm or lasting more than one week. Five
patients reported genital, esophageal, or colonic ulcers. Nine patients had cognitive
or motor delay. Two patients had symptoms of a bleeding diathesis with subdural hematoma,
petechiae, and/or menorrhagia with normal platelet counts; the platelets of these
patients had fewer dense granules by electron microscopy. Patients had elevated peripheral
absolute monocyte count (average 970 cells/uL), but none had chronic myelomonocytic
leukemia, acute myeloid leukemia or myelodysplasia. Whole blood gene expression revealed
upregulation of IL-1-, TLR- and NF-ĸB-related genes. CD14+ monocytes had a significantly
higher percentage of cells with trisomy 8 compared to CD3+ T cells and CD19+ B cells
(chromosome 8 copy number was 2.8 in CD14+ cells vs. 2.5 in CD19+ [p=0.01] and 2.3
in CD3+ cells [p =0.001]). Four out of 5 patients had partial improvement on daily
colchicine, 3 out of 6 reported improvement with intermittent or daily anakinra, 2
out of 3 had improvement on TNFα inhibitors (etanercept or infliximab), and one patient
improved following hematopoietic stem cell transplant.
Conclusion: We report the spectrum of clinical and immunologic manifestations in patients
with trisomy 8 mosaicism, a disease we name trisomy 8-associated autoinflammatory
disease (TRIAD). Patients with TRIAD present with (1) recurrent fever and/or severe
mucosal ulcerations, (2) bleeding diatheses, and (3) developmental delay. Patient
monocytes are elevated in number and have higher percentage of trisomy 8, indicating
that an extra copy of chromosome 8 may confer a survival advantage preferentially
to monocytes. In addition, activation pathways in monocytes are upregulated, and patients
have symptom improvement in response to blockade of TNFα and IL-1, prominent cytokines
associated with myeloid cell activation. Like monocytes, megakaryocytes and platelets
develop from a common myeloid progenitor suggesting that cell development in the myeloid
lineage may be affected. Further studies are underway to better characterize the inflammatory
and survival pathways in myeloid cells with trisomy 8.
Disclosure of Interest
None Declared
Deficiencies in key regulatory signals
O25 A combined immunodeficiency with severe infections, inflammation and allergy caused
by ARPC1B deficiency
Stefano Volpi1,2, Maria Pia Cicalese3, Paul Tuijnenburg4,5, Anton T. J. Tool6, Eloy
Cuadrado7, Hamid Ahanchian8, Raed Alzyoud9, Zeynep C. Akdemir10, Federica Barzaghi11,
Alexander Blank12, Bertrand Boisson13, Cristina Bottino14, Roberta Caorsi15, PaoloPicco15,
Jean-Laurent Casanova13,16, Sabrina Chiesa17, Ivan Kingyue Chinn18, Gregor Dückers19,
Anselm Enders20, Hans Christian Erichsen21, LisaR. Forbes18, Tomasz Gambin22,23, Marco
Gattorno24, Ehsan G. Karimiani25, Silvia Giliani26, Michael S. Gold27, Marwan Abu-Halaweh28,
Eva-Maria Jacobsen12, Machiel H. Jansen29,30, Jovanka R. King27, Ronald M. Laxer31,
James R. Lupski22,32, Emily Mace18, Stefania Marcenaro33, Reza Maroofian34, Alexander
B. Meijer35, Tim Niehues19, Luigi D. Notarangelo36, Jordan Orange18, Ulrich Pannicke37,
Chris Pearson38, Patrick J. Quinn27, Ansgar Schulz12, Filiz Seeborg18, Asbjørg Stray-Pedersen39,
Hasan Tawamie40, Ester M. M. van Leeuwen30, Alessandro Aiuti11, Rae Yeung31,41, Klaus
Schwarz37,42, Taco W. Kuijpers29,43
1Clinica Pediatrica e Reumatologia, Centro per le malattie Autoinfiammatorie e Immunodeficienze,
Istituto Giannina Gaslini; 2DINOGMI, Università degli Studi di Genova, Genova; 3Pediatric
Immunohematology, San Raffaele Hospital and San Raffaele Telethon Institute for Gene
Therapy (SR-TIGET), Milan, Italy; 4Department of Pediatric Immunology, Rheumatology
and Infectious diseases, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam;
5Department of Experimental Immunology, Amsterdam Infection & Immunity Institute;
6Department of Blood Cell Research; 7Department of Immunopathology, Sanquin Research
and Landsteiner Laboratory AMC, University of Amsterdam, Amsterdam, Netherlands; 8Department
of Allergy and immunology, School of medicine, Mashhad university of Medical Sciences,
Mashhad, Iran, Islamic Republic Of; 9Immunology, Allergy and Rheumatology section-
Bone Marrow Transplantation for Primary Immunodeficiency Disorders, Queen Rania Children's
Hospital, Amman, Jordan; 10Baylor-Hopkins Center for Mendelian Genomics of the Department
of Molecular and Human Genetics, Baylor College of Medicine, Huston, United States;
11Pediatric Immunohematology, San Raffaele Hospital and San Raffaele Telethon Institute
for Gene Therapy (SR-TIGET), Milan, Italy; 12Department of Pediatrics, University
Medical Center Ulm, Ulm, Germany; 13St Giles Laboratory of Human Genetics of Infectious
Diseases, Rockefeller Branch, The Rockefeller University, New York, United States;
14Department of Experimental Medicine (DIMES), University of Genoa; 15Centro per le
Malattie Infiammatorie e Immunodeficienze, Clinica Pediatrica e Reumatologia, Istituto
Giannina Gaslini, Genova, Italy; 16Pediatric Hematology-Immunology and Rheumatology
Unit, Necker Hospital for Sick Children, APHP, Paris, France; 17Clinica Pediatrica
e Reumatologia, Centro per le malattie Autoinfiammatorie e Immunodeficienze Istituto
Giannina Gaslini, Genova, Italy; 18Department of Pediatrics, Section of Allergy, Immunology,
and Rheumatology & Center for Human Immunobiology, Texas Children's Hospital, Houston,
United States; 19Center for Child and Adolescent Medicine, Helios-Clinic, Krefeld,
Germany; 20Department of Immunology and Infectious Disease, John Curtin School of
Medical Research and Centre for Personalised Immunology, Australian National University,
Canberra, Australia; 21Section of Paediatric Medicine and Transplantation, Division
of Paediatric and Adolescent Medicine, Oslo University Hospital, oslo, Norway; 22Baylor-Hopkins
Center for Mendelian Genomics of the Department of Molecular and Human Genetics, Baylor
College of Medicine, Houston, United States; 23Institute of computer science, Warsaw
University of Technology, Warsaw, Poland; 24. Clinica Pediatrica e Reumatologia, Centro
per le malattie Autoinfiammatorie e Immunodeficienze Istituto Giannina Gaslini, Genova,
Italy; 25Molecular and Clinical Sciences Institute, St. George’s, University of London,
Cranmer Terrace, London, United Kingdom; 26Medical Genetics Unit and “A. Nocivelli”
Institute for Molecular Medicine, Spedali Civili Hospital, Department of Molecular
and Translational Medicine, University of Brescia, Brescia, Italy; 27Discipline of
Pediatrics, School of Medicine, University of Adelaide and Department of Allergy and
Clinical Immunology, Women's and Children's Health Network, Adelaide, Australia; 28Department
of Biotechnology and Genetics Engineering in Philadelphia University, Jordan, United
States; 29Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Department
of Pediatric Immunology, Rheumatology and Infectious diseases; 30Amsterdam UMC, University
of Amsterdam, Department of Experimental Immunology, Amsterdam Infection & Immunity
Institute, Amsterdam, Netherlands; 31Division of Rheumatology, Department of Paediatrics
and Department of Medicine, University of Toronto, The Hospital for Sick Children,
Toronto, Canada; 32Department of Pediatrics, Baylor College of Medicine, Houston,
United States; 33Istituto Giannina Gaslini, Genova, Italy; 34Medical Research, RILD
Welcome Wolfson Centre, Exeter Medical School, Royal Devon and Exeter NHS Foundation
Trust, Exeter and Genetics and Molecular Cell Sciences Research Centre, St George's
University of London, London, United Kingdom; 35Department of Plasma proteins, Sanquin
Research and Landsteiner Laboratory AMC, University of Amsterdam, Amsterdam, Netherlands;
36Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy
and Infectious Diseases, Bethesda, United States; 37Institute for Transfusion Medicine,
University Ulm, Ulm, Germany; 38Department of General Medicine, Women's and Children's
Health Network, Adelaide, Australia; 39Norwegian National Unit for Newborn Screening,
Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway;
40The Institute of Human genetics of Leipzig, Leipzig, Germany; 41Departments of Paediatrics,
Immunology, Institute of Medical Science, University of Toronto, Cell Biology Program,
The Hospital for Sick Children, Toronto, Canada; 42Institute for Clinical Transfusion
Medicine and Immunogenetics Ulm, German Red Cross Blood Service Baden-Wuerttemberg
– Hessen, Ulm, Germany; 43Department of Blood Cell Research, Sanquin Research and
Landsteiner Laboratory AMC, University of Amsterdam, Amsterdam, Netherlands
Correspondence: Stefano Volpi
Introduction: Genetic defects in regulatory proteins of the cytoskeleton are known
to cause different syndromes, mostly dominated by hematologic and immune phenotypes.
Recently has been reported a novel syndrome of combined immunodeficiency, allergy
and autoinflammation caused by mutations in the ARPC1B gene, one of the seven subunits
of the ARP2/3 complex, which regulates actin polymerization.
Methods: We report the natural history, clinical manifestations, genetics, and immunohematological
findings in 14 patients from 12 families with ARPC1B deficiency.
Results: Although consanguinity was not revealed by clinical history in five families,
all cases carried homozygous mutations in ARPC1B. The mutations resulted in undetectable
or reduced protein expression. Early-onset gastrointestinal bleeding and skin rash
were common findings (7/14 and 9/14, respectively), whereas bacterial (12/14) and
viral (10/14) infections (including warts, molluscum and CMV infections), vasculitis
(9/14) and growth failure (10/14) became prominent features later in life. The majority
of children developed severe allergy in the presence of extensive eczema (8/14) and
a universal increase in IgA and IgE levels. Moderate thrombocytopenia was present
in the majority of patients while overt bleeding tendency was absent after infancy.
Immunophenotyping showed a B-cell lymphocytosis and abnormalities in T- and NK-lymphocyte
subsets. In vitro T- and B-lymphocyte proliferation and in vivo response to vaccination
were normal. Most noticeable was the strongly reduced regulatory T-cell function in
those patients tested.
Conclusion: In conclusion, our cohort delineates the spectrum of clinical, hematological
and immunological manifestations of subjects with ARPC1B deficiency. The disease appears
progressive in most cases and challenging to manage clinically with prophylactic measures
and immunosuppression alone.
Disclosure of Interest
None Declared
O26 ARPC1B-deficiency causes defective cell migration, loss of actin polymerization
and hyperresponsiveness in zebrafish and patient-derived cells
Gabriella Leung1,2, Aleixo M. Muise2,3
1Cell Biology; 2Gastroenterology, Hepatology and Nutrition; 3Inflammatory Bowel Disease
Centre, Hospital for Sick Children, Toronto, ON, Canada
Correspondence: Gabriella Leung
Introduction: ARPC1B-deficiency is a rare paediatric genetic disorder identified in
2017 with autoinflammatory components. Primary symptoms include cutaneous vasculitis,
increased susceptibility to infection, microthrombocytopenia, and colitis. ARPC1B
is a component of the Arp2/3 complex which regulates branched actin polymerization.
Its expression is limited to the haematopoietic compartment, however its function
in macrophages and B cells has not been characterised.
Objectives: To determine the effect of ARPC1B-deficiency on macrophage migration and
B cell activation.
Methods: Mutant Arpc1b-deficient zebrafish were generated by targeting CRISPR-Cas9
to exon 4 of arpc1b in AB zebrafish embryos, and crossing F1 mutants to mpeg1-GFP+
fish. Four days post-fertilization, tails were cut transversely just distal to the
notochord, and GFP+ cells imaged over an 8 hr period. Cells were tracked individually
and migration behaviour quantified using Volocity. EBV-transformed lymphoblasts (LCLs)
were derived from three previously characterised ARPC1B patients. Patient 1 has a
null mutation (c.387_388insCT, L90fs). Patients 2 and 3 are brothers with two SNPs
(c.434C>T, A105V; c832G>A, A238T). LCLs were also derived from the parents of Patient
2 and 3, heterozygous for both mutations. Cell phenotype was assessed by immunoblotting,
immunofluorescence, and flow cytometry. Calcium flux was analysed by flow cytometry
using ratiometric dye Fura Red-AM and stimulating LCLs with anti-IgG. The VCA domain
of WASP binds and activates the Arp2/3 complex and was used to stimulate pyrene-actin
polymerization activity. Protein interaction between ARPC1B vs. ARPC1A to VCA and
WASP were also tested by immunoprecipitation.
Results: ARPC1B-deficient zebrafish were significantly smaller, and monocytes migrated
slower compared to WT fish in response to injury. In the patient LCLs, loss of ARPC1B
protein, compensatory upregulation of isoform ARPC1A, and loss of total F-actin were
confirmed. Patient 1 LCLs were unusually adherent in the absence of stimulation, suggesting
constitutive activation. To measure activation, LCLs were stimulated with anti-IgG
to measure calcium flux; Patient 1 had a statistically significant higher calcium
flux peak compared to control. To address whether Arp2/3 function was compromised,
LCL lysates were stimulated with (activating domain) VCA and actin assembly was measured.
Although both ARPC1B and ARPC1A isoforms were found to interact with VCA and full-length
WASP in immunoprecipitation experiments, VCA-induced actin polymerization in cell
lysates was completely abolished in Patients 1-3. Patient 1 was treated with an allogeneic
HSCT in January 2018.
Conclusion: Loss of ARPC1B leads to impaired cell migration, loss of Arp2/3 function,
and hyperactivation in B cells, which together likely contribute to the dysfunctional
immune phenotype. HSCT may represent a curative option for patients with severe ARPC1B-deficiency.
Disclosure of Interest
None Declared
Nucleic acid sensing and interferon
O27 Heterozygous mutations in COPA are associated with enhanced type I interferon
signalling
Marie-Louise Frémond1, Alice Lepelley1, Carolina Uggenti2, Maria José Martin-Niclos1,
Marine Depp2, Vincent Bondet3, Darragh Duffy3, Gillian I. Rice4, Mary Brennan5, Caroline
Thumerelle6, Siham Boulisfane6, Marie Legendre7, Serge Amselem7, Thierry Molina8,
Nadia Nathan9, Yanick J. Crow2
1Laboratory of Neurogenetics and Neuroinflammation, Imagine Institute, Paris, France;
2Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular
Medicine, Edinburgh, United Kingdom; 3Immunobiology of Dendritic Cells, Institut Pasteur,
Paris, France; 4Division of Evolution and Genomic Sciences, Manchester Academic Health
Science Centre, Manchester; 5Department of Paediatric Rheumatology, Royal Hospital
for Sick Children, Edinburgh, United Kingdom; 6Pediatrics Department, CHRU de Lille,
Lille; 7Genetic Department and Inserm UMR S933, Trousseau Hospital-APHP and Sorbonne
Université; 8Pathology Department, Necker Hospital-APHP; 9Inserm UMR S933 and Pediatric
Pulmonology department and Reference Centre for Rare Lung Diseases, RespiRare, Trousseau
Hospital-APHP and Sorbonne Université, Paris, France
Correspondence: Marie-Louise Frémond
Introduction: Heterozygous mutations in COPA, encoding coatomer protein subunit alpha,
cause an autosomal dominant inflammatory syndrome associating lung, joint and renal
disease, showing some overlap with STING-associated vasculopathy with onset in infancy
(SAVI). Mutations were originally described to cause endoplasmic reticulum (ER) stress
and priming of a T helper 17 response. More recently, increased transcription of interferon
(IFN)-stimulated genes (ISGs) was reported in blood circulating cells of affected
individuals. However, the precise pathophysiology of this disease remains unclear.
Objectives: To better decipher the mechanism of COPA syndrome.
Methods: We studied 8 patients from 3 unrelated families, each segregating a heterozygous
mutation in COPA. We assessed type I IFN status by IFNa ultra-sensitive digital quantification
in plasma, STAT1 phosphorylation and RNA expression of ISGs in whole blood from patients.
In vitro assays also were performed in HEK293T and THP-1 cells to study IFN signalling
in the context of COPA mutations.
Results: We observed commonalities in the lung pathology between COPA and SAVI, as
well as an IFN signature, raised levels of IFNa protein in the serum and phosphorylation
of STAT1 in patient T cells. In a cellular model of HEK293T, phosphorylation of IRF3
and increased ISG expression were observed in cells co-transfected with wild type
STING and mutant COPA plasmids. In THP-1 cells, short hairpin RNA knockdown of COPA
induced IFN signalling that was abrogated in the absence of STING.
Conclusion: Our data suggest that mutations in COPA lead to constitutive activation
of type I IFN signalling through STING. Based on these results, one patient has been
treated with the JAK1/2 inhibitor ruxolitinib for the last 12 months. How COPA interacts
with ER-resident STING remains to be investigated.
References
Watkin et al, Nat Genet 2015;47:654-60.
Volpi et al, Clin Immunol 2018;187:33-36.
Disclosure of Interest
None Declared
O28 Sting-associated vasculopathy in mice requires adaptive immunity but not cGAS
or type I interferon
Hella Luksch1, Angela Rösen-Wolff1, Alexander Gerbaulet2, W. Alexander Stinson3, Brock
G. Bennion3, Gowri Kalugotla4, Wei Qian3, Catherine A. Miner4, Jonathan Miner5
1Department of Pediatrics, University Clinic Carl Gustav Carus, TU Dresden; 2Department
of Immunology, Faculty of Medicine,TU Dresden, Dresden, Germany; 3Department of Pathology
and Immunology; 4Department of Medicine, Washington University School of Medicine;
5Departments of Pathology and Immunology, Medicine and Molecular Microbiology, Washington
University School of Medicine, Saint Louis, St. Louis, United States
Correspondence: Angela Rösen-Wolff
Introduction: It is assumed that monogenic interferonopathies are mediated by type
I interferon (IFN) inducing autoinflammation. For instance, it has been shown that
a gain-of-function mutation in STING (STING N153S) up-regulates type I IFN-stimulated
genes (ISGs) and results inperivascular inflammatory lung disease in mice. The corresponding
mutation in humans also causes lung disease. It is thought that signaling via the
cGAS-STING pathway and subsequent activation of type I IFN, IFN regulatory factors
(IRF) 3/7, and ISGs are involved.
Objectives: We decided to characterize the role of cGAS, IRF3/7, the type I IFN receptor
(IFNAR1), and adaptive immunity in the spontaneous inflammatory lung disease in STING
N153S mice.
Methods: Hence, we crossed STING N153S mice to animals lacking cGAS, IRF3, IRF7, IFNAR1,
adaptive immunity, alph/beta T cells, and mature B cells. As read out we evaluated
the mice for development of spontaneous inflammatory lung disease.In addition we generated
bone marrow chimeric mice and examined severity of the lung disease and survival of
the transplanted animals for 322 days.
Results: We found that spontaneous inflammatory lung disease in STING N153S mice developed
independently of cGAS, IRF3, IRF7, and type I IFN signaling. Bone marrow transplantation
experiments revealed that certain aspects of STING N153S-associated disease are intrinsic
to the hematopoietic system. In additon, we discovered that Rag1-/- STING N153S mice
have histologically normal lungs without perivascular infiltrates.Tcr beta-/- STING
N153S animals developed a mild lung phenotype.
Conclusion: Spontaneous inflammatory lung disease in STING N153S mice develops independently
of cGAS and type I IFN signaling.STING N153S depends on adaptive immunity to induce
inflammatory lung disease in mice.
Disclosure of Interest
None Declared
New frontiers in the treatment of SAID
O29 Preclinical studies of gene therapy for deficiency of adenosine deaminase type
2 (DADA2)
Ying Hong, Marina S. Casimir, Barbara Jensen, Benjamin Houghton, Adrian Thrasher,
Paul Brogan, Despina Eleftheriou
Infection, immunity and inflammation, UCL Great Ormond Street Institute of Child Health,
London, United Kingdom
Correspondence: Ying Hong
Introduction: Deficiency of adenosine deaminase type 2 (DADA2) is an autosomal recessive
autoinflammatory disease and vasculitis, caused by loss-of-function mutations in ADA2.
Treatment with anti-TNF-α is effective for the autoinflammation and vasculitis of
DADA2, but may add to the burden of immunosuppression, is expensive, and is required
for life. This treatment may also not effectively treat bone marrow failure or the
associated immunodeficiency. Since haematopoietic stem cell transplantation (HSCT)
may be curative, but is toxic, we are currently exploring gene therapy for DADA2.
Objectives: (i) develop specific self-inactivating (SIN) lentivirus vectors encoding
ADA2 cDNA; (ii) explore the efficacy of gene transfer using this vector in monocyte
derived macrophages (MDM) from DADA2 patients; and in an ADA2 knockout (KO) monocyte
cell-line (THP-1) model generated using CRISPR/CAS9.
Methods: We generated an ADA2-SIN lentivirus under the control of the elongation-1a-factor
(EFS) promoter, that we then used to transduce ADA2 KO THP-1/ wild type (WT) control
THP-1 cells; or patient and healthy control-derived MDM, at different multiplicity
of infection, and examined the following:
(i)
ADA2 protein expression.
(ii)
ADA2 enzyme activity
(iii)
M1/M2 macrophage immunophenotype. MDM and THP-1 differentiated macrophages were incubated
with IL-4, IL-10 and IL-13 to obtain M2 polarized macrophages or with IFN-γ/LPS to
induce polarization to M1. Immunophenotyping was assessed in transduced or non-transduced
M1 and M2 polarised macrophages using qPCR, flow cytometry, and ELISA-cytokine quantification
in culture supernatants.
(iv)
macrophage induced endothelial activation. Transduced or non-transduced MDM from DADA2
patients and healthy controls were also cultured with endothelial cells, and CD62E
expression (marker of endothelial activation) was examined with flow cytometry
Results: In the THP-1 KO cell line we observed:
(i)
full restoration of ADA2 protein expression and ADA2 enzyme activity in transduced
ADA2 KO THP-1 cells compared to non-transduced cells;
(ii)
amelioration of M1 proinflammatory molecule gene expression: polarized M1 cells derived
from transduced ADA2 KO THP-1 cells exhibited a similar gene expression profile for
proinflammatory cytokines (TNF-α, CXCL-10, STAT-1, and IL-1β) to that observed in
M1 derived from WT control THP-cells; in comparison, non-transduced ADA2 KO THP-1
cells exhibited significant up-regulation of gene expression for these proinflammatory
cytokines (p<0.0001).
Using DADA2 patient derived cells (n=3) we also established:
(iii)
full restoration of ADA2 protein expression and enzyme activity: transduction of DADA2
MDM led to full restoration of ADA2 protein expression and enzyme activity to levels
observed in healthy controls (p=0.0001);
(iv)
amelioration of M1 proinflammatory gene expression in patient cells: transduced DADA2
MDM were restored to levels seen in healthy control MDM cells for proinflammatory
cytokine gene expression (p=0.0001); cytokine production at protein level (p=0.01);
and reduced M2 apoptosis (p=0.0001).
(v)
prevention of endothelial activation: transduction of DADA2 MDM significantly prevented
endothelial activation in co-culture experiments, compared with non-transduced DADA2
MDM, that continued to induce significant endothelial activation (p=0.0002).
Conclusion: We have used a gene therapeutic approach to successfully demonstrate rescue
of the immunophenotype of DADA2 using a THP-1 ADA2 KO cell line model; and primary
cells from DADA2 patients, thus providing proof of principle that gene therapy might
work in patients with DADA2. Next steps now include: 1. gene correction in CD34 cells
from DADA2 patients; and 2. safety studies in animal models.
Disclosure of Interest
None Declared
O30 Experience with and management of HLH-like toxicities following chimeric antigen
receptor T-cell therapy for treatment of relapsed/refractory pre-B ALL
Amanda K. Ombrello1, Bonnie Yates2, Haneen Shalabi2, Terry J. Fry3, Nirali N. Shah2
1NHGRI; 2NCI, NIH, Bethesda; 3Children's Hospital of Colorado, Denver, United States
Correspondence: Amanda K. Ombrello
Introduction: Chimeric antigen receptor T-cell (CAR-T) therapy is a highly effective
form of adoptive cell immunotherapy combining antigen specific targeting capabilities
with T-cell based cytotoxicity. Particularly effective against B-cell antigens (CD19/CD22),
CAR-T cell activation leads to a systemic inflammatory response called cytokine release
syndrome (CRS) that can further evolve into hemophagocytic histiocytosis (HLH) symptomatology.
Objectives: To evaluate the presentation, incidence and management of HLH toxicities
in children/young adults with relapsed/refractory pre-B acute lymphoblastic leukemia
(pre-B ALL) treated on a phase I study of anti-CD22 CAR-T cell therapy (Clinicaltrials.gov
NCT02315612).
Methods: Using modified diagnostic criteria to define CAR-T cell related HLH, it was
established in those with ferritin of > 100,000 ng/mL and at least 1 of the following:
> grade 3* AST/ALT elevation or hyperbilirubinemia; > grade 3* oliguria or increase
in serum creatinine; > grade 3* pulmonary edema; or hemophagocytosis in the bone marrow.
Serial inflammatory markers (ferritin, CRP) and serum cytokines were prospectively
monitored from CAR-T cell infusion through day +28 (+/-4) and retrospectively analyzed
comparing peak values in those who did/did not develop HLH. Treatments included supportive
care, glucocorticoids +/- anakinra.
*Grading as per Common Terminology Criteria for Adverse Events, v4.03
Results: In 52 subjects, 46 experienced CRS, of whom 37 (80.4%) achieved complete
remission and 18 (39.1%) developed HLH. Median ferritin in those with/without HLH
was 206740 vs. 22758 (ng/mL) (Table 1). Clinical manifestations included: > grade
3* creatinine (n=2); > grade 3* AST/ALT elevation or hyperbilirubinemia (n=23, including
6 without HLH), > grade 3* pulmonary edema (n=5, including 2 without HLH); and hemophagocytosis
in the bone marrow (n=9). Cytokine profiling demonstrated significantly higher levels
of IFN-y, IL-1B, IL-6, IL-10, TNFa and MIP-1a (Table 1). Limited paired samples of
sIL-2R showed statistically significant increase from baseline (median level 1254)
to HLH presentation (median 9310), with 6/9 having substantial increase (peak 123700).
All had resolution of HLH symptoms, except 1 who died from gram-negative rod sepsis
complications prior to resolution. Three had asymptomatic lab abnormalities that self-resolved
(median 14 days) without intervention. Anakinra monotherapy (median 5 mg/kg/day) was
used in 3 and the remainder (n=3) received anakinra + steroids. Both regimens resolved
HLH. There was no statistically significant difference in underlying leukemia burden
or efficacy following CAR-T cell therapy in those who did/did not develop HLH. Notably,
use of anakinra +/- steroids did not diminish therapeutic efficacy of CAR-T cells.
Conclusion: Ferritin and cytokine profiling revealed HLH patients had a different
inflammatory response independent of disease burden. Anakinra +/- steroids was effective
and did not impede CAR-T cell expansion. Further analysis to identify HLH-predictive
parameters and optimizing interventions to treat/prevent these complications are ongoing.
Disclosure of Interest
None Declared
Table 1 (abstract O30).
See text for description
Inflammatory Marker
No HLH, median (25-75% IQR)
HLH, median (25-75% IQR)
p value (1- tailed)
Ferritin*
22758 (3554-52686)
206740 (171968-420273)
<0.0001
Cytokines* (pg/mL)
IFNy
352.2 (196.7-1041)
2800 (1838-2900)
<0.0001
IL-1B
0.77 (0.45-2.09)
3.51 (1.02-48.95)
0.001
IL-6
41.58 (18.83-214.5)
904.5 (264.1-1480)
<0.0001
IL-10
55.94 (22.02-154)
338.7 (128.1-567.4)
0.0001
TNFa
12.77 (9.17-23.62)
27.1 (16.2-43.91)
0.002
MIP-1a
105.7(67.12-180.1)
223.8 (157-422.2)
0.0001
*For ferritin, n=19 (No HLH) and n=18 (HLH) due to initial lack of ferritin monitoring.
All other cytokines, n=27 (No HLH) and n=18 (HLH)
Novel targets and therapies in autoinflammation
O31 Novel NLRP3 targeted therapy in caps
Laela M. Booshehri1, Matthew McGeough1, Ben Keer1, Milos Lazic2, Christopher McBride2,
Davide Povero2, James Veal2, Gretchen Bain2, Hal M. Hoffman1
1Pediatrics, University of California San Diego, La Jolla; 2Jecure Therapeutics, San
Diego, United States
Correspondence: Hal M. Hoffman
Introduction: Cryopyrin-associated periodic syndrome (CAPS) is an autoinflammatory
disease characterized by a hyperactive inflammasome leading to the overproduction
of interleukin-1b (IL-1b). Assembly of the NLRP3 inflammasome is central to the CAPS
disease process resulting in subsequent activation and prolific release of inflammatory
cytokines, which further propagate inflammation and disease. Current therapies for
CAPS patients directly target IL-1b or IL-1 receptor to mitigate excess inflammation
caused by NLRP3 activation. While there are a number of new compounds in pre-clinical
development that target NLRP3 directly, there is little data on the efficacy of these
compounds in CAPS versus healthy controls.
Objectives: To study the ex vivo efficacy of a novel NLRP3 selective small-molecule
inhibitor compound 1 (C1) in monocytes from CAPS patients with multiple Nlrp3 mutations
as compared to healthy controls and in bone marrow derived dendritic cells from murine
Nlrp3 mutant CAPS models as compared to wild type mice, with the goal of identifying
an effective NLRP3 specific inhibitor for CAPS patients.
Methods: Peripheral blood mononuclear cells from 7 CAPS patients with 6 different
NLRP3 mutations and 4 healthy donor controls were isolated by gradient centrifugation,
and monocytes were allowed to adhere for 4 hours prior to treatment and stimulation.
Samples were obtained under an approved Institutional Review Board protocol for human
subjects. Bone marrow was isolated from MWS Nlrp3
A350V/+
CreT, FCAS Nlrp3
L351P/+
CreT, and NOMID Nlrp3
D301N/+
CreT conditional knock-in mice and cells were cultured with GMCSF for 1 week and treated
with tamoxifen 1 day prior to drug treatment to induce expression of the mutation.
Cells were treated with C1 at varying concentrations prior to stimulation with LPS
(mutants) or LPS and ATP (controls), and supernatants were collected after overnight
incubation for analysis of IL-1b by ELISA. C1 was also orally administered to MWS
Nlrp3
A350V/+
CreT mice prior to in vivo tamoxifen administration to determine in vivo efficacy
and pharmacodynamics. Whole body and spleen weights were measured and blood was obtained
for complete blood counts in treated and untreated mice. Animal studies were performed
in accordance with the University of California San Diego and IACUC policies and procedures.
Results: Robust inhibition of IL-1b release from C1 treated cells was shown with comparable
activity across multiple human NLRP3 mutations and murine Nlrp3 mutant models. Compound
efficacy and pharmacodynamics were also shown to be similar between CAPS mutant cells
and cells from respective healthy donors or wild-type controls. Daily oral administration
of C1 was well tolerated and demonstrated efficacy in preventing weight loss, splenomegaly,
and neutrophilia in MWS Nlrp3
A350V/+
CreT mice.
Conclusion: The novel NLRP3 inhibitor C1 was shown to significantly reduce LPS induced
IL-1b release in cells from CAPS patients and murine Nlrp3 mutant models indicating
direct and effective inhibition of mutant NLRP3. C1 and other emerging NLRP3 inhibitors
present an additional avenue for future CAPS patient therapy by directly targeting
the inflammasome. Similar efficacy of C1 on both normal and mutant NLRP3 likewise
indicate potential applications in other inflammatory diseases beyond CAPS.
Disclosure of Interest
None Declared
O32 Preclinical efficacy of NLRP3 small molecule inflammasome inhibitors: implications
for future treatment of autoinflammatory syndromes
Angela Abad-Perez1, Stefan Frischbutter1,2, Niklas A. Mahnke1, Jens v. Kries3, Marc
Nazaré4, Marcus Maurer1, Jörg Scheffel1,2, Karoline Krause1,2
1Department of Dermatology, Venereology and Allergology; 2Autoinflammation Reference
Center Charité (ARC2), Charité Universitätsmedizin Berlin; 3Screening Unit Cell Biology
and High Content Screen; 4Medicinal Chemistry, Leibniz-Forschungsinstitut für Molekulare
Pharmakologie (FMP), Berlin, Germany
Correspondence: Angela Abad-Perez
Introduction: Systemic autoinflammatory diseases (SAIDs) are characterized by abnormally
increased inflammation affecting different organs. They are mediated predominantly
by the cells and molecules of the innate immune system. Inflammasome activation represents
the critical pathogenic mechanism shared by most SAIDs. Current treatment strategies
are limited to downstream cytokine blockade. Specific inflammasome inhibitors are
not available so far.
Objectives: To address this unmet medical need, we performed a high content screening
of more than 60.000 small molecules from the compound collection of the …Leibniz-Forschungsinstitut
für Molekulare Pharmakologie (FMP)”, which includes the ChemBioNet and LOPAC®1280 libraries
as well as donations of academic chemists, FDA approved drugs (Selleck library) and
a natural product collection from AnalytiCon Discovery.
Methods: For the primary screen, we used a fluorescent murine inflammasome reporter
cell line to detect ASC speck formation, a marker of inflammasome activation. Compounds
were selected based on their inhibitory capacity on ASC speck formation, as observed
by automated fluorescence microscopy, and IL-1ß release after activation with canonical
NLPR3-inflammasome inducers ATP and nigericin. The 10 most potent and druggable hit
compounds were tested in peripheral blood mononuclear cells (PBMCs) obtained from
venous blood of patients with Schnitzler syndrome (N=8), familial Mediterranean fever,
FMF (N=8) and from unmatched healthy donors (N=18). In vitro effect on cellular IL-1ß
release was measured by ELISA.
Results: Selected compounds proved to efficiently inhibit the secretion of IL-1ß in
PBMCs from both patients and healthy controls in a dose dependent manner, validating
their inhibitory capacities in human and murine cellular assays. Among these compounds
were known anti-inflammatory drugs such as auranofin and a VEGFR2 tyrosine kinase
inhibitor. The median inhibitory capacity upon stimulation with lipopolysaccharide
(LPS) and ATP at 10 μM ranged between 50% to 80% with IC50s in the low μM region.
A similar inhibitory profile could be observed for the previously reported inflammasome
inhibitor MCC950, which was included in our assays as a reference substance. Moreover,
compounds had similar efficacy in inflammasome inhibition PBMCs obtained from patients
and healthy controls.
Conclusion: Based on our results in murine and human cells in vitro, small molecule
inflammasome inhibitors my complement current treatment options for SAIDs in the future.
Disclosure of Interest
None Declared
Oral communications – new diseases
O33 Biallelic loss of function mutations in sharpin cause autoinflammation
Hirotsugu Oda1, David Beck1, Kalpana Manthiram1, Hye Sun Kuehn1, Natalia Sampaio Moura1,
Rao Anand2, Mariana Kaplan1, Douglas Kuhns3, Wanxia Li Tsai1, Hiroyuki Yoshitomi4,
Junya Toguchida4, Gustavo Gutierrez-Cruz1, Jeremy Davis1, Massimo Gadina1, Jennifer
Stoddard1, Kazuhiro Iwai4, Sergio Rosenzweig1, Luigi Notarangelo1, Daniel L. Kastner1,
Ivona Aksentijevich1
1NIH, Bethesda, United States; 2Manipal Hospital, Bangalore, India; 3NIH, Frederick,
United States; 4Kyoto University, Kyoto, Japan
Correspondence: Hirotsugu Oda
Introduction: The linear ubiquitination chain assembly complex (LUBAC) consists of
HOIP, HOIL1 and SHARPIN and mediates linear ubiquitination. LUBAC is essential for
NF-κB signaling and thus proper innate and adaptive immunity. Patients with HOIP and
HOIL1 deficiencies have been reported to have immunodeficiency, autoinflammation and
amylopectinosis. Although mice deficient in Sharpin have severe TNF-dependent skin
inflammation due to enhanced apoptosis and necroptosis of the keratinocytes, the role
of SHARPIN in human diseases is unknown.
Objectives: We aimed to investigate a 14 year-old boy from a consanguineous family
in India with polyarthritis, parotitis, hepatosplenomegaly and colitis associated
with anorectal fistula, but without skin manifestations or any history of severe infections.
The patient’s symptoms dramatically improved on anti-TNF therapy.
Methods: We performed whole exome sequencing to identify the genetic cause of the
patient's phenotypes.
Results: We identified a homozygous frameshift mutation in SHARPIN in our proband
(c.220dupC). Patient derived dermal fibroblasts have no detectable SHARPIN protein
with markedly reduced HOIP, and HOIL1 suggesting destabilization of the LUBAC complex.
These cells also displayed impaired canonical NF-κB activity, as exemplified by induction
of IκBα phosphorylation and nuclear translocation of p65. However, in contrast to
HOIP and HOIL1 deficiencies, the patient’s monocytes did not show hyperresponsiveness
to IL-1β stimulation.SHARPIN deficient patient fibroblasts demonstrated enhanced apoptosis
induced by FAS stimulation as compared to control cells, which parallels the enhanced
apoptosis observed in the Sharpin deficient mice. We knocked out SHARPIN in a human
immortalized osteoblast cell line (hFOB1.19) and interestingly, despite attenuated
NF-κB activity, these cells secrete higher amounts of IL-6 more rapidly after IL-1β
stimulation than control cells.
Conclusion: We identified the first case of human SHARPIN deficiency in a patient
with autoinflammation. Molecular consequences of the SHARPIN deficiency are currently
being investigated in comparison to other LUBAC deficiencies.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
O34 A loss-of-function mutation in USP43, a deubiquitinase gene, is linked to an interferon-mediated
autoinflammatory disorder with proteasome defects
Hongying Wang1, Qing Zhou1, Anna Kozlova2, Vasili Burlakov2, Daniel Kastner1, Ivona
Aksentijevich1, Anna Shcherbina2
1Inflammatory Disease Section, National Human Genome Research Institute (NHGRI) /
NIH, Bethesda, United States; 2National Research and Practical Center of Pediatric
Hematology, Oncology and Immunology, Moscow, Russian Federation
Correspondence: Hongying Wang
Introduction: Deubiquitinase enzymes (DUBs) function in the removal of poly-ubiquitin
chains from substrate proteins to regulate their activity and degradation by the ubiquitin-proteasome
system (UPS). Deficiency of DUB activity may lead to excessive immune signaling as
has been observed in patients with haploinsufficiency of A20 (HA20) and OTULIN deficiency.
Through whole exome sequencing analysis (WES), we identified a novel homozygous missense
mutation (c. 2509G>A; p. E837K) in a deubiquitinase encoding gene USP43, in a Russian
patient of Tatar ancestry. The patient presented with early-onset recurrent fevers,
rash, subcutaneous skin nodules, lipodystrophy, and prominent arthritis, and this
phenotype was suggestive of the CANDLE syndrome.
Objectives: USP43 is a poorly characterized ubiquitin specific protease (USP).We aimed
to study the disease-causing mechanism underlying this novel mutation, E837K, as well
as the biological function and targets of USP43.
Methods: We performed WES in the patient’s family and RNA sequencing in whole blood
samples. We generated a fibroblast cell line and EBV-transformed B cells from the
patient’s primary cells. We used USP43 knockdown and CRISPR/Cas9 knockout in 293T
cells to study the effects of the USP43 depletion. A series of USP43 truncated mutants
were generated to study the effect of protein domains on its DUB activity. Immunoprecipitation
and immunoblot, luciferase assays, serum and plasma cytokine profiling, immunofluorescence,
real-time PCR, and flow cytometry were used to investigate abnormalities in patient-derived
cells.
Results: We found that the novel USP43 mutation leads to an upregulation in interferon
signaling and causes an impairment in the proteasome-mediated protein degradation
pathway. The patient’s EBV-transformed B cells had increased phospho-STAT levels in
response to interferon stimulation and spontaneously produced a significantly higher
level of IL-6. This cellular phenotype was rescued by transfection with wild-type
USP43, which suggests that this mutation is loss-of-function.The patient’s primary
cells showed decreased proteasome activity and excessive accumulation of K48-ubiquinated
proteins following stimulation with a proteasome inhibitor MG132. Similarly, transient
knockout of USP43 in 293T cells led to increased levels of ubiquitinated proteins.
Reintroducing wildtype USP43 to EBV-transformed patient B cells markedly decreased
the expression of ubiquitinated proteins. These data suggest that the mutant USP43/E837K
protein loses the ability to remove K48-ubiquitin chains from target proteins. Overexpression
of a series of truncated USP43 mutants with K-48 Ub chains in 293T cells confirmed
that the C-terminal domain is required for the DUB function of USP43. In addition,
USP43 mutants possessing the E837K mutation lost the ability to clear accumulated
K48-Ub chains. Interferon-stimulated patient’s EBV cells and fibroblasts showed decreased
protein levels of PSMB8.PSMB8 encodes the catalytic subunit of the immunoproteasome.
Co-transfection of USP43/E837K mutant with PSMB8 in 293T cells reduced the expression
of PSMB8 precursor protein compared to cells transfected with USP43 wild type.
Conclusion: Our data suggest that the loss-of-function mutation in USP43 decreases
immunoproteasome activity and causes an upregulation in type I interferon signaling,
similar to what is observed in patients with CANDLE. Treatment with a JAK inhibitor
has been very effective in controlling the disease activity in this patient. To our
knowledge, this is the first report of a human disease caused by mutation in USP43.
Disclosure of Interest
None Declared
O35 A novel autoinflammatory disease characterized by neonatal-onset cytopenia with
autoinflammation, rash, and hemophagocytosis (NOCARH) due to aberrant CDC42 function
Michael T. Lam1,2,3, Simona Coppola4, Oliver H. Krumbach5, Giusi Prencipe6, Antonella
Insalaco6, Cristina Cifaldi7,8, Immacolata Brigida9, Serena Scala9, Marcello Niceta10,
Andrea Ciolfi10, Alexandre F. Carisey1,2, Mohammad Akbarzadeh5, Andrea Finocchi7,8,
Franco Locatelli11, Caterina Cancrini7,8, Alessandro Aiuti9,12,13, Mohammad R. Ahmadian5,
Jordan S. Orange2, Fabrizio De Benedetti6, Marco Tartaglia10
1Department of Pediatrics, Baylor College of Medicine, Houston; 2Department of Pediatrics,
Columbia University, Irving Medical Center, New York; 3Translational Biology and Molecular
Medicine Graduate Program and Medical Scientist Training Program, Baylor College of
Medicine, Houston, United States; 4National Center for Rare Diseases, Istituto Superiore
di Sanità, Rome, Italy; 5Institute of Biochemistry and Molecular Biology II, Medical
Faculty of the Heinrich-Heine University, Düsseldorf, Germany; 6Division of Rheumatology;
7Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, IRCCS; 8Department of
Systems Medicine, University of Rome Tor Vergata, Rome; 9San Raffaele Telethon Institute
for Gene Therapy (SR-TIGET), IRCCS San Raffaele Scientific Institute, Milan; 10Genetics
and Rare Diseases Research Division; 11Department of Pediatric Hematology and Oncology,
Ospedale Pediatrico Bambino Gesù, IRCCS, Rome; 12Pediatric Immunohematology, San Raffaele
Scientific Institute; 13Vita Salute, San Raffaele University, Milan, Italy
Correspondence: Antonella Insalaco
Introduction: Despite continuous advances in the identification of novel causative
genes, several patients with a clinical autoinflammatory phenotype remain unclassifiable.
Objectives: to describe a novel hematological and autoinflammatory disorder in three
unrelated patients caused by a de novo missense mutation of CDC42
Methods: Whole exome sequencing was used to identify the novel variant. The functional
impact of altered CDC42 function on hematopoiesis and inflammation was assessed through
patient peripheral blood and bone marrow analyses, protein behavior and immune and
non-immune cell functioning through in vitro biochemical and functional assays and
in vivo C. elegans modeling.
Results: Patients shared the same de novo missense mutation of CDC42 (NM_001791, Chr1:22417990,
c.556C>T, p.R186C).Disease features included neonatal-onset cytopenia with dyshematopoiesis,
autoinflammation, rash, and hemophagocytosis (collectively termed NOCARH syndrome)
(Table). An altered hematopoietic compartment (prevalence of early differentiation
elements and substantially decreased clonogenic progenitors) was demonstrated. Complementary
assays documented the unique consequences of this mutation on CDC42 localization and
function, and its disruptive effect on cell behavior and developmental processes,
possibly linked to actin dysregulation. Increased secretion of IL-1β, and particularly
of IL-18, was observed via ex vivo spontaneous release from unstimulated bone marrow
mononuclear cells and by high levels in bone marrow supernatants and plasma. IFNγ
was alsoincreased and correlated to CXCL9 levels which were strictly related to ferritin
levels. Treatment with anakinra and emapalumab, a monoclonal antibody to IFNγ, was
identified as critical in the survival of one patient, who underwent successful hematopoietic
stem cell transplantation.
Conclusion: The p.R186C amino acid substitution in CDC42 underlies a novel, unique
syndrome where CDC42 functional dysregulation has pleiotropic effects, causing hematopoietic
disturbance, hyperinflammation, and immune impairment. Early recognition and control
of HLH, through neutralization of IFNγ, followed by hematopoietic stem cell transplantion,
appear to be crucial to survival.
Disclosure of Interest
None Declared
Table 1 (abstract O35).
See text for description
Outcome and status
Patient 1
Patient 2
Patient 3
Alive, 6 yrs
Dead, 6 mos
Dead, 1.5yrs
Fever
+
+
+
Skin rash
+
+
+
Hepato-Splenomegaly
+
+
+
Hemophagocytic lymphohistiocytosis
+
+
+
Gastrointestinal symptoms
+
+
+
Cytopenia
+
+
+
Acute phase response
+
+
+
Bone marrow dysplasia
+
+
+
O36 PSMB10, The last immunoproteasome gene missing for PRAAS (Proteasome-Associated
Autoinflammatory Syndrome)
Guillaume Sarrabay1,2, Déborah Méchin1,2, Aicha Salhi3, Guilaine Boursier1, Cécile
Rittore1, Yanick Crow4, Gillian Rice5, Tu-Ahn Tran2,6,7, Renaud Cezar7, Darragh Duffy8,
Vincent Bondet8, Lakhtar Boudehane9, Sylvie Grandemange1,2, Florence Apparailly2,
Isabelle Touitou1,2
1Department of Medical Genetics, Rare diseases and Personalized medicine, Rare and
Autoinflammatory diseases unit; 2IRMB, INSERM, CHU Montpellier, Univ Montpellier,
Montpellier, France; 3Dermatology department, Alger medicine University, Alger, Algeria;
4Laboratory of Neurogenetics and Neuroinflammation, Institut Imagine, Paris Descartes
University, Paris, France; 5Division of Evolution and Genomic Sciences, School of
Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester,
Manchester Academic Health Science Centre, Manchester, United Kingdom; 6Paediatrics
department, University Hospital Nimes; 7Immunology department, CHU Nîmes, Univ Montpellier,
Nîmes; 8ICD Unit, Inserm U1223, Institut Pasteur, Paris, France; 9Paediatrician office,
Liberal, Sétif, Algeria
Correspondence: Guillaume Sarrabay
Introduction: PRAAS defines a clinical spectrum encompassing JMP (joint contractures,
muscle atrophy, microcytic anemia and panniculitis-induced childhood-onset lipodystrophy
syndrome), NNS (Nakajo-Nishimura syndrome) and CANDLE (chronic atypical neutrophilic
dermatosis with lipodystrophy and elevated temperature). PRAAS is caused by autosomal
recessive, autosomal dominant, or digenic mutations in several genes encoding for
either constitutive proteasome subunits (PSMB4, PSMA3), immunoproteasome subunits
(PSMB8, PSMB9) or chaperone protein (POMP). We describe here a 3-year-old female patient
with clinical features evocative of PRAAS in whom no mutations have been found using
our 62 gene panel sequencing that includes known PRAAS genes.
Objectives: The aim of the study was to identify the molecular cause responsible for
the PRAAS phenotype in this patient.
Methods: We performed a trio-based whole exome sequencing (WES) in the patient and
her parents. Functional assays were conducted to confirm the pathogenic effect of
the mutated candidate gene. They included: enzymatic protease activity in the patient’s
peripheral blood monocyte cells (PBMC) and in transfected HEK293T cells, interferon
(IFN) signature and IFNα dosage, multiplexed cytokines measurement from patient’s
serum, and protein maturation assays by WB (western-blot) analyses in transfected
wild-type and mutant HEK293T cells.
Results: The patient is a 3-year-old female patient of Algerian descent, born to related
parents. She developed a cutaneous rash on the 7th day of life and became febrile
at the age of one year. The rash was polymorphic, annular shaped and predominantly
periorbital She failed to thrive and has long-lasting hepatosplenomegaly. She has
an emaciated face, a distinctive nose, and long and gracile fingers. She had elevated
acute phase reactants, microcytic anemia and hypertriglyceridemia. She exhibited partial
response to steroid and methotrexate treatment and relapsed when the doses were lowered.
WES revealed a homozygous missense mutation in the candidate gene PSMB10, located
in the N-terminal part of protein which is cleaved in the mature form. This variant
is absent from the GnomAD cohort, and predicted to be pathogenic according to in silico
bioinformatic tools. The patient had a positive interferon signature and elevated
IFNα protein in the serum on the one occasion tested. Cytokines multiplexed measurement
showed raised IL-6, TNFα, MIG and MCP-3 in the patient’s serum whereas IL-1β level
was similar to healthy pediatric controls. WB assays in HEK293T cells showed defective
cleavage of the mutant protein upon IFNγ induction compared to the wild-type protein.
Patient’s PBMC and mutant HEK293T cells showed an alteration in trypsin-like proteasome
activity.
Conclusion: We report here a patient with clinical and biological criteria consistent
with PRAAS, with a homozygous PSMB10 mutation. This is the third and last immunoproteasome
subunit involved in this disease, and this new gene responsible for PRAAS expands
the number of genes involved in this spectrum.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
O37 WNT6 mutation causes an early onset granulomatosus intestinal disease with recurrent
hemophagocytic lymphohistiocytosis (HLH)
Claudia Bracaglia1, Daniela Knafelz2, Fiammetta Bracci2, Antonella Insalaco1, Giulia
Marucci1, Manuela Pardeo1, Giusi Prencipe1, Ivan Caiello1, Antonia Pascarella1, Marcello
Niceta3, Francesca Pantaleoni3, Andrea Ciolfi3, Bronislava Papadatou2, Marco Tartaglia3,
Giuliano Torre2, Fabrizio De Benedetti1
1Division of Rheumatology; 2Hepatology, Gastroenterology and Nutrition Unit; 3Genetics
and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome,
Italy
Correspondence: Claudia Bracaglia
Introduction: Use of NGS in patients with unclassifiable disease lies a possible approach
to the identification of novel disease causing genes.
Objectives: We report a patient with an early onset inflammatory bowel disease with
granulomatous lesions and recurrent HLH episodes carrying a missense mutation in the WNT6 gene.
Methods: A trio based Whole Exome Sequencing (WES) approach was used. Cytokine levels
were measured by multiplex assay and by specific ELISAs.
Results: Ten years old Caucasian boy affected by early onset pan-colitis from 9 months
of age. Since the disease onset the patient is on glucocorticoid treatment with amino
acidic enteral nutrition and oligo antigenic diet. Because of recurrent disease relapses
at any attempt of glucocorticoid withdrawal, azathioprine and cyclosporine treatments
were also added. At 2 years of age he received total colectomy with ileostomy. Because
of insufficient disease control, treatment with a TNF-inhibitor (infliximab) was started
with apparent improvement of intestinal symptoms.However, persistent granulomatous
inflammatory disease of the distal portion of the ileus-rectal anastomosis persisted.
Moreover, the patient presented recurrent HLH episodes that required high dose of
glucocorticoid and cyclosporine-A treatment. Except one HLH episode related to a varicella
zoster infection, the other HLH events were most likely triggered by his underlying
inflammatory condition. During the HLH episodes levels of IL-18 were moderately elevated
(10.880 pg/ml) the IFN-gamma induced chemokine CXCL9 was markedly high (21.871 pg/mL)
and remained markedly elevated also during clinical and laboratory HLH remission (3.121
pg/ml and 9.929 pg/ml respectively). Considering the early disease onset, primary
immunodeficiency and early intestinal bowel disease onset were genetically ruled out
as well as chronic granulomatosis diseases through extensive NGS panels. WES revealed
carriage of a private (MAF: 1/125568, TOPMED), predicted pathogenic (CADD: 31), homozygous
variant of WNT6 (c.793G>C; p.(Asp265His); NM_006522.3). The patient is now partially
controlled on low dose of oral glucocorticoid (0.1 mg/kg), cyclosporine-A (5mg/kg)
and antimicrobic treatment.
Conclusion: WNT signalling has been primarily described as a regulatory pathway in
ontogeny and homeostatic processes. Schaale at al. demonstrated that WNT6 is expressed
in granulomatous lesions in the lung of Mycobacterium tuberculosis–infected mice.
Moreover, they found that the transcription factor c-Myc is significantly induced
in murine macrophages by WNT6. This identifies WNT6 as a novel factor driving macrophage
polarization toward an M2-like phenotype, suggesting a role for WNT6 in macrophage
differentiation. Our case suggests defective function of WNT6 might be involved in
the development of a granulomatous disease. WNT6 role in macrophage differentiation
and polarization might also be important in the activation of the IFN-gamma pathway
and in recurrent HLH episodes.
Reference
K. Schaale et al. Wnt6 Is Expressed in Granulomatous Lesions of Mycobacterium tuberculosis–Infected
Mice and Is Involved in Macrophage Differentiation and Proliferation. J Immunol 2013;
191:5182-5195.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
C. Bracaglia: None Declared, D. Knafelz: None Declared, F. Bracci: None Declared,
A. Insalaco: None Declared, G. Marucci: None Declared, M. Pardeo: None Declared, G.
Prencipe: None Declared, I. Caiello: None Declared, A. Pascarella: None Declared,
M. Niceta: None Declared, F. Pantaleoni: None Declared, A. Ciolfi: None Declared,
B. Papadatou: None Declared, M. Tartaglia: None Declared, G. Torre: None Declared,
F. De Benedetti Grant / Research Support from: Novartis, Novimmune, Hoffmann- La Roche,
SOBI, AbbVie, Pfizer
O38 NFIL3 mutations alter immune homeostasis and sensitize for arthritis pathology
Stephanie Humblet-Baron1, Susan Schlenner2, Emanuela Pasciuto2, Vasiliki Lagou1, Oliver
Burton2, Teresa Prezzemolo1, Steffie Junius1, Carlos Roca1, Cyril Seillet3, Cynthia
Louis3, James Dooley1, Kylie Luong3, Erika Van Nieuwenhove1, Ian P Wicks3, Gabrielle
Belz3, Adrian Liston1, Carine Wouters4
1Immunology and Microbiology, Center for Brain and disease research, KU Leuven-VIB;
2Immunology and Microbiology, Center for Brain and disease research, KU Leuven - VIB,
LEUVEN, Belgium; 3Walter and Eliza Hall Institute of Medical Research, Melbourne,
Australia; 4KU Leuven and University Hospitals Leuven, LEUVEN, Belgium
Correspondence: Stephanie Humblet-Baron
Introduction: Juvenile idiopathic arthritis (JIA) is the most common of the childhood
rheumatic diseases. JIA is characterized as juvenile-onset persistent arthritis with
no defined cause. A high degree of clinical heterogeneity is observed within the JIA
group of diseases, thought to reflect a diversity in genetic and environmental factors
and mechanistic drivers. JIA shows similarities to adult autoimmune diseases,but also
has similarities to autoinflammatory diseases, such as genetic associations to innate
inflammatory pathways and response to IL-1β blockade. The recent success in identifying
monogenic causes of autoinflammatory diseases suggests that monogenic causes may also
underlie a subset of JIA patients.
Objectives:
NFIL3 is a key immunological transcription factor, with knockout mice studies identifying
functional roles in multiple immune cell types. Despite the importance of NFIL3, little
is known about its function in humans.
Methods: Here we characterized a kindred of two monozygotic twin girls with juvenile
idiopathic arthritis at the genetic and immunological level, using whole exome sequencing,
single cell sequencing and flow cytometry. Parallel studies were performed in a mouse
model.
Results: The patients inherited a novel p.M170I in NFIL3 from each of the parents.
The mutant form of NFIL3 demonstrated reduced stability in vitro. The potential contribution
of this mutation to arthritis susceptibility was demonstrated through a pre-clinical
model, where Nfil3-deficient mice upregulated IL-1β production, with more severe arthritis
symptoms upon disease induction. Single cell sequencing of patient blood quantified
the transcriptional dysfunctions present across the peripheral immune system, converging
on IL-1β as a pivotal cytokine.
Conclusion: NFIL3 mutation can sensitize for arthritis development, in mice and humans,
and rewires the innate immune system for IL-1β over-production.
Disclosure of Interest
None Declared
O39 EROS/CYBC1 mutations: a novel cause of chronic granulomatous disease and more
David C. Thomas1, Louis M. Charbonnier2, Andrea Schejtman3, Hasan Aldhekri4, Eve Coomber5,
Elizabeth Dufficy6, Anne Beenken1, James Lee1, Simon Clare7, Anneliese Speak7, Adrian
Thrasher8, Giorgia Santilli8, Hamoud Al-Mousa9, Fowzan Alkuraya10, Talal Chatila11,
Kenneth Smith1
1Department of Medicine, University of Cambridge, Cambridge, United Kingdom; 2Paediatrics,
Harvard, Boston, United States; 3University College London, London, United Kingdom;
4Department of Paediatrics,King Faisal Specialist Hospital and Research Center , Riyadh,
Saudi Arabia; 5Wellcome Trust Sanger Institute, Cambridge; 6Medicine, University of
Cambridge, Camridge; 7WTSI, Cambridge; 8Institute of Child Health, UCL, London, United
Kingdom; 9Paediatrics; 10Genetics, KFSH, Riyadh, Saudi Arabia; 11Paediatrics, Harvard
University, Boston, United States
Correspondence: David C. Thomas
Introduction: The multi-subunit phagocyte nicotinamide adenine dinucle- otide phosphate
oxidase generates reactive oxygen species and is crucial for host defence. Deficiencies
in individual subunits (gp91phox, p22phox, p47phox, p67phox, and p40phox) cause chronic
granulomatous disease (CGD), but some patients with CGD do not have mutations in these
genes. We recently found that Eros, a hitherto undescribed protein, is essential for
the generation of reactive oxygen species because it is necessary for protein (but
not mRNA) expression of the gp91phox-p22phox heterodimer, which is almost absent in Eros-deficient
mice. Eros-/- animals succumb quickly following infection with Salmonella typhimurium or Listeria
monocytogenes. Eros is highly conserved and has a human orthologue CYBC1 (alias C17ORF62),
hereafter referred to asCYBC1 gene and essential for reactive oxygen species (EROS)
protein.
Objectives: We asked:
Whether the gene fulfilled the same function in humans.
Whether mutaions in juman EROS/CYBC1/C17ORF62 could cause a human disease
Methods: We performed CRISPR-mediated deletion of CYBC1/EROS in PLB-985 cells and
identified 2 clones with 8 bp and 1 bp deletions, respectively. Neither clone expressed
detectable EROS protein. We also identified a patient with a homozygous EROS/CYBC1/C17ORF62
who was subsequently diagnosed with chronic granulomatous disease secondary to this
mutation.
Results: We show that the function of CYBC1/EROS is conserved in human cells. Knockout
of EROS in cell lines or primary human ips derived macrophages results in abswnt gp91phox-p22phox
expression and aboloishges the phagocyte respiratory burst.We also describe a case
of CGD secondary to a homozygous CYBC1/EROSmutation that abolishes EROS protein expression.
This work demonstrates the fundamental importance of CYBC1/EROSin human immunity and
describes a novel, 6thcause of CGD.
However, EROS also regulates the expression of other proteins. Eros-/- macrophages
also express very low levels of P2X7, a ligand gated ion channel that functions as
a danger receptor by binding extracellular ATP released from damaged or dying cells.
and driving activation of the NLRP3 inflammasome. We show that Eros co-immunoprecipiates
with P2X7 and that P2X7 driven calcium flux and inflammasome activation are markedly
abnormal in Eros-/- cells. Eros also affects T cell biology, underlining key roles
beyond NADPH oxidase activation.
Conclusion: This work demonstrates the fundamental importance of CYBC1/EROSin human
immunity and describes a novel, 6thcause of CGD as well as highlighting role of EROS
that are independent of the geneartion of reactive oxygen species.
Disclosure of Interest
None Declared
O40 Cold-induced urticarial autoinflammatory syndrome related to factor XII activation
Jörg Scheffel1, Niklas Mahnke1, Zonne Hofman2, Steven de Maat2, Jim Wu1, Hanna Bonnekoh1,
Reuben Pengelly3, Sarah Ennis3, John Holloway3, Martin Church1, Marcus Maurer1, Coen
Maas2, Karoline Krause1
1Charite - Universitaetsmedizin Berlin, Berlin, Germany; 2University Medical Center
Utrecht, Utrecht, Netherlands; 3University of Southampton, Southampton, United Kingdom
Correspondence: Karoline Krause
Introduction: Early onset cold-induced urticarial rash with systemic inflammatory
symptoms are hallmarks of hereditary autoinflammatory diseases caused by gene mutations
of the innate immune pathway, e.g. nucleotide receptor protein 3 (NLRP3). However,
in many cases genetic tests are negative, suggesting the existence of unrecognized
genetic variants.
Methods: We studied eight members of a four-generation family, four of whom were affected.
Genetic analysis involved exome sequencing followed by targeted Sanger sequencing.
Functional analyses included immunoblotting, mononuclear cell stimulation and immunohistochemistry.
We generated recombinant protein variants and assessed cytokines and proteins in plasma
and skin.
Results: Affected patients had cold-induced urticarial rash, arthralgia, chills, headache
and malaise associated with an autosomal-dominant inheritance. Genetic studies identified
a novel deleterious variant in gene F12 (T859A, resulting in p.W268R) which encodes
coagulation factor XII (FXII). Occurrence of the mutation segregated with disease
status. Immunoblotting for FXII exhibited a distinct 50kDa band that was also present
in recombinant W268R-mutated proteins suggesting unusual fragmentation and spontaneous
activation of FXII. Furthermore, we observed contact system activation with reduced
plasma prekallikrein and profound cleavage of high molecular weight kininogen, representing
bradykinin production. Skin and blood neutrophils were found to be a prominent source
of FXII. Interleukin-1ß (IL-1ß) was upregulated in lesional skin and in mononuclear
cells of healthy donors exposed to recombinant proteins. In accordance with these
findings, treatment with icatibant (bradykinin-B2-antagonist) or anakinra (interleukin-1-antagonist)
reduced disease activity in patients.
Conclusion: We identified a novel autoinflammatory syndrome characterized by a substitution
in the F12 gene resulting in activation of the contact system and cytokine-mediated
inflammation.
Disclosure of Interest
None Declared
Poster presentations – Monday 1 April
Guided poster tour 1A
PT1A01 Multi-omics analysis of ADA2 deficiency in Japanese cohort
Hiroshi Nihira1, Kazushi Izawa1, Takahiro Yasumi1, Moeko Ito2, Sachiko Iwaki-Egawa2,
Yoji Sasahara3, Hirokazu Kanegane4, Tadateru Yasu5, Tomohiro Kubota6, Syuji Takei6,
Dai Keino7, Etsuro Nanishi8, Hidetoshi Takada9, Shoichi Ohga8, Syunsuke Kajikawa10,
Makio Takahashi11, Naoko Nakano12, Osamu Ohara13, Toshio Heike14, Junko Takita1, Ryuta
Nishikomori1
1Pediatrics, Kyoto University, Kyoto; 2Life Sciences, Hokkaido University of Science,
Sapporo; 3Pediatrics, Tohoku University, Sendai; 4Pediatrics, Tokyo Medical and Dental
University, Tokyo; 5Pediatrics, Nagasaki Medical Center, Omura; 6Pediatrics, Kagoshima
University, Kagoshima; 7Pediatrics, St. Marianna University, Kawasaki; 8Pediatrics,
Kyusyu University, Fukuoka; 9Pediatrics, Tsukuba University, Tsukuba; 10Neurology,
Kyoto University, Kyoto; 11Neurology, Osaka Red Cross Hospital, Osaka; 12Pediatrics,
Ehime University, Toon; 13Applied Genomics, Kazusa DNA Research Institute, Kisarazu;
14Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
Correspondence: Hiroshi Nihira
Introduction: Adenosine deaminase type 2 deficiency (DADA2) is caused by recessive
loss-of-function variants in ADA2. Most of DADA2 patients reveal systemic vasculopathy
consistent with polyarteritis nodosa and large phenotypic variability has been reported
[1, 2, 3]. However, pathogenesis of DADA2 remains unclear.
Objectives: The objective of this study is to reveal clinical and genetic characteristics
of Japanese DADA2 patients, and to gain insight into the pathogenesis of DADA2 by
multi-omics analysis.
Methods: We performed the genetic analysis of the ADA2 gene and measured ADA2 activity
of the patients from 2016 to 2018 in Japan. Multi-omics analysis had been done in
4 out of 8 DADA2 patients and 4 healthy donors using their peripheral blood mononuclear
cells (PBMCs). The samples were taken before and after introduction of anti-TNFα agents
(meaning acute and remission phase) in the patients.
Results: We found 8 DADA2 patients. In this cohort, central neurological manifestations
were present in 5 (63%), including asymptomatic small lacunar infarction. Seven subjects
(88%) had livedo racemose, but there was no digital ulcer or necrosis. Low levels
of IgG and IgM were revealed in 3 (37.5%) and 5 (62.5%) patients respectively, but
there was no recurrent infectious episode in this case series. There were two (25.0%)
who revealed pure red cell aplasia (PRCA); one revealed only anemia without any inflammation,
the other revealed anemia transiently and recovered from it spontaneously but he revealed
chronic inflammation afterwards. All 8 patients received anti-TNFα agent and all except
one with CsA-dependent PRCA were well controlled.
We identified 6 previously described and 4 novel variants in ADA2, which included
two that we reported before [3]. Overexpression of ADA2 variant constructs in HEK
293 cells showed that some variants had comparable protein expression levels to wild-type
in cell lysate but most of them were not secreted and all the variants had low or
absent ADA2 enzyme activities.
In multi-omics analysis, differentially expressed (DE) genes were analyzed at the
mRNA and protein levels. We found 64 and 58 genes that were differentially expressed
in acute phase vs control and remission phase vs control in common at the transcriptome
and proteome levels respectively. Gene ontology analysis of these datasets revealed
constitutive up-regulation of type 1 and type 2 interferon pathway. Some genes were
common to both datasets.
Conclusion: We have found 8 DADA2 patients in Japan and identified some novel disease-causing
variants. Using multi-omics analysis, we also have found differentially expressed
genes in DADA2 patients. Some genes were consistently up-regulated even in the remission
period. This may provide further insights into the pathogenesis of DADA2.
References
[1] Zhou Q., et al. N Engl J Med, 2014.
[2] Navon Elkan P., et al. N Engl J Med, 2014.
[3] Meyts I., Aksentijevich I. J Clin Immunol, 2018.
[4] Nihira H., et al. Scand J Rheumatol, 2017.
Disclosure of Interest
None Declared
PT1A02 The clinical and immunological profiles of haploinsufficiency of A20 in Japan
Hidenori Ohnishi1, Tomonori Kadowaki1, Norio Kawamoto1, Tomohiro Hori1, Kenichi Nishimura2,
Chie Kobayashi3, Tomonari Shigemura4, Shohei Ogata5, Yuzaburo Inoue6, Tomoki Kawai7,
Eitaro Hiejima7, Kazushi Izawa7, Tadashi Matsubayashi8, Kazuaki Matsumoto9, Masatoshi
Takagi9, Kohsuke Imai9, Ryuta Nishikomori7, Shuichi Ito2, Toshio Heike7, Osamu Ohara10,
Tomohiro Morio11, Hirokazu Kanegane12, Toshiyuki Fukao1
1Pediatrics, Gifu University Graduate School of Medicine, Gifu; 2Pediatrics, Yokohama
City University, Kanagawa; 3Child Health, Faculty of Medicine, University of Tsukuba,
Ibaraki; 4Pediatrics, Shinshu University School of Medicine, Matsumoto; 5Pediatrics,
Kitasato University Hospital, Kanagawa; 6Allergy and Rheumatology, Chiba Children’s
Hospital, Chiba; 7Pediatrics, Kyoto University Hospital, Kyoto; 8Pediatrics, Seirei
Hamamatsu General Hospital, Shizuoka; 9Community Pediatrics, Perinatal and Maternal
Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental
University, Tokyo; 10Applied Genomics, Kazusa DNA Research Institute, Chiba; 11Pediatrics
and Developmental Biology; 12Child Health and Development, Graduate School of Medical
and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
Correspondence: Hidenori Ohnishi
Introduction: A20, encoded by the TNFAIP3gene, is a negative regulator of the tumor
necrosis factor (TNF)-nuclear factor (NF)-κB signaling pathway. Recently, the haploinsufficiency
of A20 (HA20) caused by heterozygous mutations in the TNFAIP3gene was identified to
cause early onset autoinflammatory disease resembling Behçet’s disease.
Objectives: In this study, we performed a multicenter survey investigating HA20 patients
found in Japan and characterized immunological profile.
Methods: We summarized the detailed clinical manifestations, genetic analyses and
several immunological parameters of Japanese patients with HA20. Serum cytokine levels
and the production levels of IL-1β and TNF-α from the peripheral blood mononuclear
cells (PBMCs) were measured using ELISA. Multicolor flowcytometry analysis was performed.
To detect A20 protein expression, immunoblot analysis was performed for PHA blast
derived from the patients and A20 transfected HEK293T cells. The NF-κB reporter gene
activity was analyzed using the dual-luciferase reporter assay system.
Results: A total 32 patients from 10 independent families were enrolled in this study.
Age of onset was 0 to 20 years. Three mutations in the TNFAIP3gene were previously
reported; however, seven were novel. All these mutations were evaluated to be functionally
pathogenic by several in vitroassays. The production levels of proinflammatory cytokines
such as TNF-α and IL-1β from PBMCs were increased. In the detailed analysis of lymphocyte
subsets including T, B and NK cells, regulatory T cells (Treg) were increased in all
analyzed patients. The increase of double-negative T (DNT) and T helper 17 cell (Th17)
cells were observed in 7 and 3 out of 18 analyzed patients, respectively. In addition,
follicular helper T cells (Tfh) were significantly increased especially in younger
patients. Memory B cells were decreased in most of analyzed patients. Intriguingly,
in the complications of HA20 patients, 9 out of 32 of them had not only autoinflammatory
phenotypes but also several autoimmune disorders including psoriatic arthritis, Hashimoto’s
thyroiditisand autoimmune lymphoproliferative syndromewere observed. The immune dysregulation
derived from the defect of A20 may cause the increase of the autoimmune related T
cell subsets and the secondary Treg expansion as well as the phonotype of the previously
reported A20 knockout mice.
Conclusion: Our study revealed unexpected variation in phenotypes of HA20 including
autoimmunity. In the analysis of lymphocyte subsets for HA20 patients, the characteristic
findings such as the increase of Treg and the decrease of memory B cells were observed.
The increase of DNT, Th17 and Tfh cells may be involved in onset of several autoimmune
disorders.
Disclosure of Interest
None Declared
PT1A03 Use of SIGLEC1/CD169 as a biomarker for monogenic interferonopathies
Banu Orak1,2, Axel Panzer3, Manuela Theophil3, Elke Krüger4, Frédéric Ebstein4, Barbara
Zieba4, Nadine Unterwalder5, Christian Meisel5, Tilmann Kallinich2
1Center for chronically sick children, Charité University Medicine Berlin; 2Department
of Pediatrics, Division of Pneumology, Immunology with intensive Medicine, Charité
University Medicine Berlin; 3Pediatric Neurology, DRK Klinikum Berlin-Westend, Berlin;
4Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald,
Greifswald; 5Department of Immunology, Labor Berlin GmbH, Berlin, Germany
Correspondence: Banu Orak
Introduction: Monogenic Interferonopathies represent a rare group of inflammatory
diseases with difficulties in early diagnosis. Expression of SIGLEC1, also known as
CD169, on monocytes is the second highest interferon stimulated gene (ISG) in systemic
lupus erythematodes (SLE).A correlation of SIGLEC1 expression with ISG in SLE is well
established. Furthermore, SIGLEC1 seems to estimate disease activity more accurately
than anti-dsDNA antibodies.
Objectives: To show the relevance of SIGLEC1 as a diagnostic marker for detection
of Interferonopathies.
Methods: Eight patients with genetically confirmed monogenic Interferonopathies were
included. Clinical data, classical inflammatory markers and blood count were obtained
by patients file. SIGLEC1 expression was measured by flow cytometry with a highly
standardized quantitative assaywith a reference range in healthy controls less than
2500 SIGLEC1 molecules/monocyte.In order to quantify the antigen expression by every
single cell QuantiBRITE™ PE tubes were applied. Additionally, transcriptional level
of SIGLEC1, IFI44L, IFI27, ISG15 and RSAD2 as type I Interferon stimulated genes were
assessed by real-time PCR.
Results: All patients showed homozygous mutations. Three patients displayed TREX-1,
two patients IFIH-1, two patients SAMDH1 and one patient RNASE2HB mutations. Mean
age of patients was 12 years (min. 6 months, max. 49 years, SD+/- 17 years). Six of
eight patients showed neurological symptoms consistent with Aicardi-Goutières-Syndrome
like neurological development retardation and microcephaly. Five patients showed abnormalities
on brain MRI, like periventricular calcifications or corpus callosum thinning. Two
patients (homozygous for IFIH-1 mutation) were diagnosed with Singleton-Merten-Syndrome
presenting abnormal ossification of extremities and dental anomalies.One patient with
homozygous TREX1 mutation presented with postnatal glaucoma, microcephaly, developed
sensorimotor polyneuropathia and suffered from recurrent fever with persistent chilblain
lesions.
All eight patients (100%) showed elevated results for SIGLEC1 expression (mean molcules/monocyte
+/- SD: 10272 +/- 3746) without having high levels of standard inflammatory markers.
In six patients elevated SIGLEC1 expression showed dysregulation of the type 1 interferon
pathway prior to genetic testing. In three patients with unclear disease phenotype
measuring expression of SIGLEC1 contributed to establish the right diagnosis. On transcriptional
level SIGLEC1 and the other ISGs were also elevated in comparison to healthy controls.
Conclusion: In all patients with monogenic Interferonopathies like Aicardi-Goutières-Syndrome
high expression of SIGLEC1 was observed, either before diagnosis was established or
during disease course.
Therefore, SIGLEC1 qualifies as an easy accessible and cheap diagnostic marker with
short turnaround time to screen patients with suspected Interferonopathy.
Disclosure of Interest
None Declared
PT1A04 Screening of patients with idiopathic polyarteritis nodosa, granulomatosis
with polyangiitis, and microscopic polyangiitis for deficiency of adenosine deaminase
2
Oskar Schnappauf1, Monique Stoffels2, Ivona Aksentijevich1, Amanda Ombrello1, Natalia
Sampaio Moura1, Karyl Barron1, Daniel Kastner1, Peter Grayson3, Peter Merkel4, on
behalf of Vasculitis Clinical Research Consortium
1National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH);
2National Human Genome Research Institute (NHGRI), National Institutes of Health;
3National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National
Institutes of Health (NIH), Bethesda; 4Division of Rheumatology and the Department
of Biostatistics, Epidemiology, and Informatics (DBEI), University of Pennsylvania,
Philadelphia, United States
Correspondence: Oskar Schnappauf
Introduction: Deficiency of adenosine deaminase 2 (DADA2) is the first described monogenic
vasculitis. Patients usually present in childhood, but age of onset, disease severity,
and organ involvement of DADA2-associated vasculitis is highly variable. Clinical
manifestations of DADA2 overlap with the typical features of necrotizing vasculopathies
such as polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA), and microscopic
polyangiitis (MPA).
Objectives: This study aimed to test the prevalence of DADA2 in patients with presumed
idiopathic PAN, GPA or MPA.
Methods: Patients (n=117) with idiopathic PAN, all of whom tested negative for hepatitis
B virus infection, and patients (n=1107) with GPA or MPA were screened for mutations
in ADA2. To further assess the pathogenicity of identified variants on a functional
level, ADA2 activity was determined on available serum samples of patients with PAN.
Results: Nine of 118 patients with PAN (7.6%) were identified as having rare missense
variants in ADA2 with a minor allele frequency of < 0.005. Four patients (3.4%) were
homozygous or compound heterozygous for variants in ADA2. Of the seven distinct variants
present in these four patients, G47A, G47W, R169Q, E328K, F355L, and G383S had previously
been reported as causative for DADA2. The remaining variant, P106S, is a rare variant
predicted to be damaging to protein function by in silico algorithms. Five additional
patients were carriers for the monoallelic variants R34W, T65M, M309I, V349I, and
Y453C. R34W and Y453C were reported in DADA2 before, while the three remaining variants
are of unknown clinical significance. None of the patients with GPA or MPA were biallelic
for rare missense variants in the ADA2 gene but 32 individuals (2.9%) were carriers
for monoallelic rare missense variants.
Serum samples of patients with PAN were available on the individuals with the G383S/G383S
and E328K/F355L genotypes and showed markedly reduced ADA2 enzyme activity, comparable
to levels seen in patients with DADA2. ADA2 activity of three of the four available
serum samples on monoallelic carriers was not reduced, confirming the non-pathogenicity
of T65M, M309I, and V349I. The serum sample on the individual carrying the pathogenic
variant Y453C showed ADA2 activity in the range of carriers. ADA2 enzyme activity
testing of the remaining serum samples revealed one additional individual with strongly
reduced ADA2 activity levels as well as five individuals with enzymatic activity in
the range of carriers. Sanger sequencing of the ADA2 gene in these individuals did
not identify any pathogenic variants and indicates the presence of cryptic mutations
undetectable by conventional sequencing. In summary, for five out of 118 patients
with PAN the diagnosis of DADA2 can be applied.
Conclusion: This is the first study to report biallelic pathogenic variants in ADA2
in patients with adult-onset, idiopathic PAN, and demonstrates that DADA2 specifically
accounts for a subset of patients with idiopathic PAN but not GPA or MPA. Given the
potential efficacy of TNF-inhibitors in DADA2, that anti-TNF treatment is not the
conventional therapy in PAN, and the consequences for other family members, these
findings suggest that ADA2 testing and/or ADA2 activity testing should be considered
in patients with HBV-negative idiopathic PAN, especially in patients with an early
onset of this potentially life-threatening disease.
Disclosure of Interest
None Declared
PT1A05 Diagnosis and long term management of type I interferonopathies in a pediatric
rheumatology center
Stefano Volpi1,2, Elettra Santori3, Margherita Ricci1, Paolo Picco1, Alessandra Tesser4,
Gillian I. Rice5, Roberta Caorsi1, Alice Grossi6, Isabella Ceccherini6, Alberto Martini2,
Yanick J. Crow7,8, Alberto Magnasco9, Alberto Tommasini4, Fabio Candotti3, Marco Gattorno1
1Centro per le Malattie Infiammatorie e Immunodeficienze, Clinica Pediatrica e Reumatologia,
Istituto Giannina Gaslini; 2DINOGMI, Università degli Studi di Genova, Genova, Italy;
3Allergy and Immunology, Lausanne University Hospital, Lausanne, Switzerland; 4IRCCS
Buro Garofalo, Trieste, Italy; 5Genetic Medicine, Manchester Academic Health Science
Centre, University of Manchester, Manchester, United Kingdom; 6UOC Genetica Medica
e UOSD Genetica e Genomica delle Malattie Rare, Istituto Giannina Gaslini, Genova,
Italy; 7Centre for Genomic and Experimental Medicine, MRC Institute of Genetics and
Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom; 8Institute
Imagine, University Paris Decartes, Paris, France; 9Nephrology, Dialysis, Transplantation
Unit, Istituto Giannina Gaslini, Genova, Italy
Correspondence: Stefano Volpi
Introduction: in recent years several genetic diseases linked to pathologic activation
of type 1 interferon (IFN) pathway have been described
Objectives: To identify type I interferonopathies in a cohort of children with early-onset
rheumatic disease and to report the long-term efficacy and side effect of pathway-specific
treatment with a Janus Kinase (JAK) inhibitor
Methods: Patients were selected based on the presence of any of the following: i)
early onset (infancy or before puberty) inflammatory SLE-like symptoms; ii) vasculopathy
(skin ulcers, chilblains, strokes) iii) panniculitis with or without lipodystrophy
iv) persistent or recurrent systemic inflammation with or without lung involvement
v) polyarthritis with lung involvement. Type 1 IFN activation was assessed by quantitative
PCR, measuring the expression of 6 type 1 interferon-related genes (IFI27, IFI44L,
IFIT1, ISG15, RSAD2, SIGLEC1) in peripheral blood. In selected patients, molecular
analysis was performed using Sanger sequencing, a NGS panel of 41 inflammatory-related
genes or whole exome sequencing. Off label therapy with the JAK inhibitor Ruxolitinib
was considered in patients with a definitive genetic diagnosis and incomplete disease
control by standard treatment
Results: We screened 324 patients evaluated in the rheumatology unit of our Institute.
132 out of 324 patients had a positive type 1 IFN signature. Based on the clinical
presentation and the result of the IFN signature we further analyzed a subset of patients
for an underline genetic defect. In 6 patients we identified pathogenic mutations
affecting TMEM173 (p.V155M in one patient and p.R281Q in a second patient), DNASE2
(p.D121V), DNASE1L3 (c.289_290delAC in 2 patients) and COPA (p.R233H) genes were identified.
Therapy with Ruxolitinib was started in 4 patients and allowed to partially control
disease manifestations and reduce or stop steroids, however, we observed the following
limitation: the patient with DNASE1L3 mutations and a severe kidney involvement at
therapy onset, despite the control of his systemic symptoms progressed to kidney failure;
one patient with SAVI and a severe lung involvement experienced severe recurrent viral
lung infections requiring intensive care and extracorporeal membrane oxygenation (ECMO)
in one episode; the patient with DNASE2 mutationsexperienced a Herpes Zoster infection
controlled with antiviral therapy and decreasing Ruxolitinib dosage.
Conclusion: Patients with type 1 interferonopathies might present with symptoms overlapping
pediatric rheumatic diseases. The combination of type 1 interferon pathway activation
assessment and NGS is an effective strategy for the diagnosis of this heterogeneous
class of diseases and can guide the choice for targeted therapies. JAK inhibitors
represent a therapeutic resource in controlling these difficult-to-treat patients,
however further studies are needed to assess their efficacy and long-term safety
Disclosure of Interest
None Declared
PT1A06 Results of international Delphi survey for the diagnosis, investigation and
management of deficiency of ADA2
Taryn A.-B. Youngstein1, Eugene P. Chambers2, on behalf of DADA2 Foundation, Helen
J. Lachmann1, DADA2 Delphi Study Participants
1National Amyloidosis Centre, UCL Division of Medicine, London, United Kingdom; 2Vanderbilt
University Medical Centre, Vanderbilt University, Nashville, United States
Correspondence: Taryn A.-B. Youngstein
Introduction: DADA2 is phenotypically heterogenous in its presentation, even within
families with the same mutation, and the absence of a murine ortholog has placed emphasis
on the study of known cases of the disease.
Objectives: We conducted an E-Delphi study to explore consensus on the diagnosis,
investigations and management of those with suspected disease.
Methods: A Delphi method over two rounds of consensus building was used. Invitation
email to participate in the study was sent to all published authors on DADA2 and physicians
and scientists known to the DADA2 Foundation, a patient advocacy group supporting
research into DADA2.Consensus was defined as > 80% agreement.
Results: 69 respondents contributed to Round 1 and 53 respondents in Round 2, 75%
of respondents were paediatricians, the rest adult physicians, a nurse specialist
and basic scientists.
Consensus was reached in 1. Suggestive diagnostic features; Livedoid Rash, Stroke,
Fever, Digital Gangrene, 2. The combined use of ADA2 gene sequencing and ADA2 enzyme
activity levels to confirm diagnosis. 3. Use of anti-TNF therapy in acute and chronic
presentations, 4. Indefinite use of anti-TNF until more information is available,
and 5. The avoidance of anticoagulation.
A wide variety in practice was identified in the use of baseline and follow up investigations
including imaging.
Conclusion: There is consensus that rash, stroke, fever, digital gangrene are highly
suggestive of DADA2 but there may be a separate haematological phenotype.Gene sequencing
and ADA2 activity levels in combination are the diagnostic gold standard but not generally
available.There is not yet consensus on the baseline screening investigations, such
as neuroimaging, for these cases. Follow-up investigations are currently guided by
clinical course and practice remains highly variable.
92% of treating physicians believe that anti-TNF therapy is the correct treatment
approach currently, and its use should be indefinite until more information is available.
The authors recommend the creation of a detailed international case registry and a
standardised series of baseline and follow-up investigations during this accelerated
learning phase about this recently described disease.
Disclosure of Interest
None Declared
PT1A07 Somatic mutations in the NLRP3-inflammasome gene in late adulthood-onset chronic
urticaria
Eman Assrawi1, Camille Louvrier1, Fawwaz Awad1, Clemence Lepelletier2, JD Bouaziz2,
William Piterboth1, Florence Moinet3, Philippe Moguelet4, Claire Jumeau1, Laetitia
Cobret1, Elma El-Khouri1, Philippe Duquesnoy1, Marie Legendre1, Sophie Georgin-Lavialle5,
Gilles Grateau5, Sonia Athina Karabina1, Serge Amselem1, Irina Giurgea1
1Sorbonne Université, inserm UMRS 993; 2Hôpital Saint-Louis , Service de Dermatologie,
Paris; 3Centre Hospitalier Universitaire de Martinique, Service de médecine interne,
Martinique; 4Hôpital Tenon , Anatomie et cytologie pathologiques; 5Hôpital Tenon,
Service de médecine interne, Paris, France
Correspondence: Eman Assrawi
Introduction: Chronic urticaria is a common dermatological disorder and one of the
most prominent symptoms of Cryopyrin-Associated Periodic Syndrome (CAPS), a systemic
autoinflammatory condition. Besides urticaria, CAPS cardinal symptoms are fever, arthralgia
and deafness; however, absence of pathognomonic symptoms makes this diagnosis challenging.
NLRP3, the disease-causing gene, encodes the cryopyrin, which upon activation initiates
NLRP3 inflammasome assembly and proinflammatory cytokine secretion. Familial cases
of CAPS are due to heterozygous germ-line NLRP3 mutations; however, sporadic cases,
more often identified in children, are related to de novo or somatic NLRP3 mutations.
Objectives: We aimed to establish the etiological diagnosis of two elderly unrelated
patients presenting with idiopathic chronic urticaria for two decades.
Methods: Molecular study of patients’ DNA was performed using a NGS panel targeting
genes involved in autoinflammatory disorders. Functional analyses of the identified
NLRP3 variants were performed using two cellular models, HEK293T cells (stably expressing
ASC-GFP and pro-caspase1-FLAG) to study ASC speck formation, and THP1 cells to assess
IL1β secretion.
Results:
In two sporadic unrelated patients, we identified two mosaic NLRP3 mutations: a novel
in-frame deletion (c.926_934del, p.Gly309_Phe311del) and a recurrent CAPS mutation
(c.1705G>A, p.Glu569Lys). In whole blood DNA, the mosaicism level was of 17.2% in
the first patient and of 11% in the second one. The patients, who are about 70 years
old, presented for two decades with late onset chronic idiopathic urticaria, occasionally
associated with fever, arthralgia and myalgia. Deafness was diagnosed at the age of
50 years in the first patient, and of 70 years, after the identification of a NLRP3
mutation, in the second one.
To assess the pathogenicity of the identified variants, we studied the activation
of NLRP3 inflammasome after transient expression of NLRP3 wild-type (WT) or of NLRP3
carrying either the p.Gly309_Phe311del or the p.Glu569Lys mutation. Both mutations
were found to significantly increase ASC speck formation andIL1β secretion as compared
to NLRP3-WT.
The diagnosis of CAPS was therefore established on the bases of these molecular and
functional data. Accordingly, complete remission was achieved with anti-interleukin
1 receptor antagonists in both patients.
Finally, we studied the mosaicism level in several cell types from both patients and
showed a wide distribution profile of the mutant alleles, suggesting that, in both
cases, the mutational event occurred early during embryogenesis.
Conclusion: In late adulthood-onset chronic urticaria, the search for autoinflammatory
markers and for somatic NLRP3 mutations may have important diagnostic and therapeutic
issues. Importantly, despite the onset of the disease after 50 years old, NLRP3 mutations
are not restricted to myelomonocytic cells.
Disclosure of Interest
None Declared
PT1A08 Idiopathic recurrent pericarditis: clinical findings and treatment approach
Camilla Celani1, Silvia Federici1, Anna Tulone1, Brigitte Bader Meunier2, Virginia
Messia1, Manuela Pardeo1, Claudia Bracaglia1, Pierre Quartier Dit Maire2, Fabrizio
De Benedetti1, Antonella Insalaco1
1Division of Rheumatology, IRCCS, Ospedale Pediatrico Bambino Gesù, Rome, Italy; 2Unité
d’Immunologie-Hématologie et Rhumatologie pédiatrique, Hôpital Necker-Enfants, Paris,
France
Correspondence: Camilla Celani
Introduction: Recurrent pericarditis affects 15-30% of patients with acute pericarditis.
The etiology is poorly understood, with about 80% being idiopathic. Several treatment
options are available for recurrences, including NSAIDs, colchicine, glucocorticoides
and IL-1 inhibitors (i.e. Anakinra). Standardized guidelines for the management of
these patients are still lacking
Objectives: To analyze clinical findings and treatment approach in a cohort of pediatric
patients with recurrent pericarditis
Methods: Patients with at least two episodes of idiopathic pericarditis, followed
at two Pediatric Rheumatology centers between 2006 and 2018, were included
Results: A total of 42 patients (18 males ) were included. Mean age at disease onset
was 11.8 years (range 4-17). Chest pain and fever were the presenting symptoms in
all patients. In 47% pleural effusion was detected. Laboratory tests showed increased
white blood cell count (mean 14.509/mm3), C-reactive protein (mean 18.01 mg/dl) and
erythrocyte sedimentation rate (mean 39 mm/h) in all patients. The first episode was
variably treated: 18/42 (43%) received NSAIDs alone, 5/42 (11.9%), colchicine alone
or associated to NSAIDs and 3/42 patients (7%) received antibiotics alone. 16/42 (38%),
not responsive to NSAIDs or colchicine, received glucocorticoides. Patients who received
glucocorticoids at the first episode relapsed earlier (median time of 2.1 months range
10 days-5 months), than patients treated with NSAIDs ( 6.6 months range 10 days -24
months) or with colchicine (5 months range 10 days-5 months) (p<0.05). In our study,
initial treatment of the first episode did not affect the number of subsequent flares.
To evaluate treatment strategy at relapses, we divided our study population in two
groups: Group 1 (20 pts) in which recurrence was treated with NSAIDs, colchicine or
glucocorticoid (alone or combined); group 2 (22 patients) in which anakinra was started.
Among patients belonging group 2, 9 received anakinra at first relapse, 7 at the second,
2 at the third and 2 at the fourth. Anakinra treatment was followed by a prompt resolution
of symptoms and inflammatory signs within 2 days. During daily treatment with full
dose anakinra, no relapses were reported over a median of 13.3 months (range 5-24
months). In 13 out of 22 patients, anakinra was gradually tapered reducing the days
of administration during the week. Four of these patients relapsed. The mean time
from the start of anakinra to tapering was 17±4 months (range 14-23 months) in the
4 patients who experienced a relapse versus 14±4 months (range 7-21 months) in patients
who did not flare, with no statistical difference. Among the 22 patients belonging
to group 2 anakinra was finally discontinued in 11 after a mean time of 23.4 months
(range 12-36). Among these, 8 relapsed after anakinra withdrawal (including 2 of the
4 patients already relapsed during tapering). Only 3 patients didn’t present any relapse
(up to 20.3 months of follow-up). All patients who relapsed responded quickly to the
reintroduction of anakinra
Conclusion: Our study confirms the lack of a standardized treatment approach in patients
with recurrent pericarditis. Patients treated with glucocorticoid at first episode
relapse before than those treated with other drugs. Anakinra is an effective treatment;
however, tapering/discontinuation of the drug lead to relapses in several cases. Further
experience on larger population is needed to define the best treatment duration and
approach to withdrawal of IL-1 inhibitor
Disclosure of Interest
None Declared
Guided poster tour 1B
PT1B01 Monocytes proteomic profile of patients with different autoinflammatory diseases:
a new approach to characterize these diseases
Federica Penco1, Andrea Petretto2, Chiara Lavarello2, Ilaria Gueli3, Arinna Bertoni1,
Alessia Omenetti3, Claudia Pastorino1, Marco Gattorno1
1Centro Malattie Autoinfiammatorie ed Immunodeficienze; 2Laboratorio Core Facilities
- Proteomica e Metabolomica Clinica; 3Clinica Pediatrica e Reumatologica, Istituto
Giannina Gaslini, Genova, Italy
Correspondence: Federica Penco
Introduction: Autoinflammatory diseases are a group of inherited diseases characterized
by early onset and systemic inflammation, often manifesting with unexplained fevers.These
pathologies are usually caused by mutations in genes involved in the regulation of
innate immune response with a consequent inflammatory phenotype. The most common genetically
defined periodic fevers are Familial Mediterranean Fever (FMF), Cryopyrin-associated
periodic syndromes (CAPS), TNF receptor-associated periodic syndrome (TRAPS) and mevalonate
kinase deficiency/hyperimmunoglobulin D syndrome (MKD/HIDS). Some patients show clinical
features similar to autoinflammatory diseases but no genetic mutation has been found.
Objectives: Our aim is to evaluate the differences in the expression of proteins or
pathway in monocytes, and plasma metabolites in patients with autoinflammatory diseases
compared with healthy subjects to clusterize and better understand the mechanisms
underlying different genetically defined disorders and try to characterize the genetically
undefined pathologies.
Methods: Monocytes, purified from peripheral blood and incubated for 4 hours with
or without LPS, were collected from 5 patients for each pathology (FMF, CAPS, TRAPS
and MKD) and healthy donors. The samples have been processed by iST protocol. Each
digested sample was analyzed by high-resolution liquid chromatography and tandem mass
spectrometry (LC-MS/MS) based on Orbitrap technology. The quantification strategy
is a label-free approach (LFQ) available in MaxQuant suite.
Results: Here we identified a median of about 5000 proteins from the monocyte samples
of each 4000 is quantified by LFQ approach. PCA analysis and Person’s correlation
show good reproducibility of data and a good separation between the different groups.
The data were then submitted to an appropriate statistic. The T-Tests highlighted
the differentially expressed proteins and through the use of Cytoscape with the ClueGo
app we obtained the differently regulated pathways in the different conditions. It
has also been constructed, starting from significative proteins, a network, related
to disease using the information of String Disease db. This was done to highlight
the proteins associated with the disease as well as to reveal new possible biomarkers.
We observed that the expression of proteins is differently enriched according to the
different conditions. For each autoinflammatory disease, a list of significantly modulated
proteins was obtained: some of which are already known to be related to the disorders,
while others have not yet been described. In FMF, MEFV, RhoA and some related proteins
were significantly up-regulated together with genes linked to the interferon pathway.
In TRAPS relevant proteins turn up related to the maintenance of Golgi and cellular
trafficking. The bioinformatics analysis allows us to better understand the functional
interaction between these monocytes proteins and map which are involved in the diseases.
Proteins thus analyzed were then contextualized in dominant pathways for each pathology
through Cytoescape network analysis.
Conclusion: Here, we addressed how a high-resolution proteomics approach could be
used to better understand the biology of autoinflammatory diseases. The characterization
of a broad spectrum of proteins and their interaction network will allow us to identify
new biomarkers for the different pathologies and better comprehend and recognize the
genetically undefined disorders.
Disclosure of Interest
None Declared
PT1B02 Prulipotent stem cell derived myeloid cell lines for dissecting the mechanism
of autoinflammation
Megumu Saito
Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
Introduction: Autoinflammatory disorders (AIDs) is defined as an disorders associated
with dysregulation of innate immune systems. In typical case, patients with AIDs show
various inflammatory symptoms, such as periodic fever, skin rash and sterile serositis.
Human induced pluripotent stem cell (iPSC) models of AIDs are supposed to be feasible
and useful, because 1) most of typical AIDs are monogenic, 2) responsible cells are
usually innate immune cells which can be robustly differentiated from PSCs, and 3)
improvement of therapeutic or diagnostic approach is still needed in many AIDs. We
therefore focused on establishing PSC models of AIDs, and applied these models to
identification of genetic and biological background of patients’ pathophysiology.
Results: We established iPSCs from patients with AIDs such as CINCA/NOMID, Nakajo-Nishimura
syndrome (NNS), and Blau syndrome (BS). We also corrected the disease-causing mutations
by genome editing technology in selected clones. iPSCs were then differentiated into
hematopoietic cells, especially into monocytic lineage cells. To stably obtain functional
monocytic cells, monocytic progenitor cells derived from iPSCs were immortalized.
The immortalized monocytic cell lines (MLs) were further differentiated into mature
macrophages and then used for functional assays. The monocytic cells from AID-iPSCs
showed increased secretion of proinflammatory cytokines such as IL-6, TNF and IL-1β.
In case of CINCA/NOMID, iPSCs established from a NLRP3-mutation negative patient were
useful for the identification of somatic NLRC4 mutation of the patient. The AID-iPSCs
were also used for dissecting underlying disease mechanism, and suitable for high-throughput
phenotypic screening.
Conclusion: We applied iPSC technology for studying autonflammatory disorders. When
combined with other novel technologies such as next generation sequencing and genome
editing, iPSC-based phenotypic dissection was useful for diagnosis of the patients
and understanding the disease mechanism.
Disclosure of Interest
None Declared
PT1B03 Loss of protein prenylation in human monocytes promotes the formation of an
NLRP3-dependent inflammasome in a model of mevalonate kinase deficiency
Oliver Skinner1, Julie Jurczyluk1,Paul Baker2, Seth Masters2, Avril Robertson3, Kate
Schroder4, Sam Mehr5, Marcia Munoz1, Michael Rogers1
1Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, Sydney;
2Inflammation Division, Walter and Eliza Hall Institute of Medical Research, Melbourne;
3School of Chemistry and Molecular Biosciences; 4Institute of Molecular Bioscience,
University of Queensland, Brisbane; 5Dept of Allergy/Immunology, Royal Children's
Hospital, Melbourne, Australia
Correspondence: Oliver Skinner
Introduction: Mevalonate kinase deficiency (MKD) is an autoinflammatory disease caused
by mutations in an enzyme of the mevalonate pathway, leading to loss of isoprenoid
lipids necessary for protein prenylation. Defective prenylation in MKD is thought
to trigger inflammasome activation, IL-1β release and recurrent episodes of systemic
inflammation. However, how loss of prenylation causes inflammasome activation remains
controversial. Recent studies have suggested that lack of Rho or K-Ras prenylation
leads to assembly of the Pyrin inflammasome in macrophages, whereas others have shown
that disruption of the mevalonate pathway in monocytes triggers IL-1β release via
NLRP3 inflammasome activation.
Objectives: To determine which type of inflammasome is activated in human monocytes
upon loss of protein prenylation in MKD.
Methods: THP-1 human monocytic cells were treated for 24 hours with 5μM simvastatin
(SIM) to pharmacologically block the mevalonate pathway, followed by stimulation with
LPS or Pam3CSK4 (TLR4 and TLR2 agonists, respectively) to induce an inflammatory response.
IL-1β and IL-18 release was quantified by ELISA whilst caspase-1 enzyme activity,
ASC immunostaining and permeability to propidium iodide were used as measures of inflammasome
formation and pyroptosis. To assess the contribution of Pyrin or NLRP3, we used inducible
CRISPR/Cas9 knockout THP-1 cells, as well as the small molecule inhibitor of NLRP3,
MCC950. Finally, inflammasome activation was examined in peripheral blood mononuclear
cells (PBMCs) from an MKD patient (bearing V377I/H20N mutations in MVK) and heterozygous
parents.
Results: SIM treatment of THP-1 cells caused a clear accumulation of unprenylated
Rab and Rap1A proteins, without affecting cell viability. Furthermore, LPS or Pam3CSK4
stimulation of SIM-treated cells resulted in a 4-fold increase in IL-1β and IL-18
release and significantly higher ASC-containing speck formation, caspase-1 activity
and pyroptosis. Importantly, all these effects were reversed to normal levels by restoring
protein prenylation using geranylgeraniol (the missing lipid metabolite necessary
for protein prenylation). In support of a predominant role for NLRP3, MCC950 completely
inhibited the stimulatory effect of SIM on LPS-induced ASC speck formation, caspase-1
activation, IL-1β release and pyroptosis. All of these were also abolished by knocking
out NLRP3, whereas deletion of Pyrin had no effect. Similarly, LPS stimulation of
MKD patient-derived PBMCs resulted in much higher IL-1β release compared to heterozygous
parents, which was completely blocked by NLRP3 inhibition with MCC950.
Conclusion: We clearly demonstrate that lack of prenylation in human monocytic cells,
using statin treatment (a pharmacologic model of MKD) or using authentic cells from
an MKD patient, leads to enhanced formation of an NLRP3-dependent, Pyrin-independent,
inflammasome upon TLR2/4 stimulation. In contrast to reports that lack of prenylation
activates the Pyrin inflammasome in macrophages, these findings indicate a prominent
additional role for NLRP3 in the pathogenesis of MKD and demonstrate that targeting
the Pyrin inflammasome in isolation may not be sufficient to resolve all the pathology
associated with MKD. Rather, approaches to overcome the metabolic defect in the mevalonate
pathway and restore normal protein prenylation could be more effective at preventing
broader inflammasome activation.
Disclosure of Interest
None Declared
PT1B04 Performance of targeted NGS for routine diagnosis of autoinflammatory diseases
Guilaine Boursier1, Cécile Rittore1, Déborah Méchin2, Muriel Gutierrez1, Florian Milhavet1,
Guillaume Sarrabay2, Isabelle Touitou2
1Department of Medical Genetics, Rare diseases and personalized medicine, Rare and
autoinflammatory diseases unit, CHU Montpellier, Univ Montpellier; 2IRMB, INSERM,
Univ Montpellier, Department of Medical Genetics, Rare diseases and personalized medicine,
Rare and autoinflammatory diseases unit, CHU Montpellier, Montpellier, France
Correspondence: Guilaine Boursier
Introduction: Monogenic systemic autoinflammatory diseases (SAIDs) are characterized
by mutations in genes coding for proteins involved in innate immunity. Since the discovery
of the first gene MEFV (OMIM 608107) responsible for familial Mediterranean fever,
more than 30 new conditions have been identified, notably through high-throughput
sequencing approaches. Currently, next generation sequencing (NGS) allows the simultaneous
investigation of multiple genes at a manageable cost. We present here our 4 years
of experience of targeted NGS as a routine diagnostic for SAIDs.
Objectives: To evaluate the performance of a panel of 49 genes targeting well-defined
autoinflammatory diseases and clinical concordance after retro-phenotyping.
Methods: DNAs from 577 patients clinically suspected for SAIDs (age 3 months to 79
years) were sequenced by NGS between September 2014 and December 2018. The libraries
were prepared using Nextera (Illumina) or SureSelect (Agilent) Target Enrichment Capture
custom kits. Sequencing reactions were performed on MiSeq or NextSeq500 equipment
(Illumina). The mutations were classified according to a 5-class scale provided by
the Infevers database or according to the American College of Medical Genetics and
Genomics (ACMG) guidelines. Epidemiological data, clinical symptoms and biological
markers were collected on a form provided with all genetic diagnosis requests.
Results: Almost a half of patients (261/577) had at least one mutation. Mutations
that were probably pathogenic (class 4) or clearly pathogenic (class 5) accounted
for one third of the mutations and were detected in only 30/49 genes. We identified
87% (100/115) missense variants and 11% (13/115) truncating mutations including whole
gene deletions. The genes in which we identified most of the pathogenic mutations
were MEFV, MVK, PSMB8, ADA2, NLRP3 and RNASEH2B then NOD2, PSTPIP1 and SLC29A3. The
most recurrent pathogenic variants were MVK:p.(Val377Ile), MEFV:p.(Met694Val) and
RNASEH2B:p.(Ala177Thr). The yield of conclusive genetic diagnosis (one class 4 or
5 mutation including mosaicism in a dominant condition or two non-allelic mutations
in a recessive condition) using this NGS strategy was 8% over this 4-year period.
We observed a rather good, though incomplete clinical concordance in patients with
a genetic diagnosis.
Conclusion: The simultaneous investigation of multiple genes using targeted NGS is
a successful routine diagnostic for SAIDs and is of particular interest for the detection
of low-level mosaic mutations and copy number variations. However, our targeted NGS
approach has resulted in genetic confirmation in a relatively small proportion of
patients. One of the reasons may be related to the stricter definition we have used
compared to previous reports. On the other hand, SAID genes or molecular mechanisms
that are still unknown are likely to be found. Finally, a better clinical filter for
ordering genetic tests through a consultation with experts could be encouraged.
Disclosure of Interest
None Declared
PT1B05 Late-onset TRAPS with low-grade mosaicism in TNFRSF1A
Barend P. Kant1, Marco J. Koudijs1, Ruben van‘t Slot2, Joyce van Kuik3, Lisanne M.
Sikkema1, Joost Frenkel4, Anna Simon5, Mariëlle E. van Gijn1
1Department of Genetics; 2Center for Molecular Medicine; 3Department of Pathology;
4Department of Pediatrics, University Medical Center Utrecht, Utrecht; 5Department
of Internal Medicine, Radboudumc Expertisecenter for Immunodeficiency and Autoinflammation,
Radboud University Medical Center, Nijmegen, Netherlands
Correspondence: Barend P. Kant
Introduction: The diagnosis of patients with systemic autoinflammatory diseases (SAID)
is difficult which can result in delayed treatment and irreversible organ damage.
In several patients, low grade mosaicism of an autosomal dominant form of SAID has
been detected. In NLRP3, even mosaic mutations with allele frequency <5% in whole
blood can result in severe disease. In recent years, high-grade mosaic mutations have
been detected in the TNFRSF1A gene in patients with late-onset TRAPS. With a new screening
assay, we investigate whether low-grade mosaic mutations in TNFRSF1A might contribute
to autoinflammatory disease.
Objectives: To examine the presence of low-grade mosaicism in a patient with clinically
suspected late-onset TRAPS.
Methods: DNA was extracted from whole blood, FACS sorted hematopoietic cells and non
hematopoietic cells. Mosaic mutation screening was performed using a single molecule
molecular inversion probe (smMIP) assay. Positive results were confirmed with droplet
digital (dd)PCR technology.
Results: Our patient is a 70 year old male with a history of episodes of fever with
migratory erythematous rash and myalgia since his 30s. Also pleuritis, cervical lymphadenopathy
and eye involvement were recorded and there was a single episode with abdominal pain
and vomiting. On average, the episodes lasted for 2 weeks and occurred every 5 weeks.
Family history was negative. Complete remission of the symptoms was achieved after
starting treatment with anakinra.
We previously screened the TNFRSF1A gene by Sanger sequencing and next generation
sequencing (NGS) with negative results. With our smMIP assay, we detected a c.269C>A
p.(Thr90Asn) likely pathogenic missense mutation with 1,3% allele frequency in whole
blood. This result was confirmed by ddPCR. The mutation was also present in sorted
granulocytes, monocytes, T and B cells, but not in non-hematopoietic cells. This distribution
is different from late-onset CAPS patients who were found to have myeloid restricted
mosaic mutations in NLRP3.
Conclusion: We report the first low-grade mosaic variant in TNFRSF1A. Based on clinical
symptoms, favorable response to anakinra and genetic findings, we diagnosed our patient
with mosaic TRAPS. Our data suggest that even mutations present in a very small number
of cells can cause systemic autoinflammatory disease.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
PT1B06 Heterozygous TNFAIP3 mutation as the cause of an interferon-mediated neuroinflammatory
disorder
Ciara M. Mulhern1, Ying Hong1, Ebun Omoyinmi1, Dara McCreary1, Marina Casimir1, Cheryl
Hemingway2, Felice D’Arco2, Paul Brogan1, Despina Eleftheriou1
1Infection, Inflammation and Rheumatology, Great Ormond Street Institute of Child
Health; 2Neurology Department, Great Ormond Street Hospital for Children, NHS Foundation
Trust, London, United Kingdom
Correspondence: Ciara M. Mulhern
Introduction: Heterozygous loss-of-function mutations in TNFAIP3 lead to haploinsufficiency
of A20 (HA20) commonly manifesting with severe orogenital ulceration and ocular inflammation.
Central nervous system (CNS) inflammation has been observed in patients with haploinsufficiency
of HA20 but CNS involvement as the sole clinical manifestation of heterozygous TNFAIP3
mutation in humans has never been described however. Herein, we report on the case
of an 8 year old female of non-consanguineous Pakistani-Indian descent who presented
with left sided focal seizures and hemiparesis, acute uveitis and congitive decline.
Magnetic resonance imaging (MRI) of her brain revealed contrast-enhancing T2 hypointense
intracranial mass lesions, in the grey matter of the paracentral lobule and the thalamus
on the left with surrounding oedema. Brain biopsy revealed necrotising granulomatous
inflammation. Brain CT revealed intracerebral calcification. Extensive screening of
infectious or malignant causes was negative.She failed to respond to multiple anti-inflammatory
treatments but had an excellent radiological and clinical response to an oral JAK-STAT
inhibitor suggesting this was likely an interferon (IFN) mediated inflammatory disease.
Objectives: To use next generation sequencing to identify the genetic cause of the
progressive neuroinflammatory disorder in this case and characterise the mechanisms
underpinning neuroinflammation
Methods: Whole exome sequencing (WES; illumina MiSeq) was carried out in all family
members. Expression of phosphorylated- p65, IRF3, STAT1 and STAT3 in both patient
and healthy control derived peripheral blood mononuclear cells was assessed by flow
cytometry. Meso Scale Discovery (MSD) assays was used to quantify cytokines in patient
serum. qPCR assays measured the expression levels of IFN stimulated gene expression.
Co-immunoprecipitation analysis assessed the binding capacity of the mutated protein
to Tank-binding kinase 1 (TBK1)
Results: WES revealed a heterozygous missense p.T647P mutation in TNFAIP3 as the cause
of the progressive neuroinflammatory disorder in this case. Patient-derived cells
exhibited enhanced phosphorylation of the p65 transcription factor, and increased
expression of NF-ƙB mediated proinflammatory cytokines. The mutated p.T647P A20 protein
failed to control interferon-regulatory-factor-3 (IRF3) activation and interferon
(IFN)-dependent gene transcription, in comparison to healthy control cells. We also
show that the mutant A20 protein cannot efficiently bind to TBK1, in order to turn
off IRF3 activation leading to an enhanced IFN signature in the patient. We believe
that failure to regulate IFN-mediated immune responses, was the driver of the CNS
inflammation observed. Furthermore, treatment with an oral JAK 1/2 inhibitor resulted
in marked clinical improvement, complete radiological resolution of neuroinflammation,
and normalisation of IFN-stimulated gene expression in whole blood. IFN mediated immune
responses were also impaired in an additional disease control case of HA20 in a 4
year old heterozygote for the p.N98Tfs25 TNFAIP3 variant.
Conclusion: We describe for the first time heterozygous p.T647P missense mutation
in TNFAIP3 as the cause ofprogressive neuroinflammation. The p.T647P mutated A20 proteinfailed
to control IRF3 activation and IFN dependent transcription. Treatment with an oral
JAK 1/2 inhibitor was highly effective. Our report now adds TNFAIP3 mediated neuroinflammation
to the ever-expanding group of monogenic interferonopathies with propensity to CNS
involvement.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
PT1B07 Systemic evaluation of genetic and biochemical testing for deficiency of ADA2
(DADA2) from the NIH patient cohort
Natalia Sampaio Moura, Oskar Schnappauf, Natalie Deuitch, Qing Zhou, Daniel Kastner,
Ivona Aksentijevich
Inflammatory Disease Section, National Institutes of Health, Bethesda, United States
Correspondence: Natalia Sampaio Moura
Introduction: Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive
autoinflammatory disorder caused by loss-of-function mutations in the ADA2 gene, which
encodes the adenosine deaminase 2 (ADA2) enzyme. Patients with DADA2 can present with
many different manifestations including early-onset lacunar stroke, recurrent fever,
hepatosplenomegaly, livedo reticularis, immune dysregulation, and hematopoietic abnormalities.
They also exhibit absent or significantly reduced ADA2 enzyme activity. Despite these
conserved features, some individuals display discordance between clinical characteristics
and genetic or enzyme activity testing.
Objectives: The goal of our retrospective study is to evaluate sensitivity of diagnostic
testing for DADA2 in our CLIA-certified laboratory at the National Institutes of Health
(NIH). We compared the diagnostic efficacy of the different types of assays, such
as Sanger sequencing, ADA2 enzymatic analysis and multiplex ligation-dependent probe
amplification (MLPA).
Methods: We reviewed all ADA2 Sanger sequencing results of individuals tested between
2014 and 2018, including confirmatory testing in referral patients, and determined
the diagnostic yield of this method in patients we suspected to have DADA2 based on
clinical phenotype. We then analyzed if subsequent ADA2 enzyme assay and/or MLPA further
increased our diagnostic yield.
Results: Out of 190 individuals with clinical characteristics suggestive of DADA2,
56 patients tested positive for biallelic mutations (29%). Eleven tested as carriers
for a monoallelic pathogenic mutation (6%), and 123 (65%) were mutation-negative based
on conventional Sanger sequencing. ADA2 enzyme activity assay was performed on 45
patients who had available serum samples. The assay corroborated the DADA2 diagnosis
on 30 patients and identified 7 individuals with monoallelic mutations (detected via
Sanger) from three different families as patients due to low enzyme activity. MLPA
successfully identified a second pathogenic copy number variation (CNV) in all patients
who displayed low ADA2 activity. Addition of ADA2 protein assay and MLPA increased
our DADA2 diagnostic rate to 33%. Thus, we observed a 13.8% (4/29) relative increase
in our diagnostic yield due to the incorporation of these testing modalities.
Conclusion: Our results suggest that the serum ADA2 enzyme assay should be considered
first tier testing for patients with suspected DADA2, given that pathogenic mutations
in ADA2 are highly heterogeneous and not always detectable by Sanger sequencing alone.
Sanger sequencing in combination with MLPA remain indispensable assays to support
and confirm enzymatic testing when indeterminate or unclear, and to identify causal
variants. Detection of mutations at the DNA level is important for genetic counseling.
Targeted next-generation testing is another method able to identify a diverse scope
of pathogenic mutations and has the potential to increase the diagnostic yield of
genetic testing.
Disclosure of Interest
None Declared
Monogenic autoinflammatory diseases (clinical)
P1001 Is there any difference between M694V heterozygote and non-exon 10 mutations
on symptoms onset and response to colchicine treatment?
Hatice Adiguzel Dundar1, Serkan Turkucar1, Ceyhun Acari1, Ozge Altug Gucenmez2, Balahan
Makay2, Erbil Unsal1
1Department of Pediatrics, Pediatric Rheumatology Unit, Dokuz Eylul University Faculty
of Medicine; 2Pediatric Rheumatology Unit, Dr. Behcet Uz Childrens’ Hospital, Izmir,
Turkey
Correspondence: Hatice Adiguzel Dundar
Introduction: Familial Mediterranean fever (FMF) is the most common inherited autoinflammatory
syndrome throughout the world. It is caused by mutations of the MEFV gene encoding
a protein called pyrin. The most frequent genotype-phenotype correlation is in a certain
part of exon 10, especially M694V mutation. There are also a group of patients with
non-exon 10 mutations, who have a similar clinical spectrum of the disease.
Objectives: We aim to investigate the genotype-phenotype differences between M694V
heterozygote mutations and non-exon 10 mutations.
Methods: Data charts of children (n=431) with FMF from Dokuz Eylul University childrens’
hospital and Dr.B.Uz childrens’ hospital were reviewed. Patients were divided into
two groups with regard to having M694V heterozygote or non-exon 10 mutations. Genotype-phenotype
features and response to treatment were compared.
Results: There were M694V heterozygote mutations in 128 (29.7%) patients and non-exon
10 mutations in 303 (70.3%) patients. The follow-up period was 54.5 (33-105) months.
There was no difference between the age of symptoms onset, the age of diagnosis, and
the diagnosis delay time. The family history in patients with M694V heterozygote mutation
was statistically positive compared to non-exon 10 mutation group (p:0.000). The symptoms
of joint involvement as arthritis were significantly higher in the M694V heterozygotegroup
(p:0.026). Additionally, biological agent need due to colchicine unresponsiveness
was statistically higher in M694V heterozygote group than group with non-exon 10 mutation
(p:0.004) (Table 1).
Conclusion: There is a significant difference between children with M694V and non-exon
10 mutations, even when the M694V mutation is present in one allele only. Family history
with FMF, musculoskeletal symptoms, and unresponsiveness to colchicine are main parameters.
Disclosure of Interest
None Declared
P1002 A case report of aicardi goutieres syndrome type 5 in two siblings mimicking
juvenile idiopathic arthritis
Buthaina Al Adba1, Hajar Dauleh2
1Paediatric Rheumatology; 2Paediatric, Sidra Medicine, Doha, Qatar
Correspondence: Buthaina Al Adba
Introduction: Aicardi-Goutières syndrome (AGS) is a genetically determined encephalopathy
characterized by calcification of the basal ganglia and white matter, demyelination,
and raised levels of lymphocytes and IFNα in the cerebrospinal fluid [1]. Neurological
dysfunction becomes clinically apparent in infancy and manifests as progressive microcephaly,
spasticity, dystonia, and psychomotor retardation. Expression of interferon-regulated
genes (IGS) in peripheral blood is also upregulated, which is sustained over time
[2]. The genes mutated in AGS have been defined to encode proteins implicated in the
metabolism of nucleic acids TREX1, the RNASEH2 complex and SAMHD1,which may all function
as cellular nucleases [3].
Objectives: Arthritis and progressive arthropathy with distal joint contractureshave
been reported in SAMHD1 mutation along with neurological symptoms [4]. We are describing
two siblings with SAMHD1 mutation who only presented with early onset polyarthritis
and no systemic or CNS manifestations.
Methods: Chart review of clinical data includes IFN signature and molecular analysis.
Results: Two brothers of consanguineous parents with no significant family history
of auto inflammatory or autoimmune disease, were born healthy, at term with normal
growth parameters.Patient one is a six yearold boy who presented at age of four with
one-year history of joint pain and morning stiffness. He had active arthritis in his
both wrists, knees and elbows. Lab testing revealed normal blood work ESR, CRP, and
negative ANA and RF. Interestingly HLAB27 was present.A diagnosis of JIA was made
and he was started on naproxen, and had intra-articular in jectionsarticular injections
twice. His arthritisHis arthritis was difficult to control and Etanercept andsubcutaneous
Methotrexate were started. His arthritis improved significantly,with residual mild
disease atboth wrist joints.His brother, patient two is a 3 year old boy who presented
similarly at age of 18 months with morning stiffness and abnormal gait for one-month
duration. He had active arthritis in both knees, hips and wrists. He had similar lab
findings and positive HLAB27.He was treated with naproxen, a short course of oral
steroid and Methotrexate. He responded faster than his brother, but continue to have
mild arthritis atboth wrists. Due to difficult to treat, early arthritis in two consanguineous
brothers, wesent genetic testing with whole exome sequencing (WES) to look for other
causes of their arthritis.Genetic testing for both siblings showed Homozygous mutation
at the SAMHD1 gene for the P.Arg 290His (CGT>CAT):c.869G >A.Both parents were heterozygous
for the same mutation. The R290H variant in the SAMHD1 gene has been reported previously
in association with AGS in an affected individual with multiple clinical features
including CNS symptoms and arthritis [5].Peripheral blood analysis of type I interferon-related
biomarkers demonstrated that both siblings have an interferon signature characteristic
of Aicardi-Goutieres syndrome (Fig 1). Both brothers continued to have normal development
with no CNS symptoms or rash and their eye exam showed no glaucoma, which was previously
reported in AGS with the SAMHD1 mutation. Despite being asymptomatic from CNS disease
we are considering brain MRI to look for inflammatory cerebral vasculopathy that has
been reported previously [6].
Conclusion: We are reporting a spectrum of AGS with a SAMHD1 mutation that mimicks
difficult to treat early onset polyarticular arthritis without any CNS or skin manifestations.
This illustrates the need to consider mutation analysis of SAMHD1 in similar presentations
as CNS and skin disease may evolve later. Finally, even though there has been partial
response to treatments,we may consider changing therapy to Janus Kinase inhibitors
to achieve complete remission of arthritis.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1003 Phenotypic and genotypic characteristics and damage accrual of monogenic autoinflammatory
diseases other than familial Mediterranean fever from the pediatric rheumatology Arab
group (PRAG)
Sulaiman Al-Mayouf1, Abdulaziz Almutairi1, Safia Albrawi2, Abdulatif AlEnazi3, Basil
Fatallah4, Abdulallh Alsonbul1, Mohammed Abu-shukair5, Raed Alzyoud5, Adel Alwahadneh5,
Mabruka Zlenti6, Ebtisam Kawaja6, Khloud Khawaja7, Zakia Almusawi8, Wafa Madan8, Muna
AlMutairi9, Nora Almuatiri10 and Pediatric Rheumatology Arab Group (PRAG)
1King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; 2Royal
Hospital, Muscat, Oman; 3King Fahad Medical City, Riyadh, Saudi Arabia; 4AlJalial
Children Hospital, Dubai, United Arab Emirates; 5Queen Rania Children Hospital, Amman,
Jordan; 6Tripoli Children Hospital, Tripoli, Libya; 7Mafraq Hospital, Abu Dhabi, United
Arab Emirates; 8Salmaniya Hospital, Bahrain, Bahrain; 9Al Adan Hospital; 10AlSabah
Hospital, Kuwait, Kuwait
Correspondence: Sulaiman Al-Mayouf
Introduction: Monogenic autoinflammatory diseases (AIDs) are a group of rare hereditary
recurrent multisystem inflammatory diseases.The available published data from Arab
countries about monogenic AIDs other tahn Familial Mediterranean fever (FMF) is very
limited.
Objectives: To report the phenotype, genotype and response to treatment in Arab children
with monogenic AIDs other than FMF, with focus on accrual damage.
Methods: We retrospectively reviewed patients with clinical and/ or genetically proven
monogenic AIDs other than FMF seen between 1990 and 2018 at 10 rheumatology clinics
from seven Arab countries. Data were collected at the last follow-up visit comprising
history of consanguinity, age at onset and diagnosis, follow-up duration, clinical
and laboratory findings, as well as the damage accrual and death related to monogenic
AIDs.
Results: Seventy (46 female) patients with monogenic AIDs were analyzed. Consanguinity
rate among the enrolled patients was 74.6% and a family history of AIDs was present
in 60%. The mean age at disease onset was 3.2±2 years and mean duration of follow-up
was 7.5±4 years. The initial diagnosis was inaccurate in 47% and the mean diagnosis
delay was 4±3 years. The most frequent monogenic AIDs were LACC1 associated monogenic
disorders (monogenic JIA and monogenic Crohn’s) (23) followed by cryopyrin-associated
periodic syndrome (CAPS) (12), tumor necrosis factor receptor associated periodic
syndrome (TRAPS) (12), hyperimmunoglobulinemia D syndrome (HIDS) (9), Majeed’s syndrome
(6) and eight patients with other monogenic AIDs. Musculoskeletal involvement was
the main feature in LACC1 associated monogenic disorders while fever and mucocutaneous
and gastrointestinal involvement were the most prevalent features in the other monogenic
AIDs. Genetic testing was performed in 67 patients, 69% had genetically confirmed
disease. Patients with mutation c.T850C p.C284R in exon 4 of LACC1 had severe arthritic
changes. Three CAPS patients with NLRP3 mutation had cognitive impairment and one
with significant hearing and ocular damage. Two HIDS patients had homozygous p.V3771
mutation and other two patients with p.V3771/compound heterozygous MEFV: p.E148Q/p.P369S/p.R408G.
Three different LPIN2 mutations were recorded for Majeed’s syndrome. Overall, growth
failure was the most frequent (36%), followed by cognitive impairment (13%). There
were three deaths due to infection.
Conclusion: The number of genetically confirmed patients with monogenic AIDs other
than FMF are not uncommon among Arab children probably due to a high consanguinity
rate. Diagnostic delay and high damage accrual emphasize the need for more awareness
and early referral to specialized centers.
Disclosure of Interest
None Declared
P1004 Auto-inflammatory diseases: a retrospective single center study in Saudi Arabia
Abdulrahman A. Alrasheed1, Ashwag Al Harthi2, Banan Al Rewaithi2, Wafa Suwairi2, Jubran
Al Qanatish2, Fayhan Al Roqi2
1King Abdullah Specialized Children Hospital; 2Pediatric, King Abdullah Specialized
Children Hospital, Riyadh, Saudi Arabia
Correspondence: Abdulrahman A. Alrasheed
Introduction: The auto-inflammatory conditions represent an emerging and over-expanding
series of diseases unified by a dysregulation of innate immunity. The current increase
in the prevalence of chronic inflammatory diseases makes this subject of interest.
Early recognition and treatment with immunomodulator agents have the potential to
improve the outcomes and the quality of life.
Objectives: The purpose of this review is to describe the clinical features, investigations,
therapeutic modalities and outcome of auto-inflammatory syndromes seen at King Abdullah
Specialized Children’s Hospital, Riyadh, Saudi Arabia.
Methods: We carried out a descriptive retrospective analysis of pediatric patients
with auto-inflammatory diseases who were seen and managed at a single tertiary center,
in Riyadh, Saudi Arabia, between 2004 and 2018. Multiple measures were investigated
including time of disease onset, clinical features, investigations, treatment, and
outcome.
Results: 67 patients (30 females and 37 males) with auto-inflammatory diseases were
identified and formed the basis of the study (Table 1).
Autoinflammatory diseases include Systemic Juvenile Idiopathic Arthritis (sJIA) 46%,
Chronic Recurrent Multifocal Osteomyelitis (CRMO) 15%, Familial Mediterranean fever
(FMF) 7%, Hyperimmunoglobulin D syndrome (HIDS) 6%, Periodic fever, aphthous stomatitis,
pharyngitis, cervical adenitis (PFAPA) 6%, Neonatal onset multisystemic inflammatory
disease (NOMID) 3%, STING-associated vasculopathy with onset in infancy (SAVI) 3%,
), Aicardi-Goutières syndrome (AGS) 1%, Deficiency of Adenosine Deaminase 2 (DADA2)
5%, Deficiency of interleukin thirty-six receptor antagonist (DITRA) 1%, Blau syndrome
1% and Uncharacterized Auto-inflammatory Disease (UAD) 3%.
The mean age at initial presentation was 58.2 months. The median Erythrocyte Sedimentation
Rate (ESR) and C - Reactive protein (CRP) were 72 mm/hr and 86 mg/dl, respectively.
Treatment modalities that have been used include Disease-modifying antirheumatic drugs
(DMARDs) and/ or biologic therapy including Anti TNF alpha, Anti IL-1 or Anti IL-6
and others (Table1).
Conclusion: We believe this cohort provides the common features of auto-inflammatory
diseases in Saudi Children and the outcome after frequently used target therapies.
Early recognition and treatment of auto-inflammatory diseases with immunomodulator
agents have the great potential to alleviate the debilitating symptoms and to improve
the quality of life.
Disclosure of Interest
None Declared
Table 1 (abstract P1004).
See text for description
Disease
No. of patients
%
gene study
treatment and outcome
SoJIA
31
46%
Negative HLH gene done for patients with MAS
good response to Anakinra or Tocilizumab
CRMO
10
15%
Negative geneexcept 1 patient with CRMO and Familial hyperphosphatemic tumoral calcinosis
who has homozygous mutation in GALNT3 gene
3 patients with mild CRMO responded to NSAIDs only.
2 patients required either pamidronate or Methotrexate.
4 patients required combination of Infliximab and Methotrexate.
1 patient who had unidentified auto- inflammatory disease responded partially to Abatacept
but not to Anakinra, Adalimumab or Tocilizumab.
FMF
5
7%
Heterozygous mutation in MEFV gene (Met694Val)
Good response to Colchicine
PFAPA
5
8%
Negative periodic fever gene panel
4 patients received no treatments with less frequent attacks during follow up and
one free of attacks after tonsillectomy
HIDS
4
6%
Mutation in MVK gene
3 patients treated with Anakinra showed good response
1 patient had infrequent attacks not on treatment
NOMID
2
3%
Negative gene
Good response to anti IL-1 therapy (Anakinra and Canakinumab)
Interferonopathies
2 SAVI
1 AGS
5%
Mutation in TMEM-173 gene (STING gene) for SAVI and RNASEH2A for AGS
1 SAVI patient treated with Ruxolitinib with significant improvement while the other
died
AGS treated with Ruxolitinib with good response
DADA2
3
5%
mutation in CECR1 gene
2 patients treated with adalimumab and GCSF with good response, and the 3rd patient
recently diagnosed
DITRA
1
1%
mutation inIL36RN gene
Response was lost on etanercept, Anakinra and then Ustekinamab
Currently on Adalimumab with no relapse so far
Blau syndrome + crohn’s disease
1
1%
mutations in NOD2/CARD15 gene
Treated with Azathioprine and steroid with partial response
P1005 Clinical and genetic characteristics of myalgia in Armenian children with familial
Mediterranean fever
Gayane G. Amaryan1, Tamara F. Sarkisian2, Nune G. Mkrtchyan3, Marina M. Papazyan4,
Artashes E. Tadevosyan5
1National Pediatric Centre for Familial Mediterranean Fever of “Arabkir” Medical Centre
- Institute of Child and Adolescent Health, Department of Pediatrics Yerevan State
Medical University; 2Centre of Medical Genetics and Primary Health Care, Depatment
of Medical Genetics Yerevan State Medical University; 3National Pediatric Centre for
Familial Mediterranean Fever of “Arabkir” Medical Centre - Institute of Child and
Adolescent Health, Department of Pediatrics Yerevan State Medical University; 4NationalPediatric
Centre for Familial Mediterranean Fever, “Arabkir” Medical Centre - Institute of Child
and Adolescent Health; 5Department of Public Health and Health Care Organization ,
Yerevan State Medical University, Yerevan, Armenia
Correspondence: Gayane G. Amaryan
Introduction: Familial Mediterranean Fever (FMF) as an ethnic disease is wide-spread
in Armenia. In most cases FMF manifests in childhood. Myalgia is an essential feature
of musculoskeletal symptoms (MSM) of FMF, which can be presented as acute muscle attacks
- spontaneous myalgia (SM) and exercise-induced myalgia (EIM), as well as prolonged
protracted febrile myalgia (PFM). Awareness of these symptoms are important for early
diagnosis and differential diagnosis of FMF.
Objectives: to study the frequency of different types of myalgia in Armenian children
with FMF and their correlation with MEFV genotype and disease severity.
Methods: A group of 715 children with FMF was observed at the National Pediatric Centre
for FMF (438 boys, 277 girls, mean age 8.64±0.17). The diagnosis of FMF was based
on the Tel-Hashomer criteria and detection of 12 MEFV mutations common for Armenians
using Viennalab Diagnostics molecular-genetic assay. For statistical analysis standard
statistical Epi-Info 2000 Program was performed. For comparison of two nominal variables
in table “two by two” Yaet’s corrected for continuity chi-square test was used, significance
level p<0.05
Results: Myalgia was observed in 37.5% (268 out of 715) of FMF patients and manifested
mainly as SM and /or EIM in 34.7% (248 patients), as well as PFM in 2.7% (20 patients).
SM and EIM manifested as transient pains of the legs without fever, disappearing after
resting or taking NSAIDs. The frequency of development of SM and EIM varied from 43.6%
to 31.2% depending on the genotype and was relatively common in M694V and V726A heterozygotes
compared to homozygotes(χ2= 3.41; p> 0.05). Risk of development of SM and EIM was
associated with severity of FMF (χ2= 23.20, p <0.0001) and was higher in severe and
moderate course of FMF compared to mild 5.6 times (χ2= 18.28; P <0.0001) and 1.9 times
(χ2= 3.77; P <0.05) respectively.
We observed prolonged PFM in 2.7% of FMF patients with more severe phenotypes, which
were characterized by 4 times higher risk of early onset (χ2= 5.94; p = 0.015) (mean
age 3 years), as well as late diagnosis of FMF (9.42 ± 0.72) and the delayed start
of colchicine therapy . This cohort of patients had also high frequency of severe
FMF attacks with generalized febrile muscle pain during 1-3 weeks, prevalence of acute
recurrent arthritis, erysipelas-like erythema. PFM manifestation usually was after
5-6 year of FMF onset. Because of PFM is considered also as vasculitis, steroid therapy
was started along with colchicine. Development of PFM was associated with severe M694V-homozygous
genotype (χ2 = 8.27; p <0.02) and was observed at 4.6% of M694V-homozygous patients.
Conclusion: The frequency of different types of myalgia in Armenian children with
FMF is high (37.5%), especially acute muscle attacks - SM and/or EIM (34.7%). PFM
is diagnosed in 2.7% patients.
The development of SM and EIM is associated with the severity of FMF and does not
depend on the MEFV genotype. The risk of development of PFM, as a part of prolonged
MSM, is associated with both: the MEFV genotype (mostly M694V- homozygous) and the
severity of the disease.
This allows to consider PFM as a marker of severe course of FMF and early disease
onset and the M694V homozygous genotype as a risk factor for the development of PFM.
MEFV mutation genetic screening is recommended for Armenian paediatric patients with
different types of myalgia, especially with PFM, for early diagnosis of FMF, treatment
and prevention of complications.
Disclosure of Interest
None Declared
P1006 The impact of aging on familial Mediterrinean fever patients
Okan Aydin1, Serdal Ugurlu1, Bugra Egeli2, Ece Soykut2, Deniz Demir2, Huri Ozdogan1
1Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty;
2University of Istanbul - Cerrahpasa, Istanbul, Turkey
Correspondence: Okan Aydin
Introduction: Familial Mediterranean Fever (FMF) is a monogenic autoinflammatory disorder
with innate immune activation with an onset before age 20 in approximately 90% of
the patients. There is scarce data on the effect of aging on FMF patients over 40
years of age
Objectives: This study aims to collect data on FMF patients who have survived over
40 years of age. Here we report our preliminary data on disease course and treatment
status and comorbidities of our patients with FMF.
Methods: Among the FMF patients who have been followed in our FMF outpatient clinic
with a pool of approximately 5000 patients, those who have aged 40 and over are being
included to the study. As by today 180 patients are considered for evaluation. The
files of patients were reviewed and a standard questionnaire was used to interview
the patients. Here we report the results of 100 of these patients (56%) who were contacted
for this purpose. These patients were questioned on their demographic characteristics,
comorbid conditions, colchicine treatment details, and attack information. In order
to see the trend of the change in the parameters assessed , the patients were divided
into two groups based on their present age(Group 1: 40-50 years, Group 2: ≥50 years).
Results: A total of 100 (78 F, 22M) patients were evaluated. There were 61(46F, 15M)
patients aged between 40-50 years and 39 (32F, 7M) over 50. The demographic characteristics
and clinical features of these patients are given in Table 1.Besides 3, all patients
were still on colchicine regularly. Ninety-six percent of the patients declared overall
benefit from colchicine therapy, however 38% experienced a side effect related to
this treatment.Over 88% of the patients reported decrease in severity and frequency
of FMF attacks.The mean daily colchicine dose was lower in the age 50 and over group
(1.7±0,77 mg versus 1,35 ±0,38 mg). There were no patients with AA amyloidosis in
neither age group. The mean duration from the last attack increased from 15.3 ±19.7
months to 35.6± 52 months in the older patients. One or more additional disease was
present in 75% of this patient group.Among the comorbidities hypertension was the
most frequent, diagnosed in 25% of the patients, followed by hypothyroidism (16%),
diabetes mellitus (10%) and cardiac disease (5% ). Sixty-five of the patients were
recieving other medications in addition to colchicine.
Conclusion: According to our preliminary data the majority of the patients continue
to take colchicine after age of 40. However the frequency of FMF attacks as well as
daily colchicine dose decrease as the patients get older.With well designed trials
stopping colchicine treatment may be considered in a subgroup of patients after 50
years of age. Approximately ¾ of the FMF population over 40 years of age has a comorbidity
that neccecitates additional medications which underlines the need for special attention.
Disclosure of Interest
None Declared
Table 1 (abstract P1006).
Clinical course and co-morbidities in two age groups over 40 years
n
Group 1*(n=61)
Group 2**(n=39)
p
Sex (F:M); current age (mean±SD) (yr)
(46 :15) ;45.5 ± 2.29
(32:7); 57.05 ± 6.81
0,43;<0.001
Mean duration since the last episode, (mean±SD, mo)
15.3 ± 19.7 (1-60)
35.67 ± 52.05 (1-276)
0,012
Number of patients on colchicine therapy, n (%)
59 (96.7)
38 (97.4)
NS
Mean colchicine dose, mg/day (current)
1.7±0.76
1.41±0.45
0.03
Number of patientswith decrease in attack severity, n (%)
54(88,5)
35 (89,7)
NS
Number of patients with decrease in attackfrequency, n (%)
57(93,4)
37 (94,8)
NS
Co-morbidities, n (%)
Hypertension, n (%)
12(19.6)
13 (33.33)
NS
Hypotyroidism, n (%)
12(19,6)
4(10,2)
NS
Type 2 Diabetes Mellitus, n (%)
5(8.2)
5(12.82)
NS
Rheumatological diseases, n (%)
5(8,2)
3(7,7)
NS
Cardiac disease, n (%)
3(4,9)
2(5,1)
NS
Malignancies, n (%)
2(3,2)
2(5.13)
NS
Additionalmedications (number of patients, %)
36 (61)
29 (74.3)
NS
P1007 Comorbidities in familial Mediterranean fever
Ummusen Kaya Akca1, Banu Balci Peynircioglu2, Zehra S. Arici1, Edibe Avci2, Zulfiye
Y. Akkaya Ulum2, Engin Yilmaz2, Yelda Bilginer1, Seza Ozen1
1Pediatric Rheumatology; 2Medical Biology, Hacettepe University, Ankara, Turkey
Correspondence: Banu Balci Peynircioglu
Introduction: Familial Mediterranean Fever (FMF) is a periodic fever syndrome, characterized
by recurrent episodes of fever and serosal inflammation accompanied with high acute
phase reactants.The analysis of possible comorbidities is important to understand
the impact of these conditions on clinical care and whether they share a common etiological
pathway.
Objectives: We aimed to evaluate the comorbidities associated with FMF patients in
a large genetically diagnosed cohort.
Methods: We retrospectively evaluated the medical records of FMF patients who were followed
up at Department of Pediatric Rheumatology in Hacettepe University between 2000 and
2015. This study was approved by the Research Ethics Committee and was conducted in
accordance with the Declaration of Helsinki. The diagnosis of FMF was made according
to Tel Hashomer diagnosis criteria for patients who applied prior to April 2009 and
to the Turkish FMF pediatric diagnosis criteria after April 2009. The FMF patients
who had homozygous or compound heterozygous mutations were included in the study.
Comorbidities associated with FMF were divided into three groups; associated with
increased inflammation, associated with FMF and incidental.
Results: A total of 1999 patients were enrolled in the study. Of all 1999 FMF patients,
636 were children (31.8 %), 1029 were males (51.4%), with a mean age of 31.60±16.01
years. The mean follow up time was 4.50±3.99 years (median:3.84 range from 0.21-29.4
years). 880 of 1999 (44%) FMF patients had homozygous MEFV gene mutation, the most
common mutation was M694V homozygous. The remaining were compound heterozygous. 656
patients (32.8%) had one or more than one comorbidity associated with FMF. Ankylosing
spondylitis was the most common comorbidity associated with increased inflammation
while the most common comorbidity in FMF related comorbidities was renal amyloidosis.
The frequency of ankylosing spondylitis, henoch schonlein purpura, juvenile idiopathic
arthritis, polyarteritis nodosa (PAN), multiple sclerosis (MS) and Behçet’s disease
were increased in patients with FMF when compared to those in the literature. Systemic
lupus erythematosus was observed less frequently in the patients with FMF than in
the population. While the increase in the frequency of MS was 3.3 times, the frequency
of PAN was increased 110 times.
Conclusion: This study shows that FMF is a hereditary disease associated with significant
comorbidity. We also confirm that inflamatory and rheumatic diseases are more common
in FMF.
Disclosure of Interest
None Declared
P1008 Bone metabolism in systemic autoinflammatory diseases (SAIDS): a case- control
study from Padova cohort
Sara Bindoli1, Giulio Franceschet2, Paola Galozzi1, Martina Zaninotto3, Valentina
Camozzi2, Paolo Sfriso1
1Rheumatology Unit, Department of Medicine; 2Endocrinology Unit, Department of Medicine;
3Department of Laboratory Medicine, University of Padova, Padova, Italy
Correspondence: Sara Bindoli
Introduction: Systemic autoinflammatory diseases (SAIDs) represent a group of disorders
characterized by recurrent fever attacks, polyserositis, skin, musculo-skeletal and
articular manifestations. A dysregulation of the innate immune response in a genetic
predisposed host leads to the development of SAIDs. In our study we included patients
affected by Familial Mediterranean Fever (FMF), TNF Receptor Associated Periodic Syndrome
(TRAPS) and Hyper-IgD Syndrome (HIDS). It is assessed that chronic inflammation, perpetuated
by pro-inflammatory cytokines, may exert a role on bone metabolism leading, in the
long run, at the onset of osteoporosis (OP). However, how OP may occur in the context
of autoinflammatory diseases remains partially unknown.
Objectives: The aims of our study are focused on the assessment of bone metabolism
in patients affected by SAIDs compared to healthy subjects and on the relationship between
bone turnover markers (Receptor activator of nuclear factor kappa-Βligand, RANKL and
osteoprotegerin, OPG) and serum inflammation markers (serum amyloid A, SAA).
Methods: 40 adults patients referring to the Rheumatology Unit of Padova University
Hospital affected by FMF, TRAPS and HIDS and 40 healthy subjects were recruited between
March and June 2018. Fasting blood samples were collected in order to determinate
calcium (Ca), phosphorus (P), magnesium (Mg), 24-h urine calcium, 24-h urine phosphorus,
albumin, parathyroid hormone (PTH), Vitamin D, creatinine, serum amyloid A (SAA),
c-terminal telopeptide of type I collagen (CTX), bone alkaline phosphatase (b-ALP).
Moreover, serum OPG and RANK-L were determined by a commercially available ELISA kit
(Pantec, Turin, Italy). Femur and lumbar dual-energy X-ray absorptiometry (DXA) was
performed with the QDR Bone Densitometer Discovery (Hologic Inc.,Waltham, MA). Trabecular
Bone Score (TBS) was calculated on DXA lumbar images, using iNsight Software (version
1.8.0.0; Medimaps, Merignac, France). The statistical analysis was performed using
Mann-Whitney U Test.
Results: We did not observe a statistically significant difference between bone mineral
density (BMD) and TBS of patients compared to controls (p=0.5037 and p=0.8031). Also,
the values of phospho-calcic metabolism samples were not statistically different between
patients and controls. As expected, SAA levels were significantly higher in patients
(p= 0.0144), and interestingly also OPG levels were significantly higher if compared
to the healthy subjects (p= 0.0018). For b-ALP, CTX and RANK-L no differences were
observed between the two groups (p=0.1466, p=0.8861, and p= 0.7890 respectively).
Conclusion: Patients of our cohort affected by FMF, TRAPS and HIDS do not present
an increased risk of OP compared to the healthy controls. Indeed, TBS and BMD are
similar between the two groups highlighting a preserved bone quality in our patients.
Interestingly, OPG levels are higher compared to controls and this could suggest a
protective role and a bone re-balancing activity in a context of inflammation. Finally,
a regulatory effect of serum amyloid A on bone homeostasis should be taken into account.
Disclosure of Interest
None Declared
P1009 Two cases of hyperzincaemia/hypercalprotectinaemia show novel phenotypic properties
Anikó Szabó1, Péter Blazsó1, Viktória Sümegi2, Tibor Kalmár1, Zoltán Maróti1, Csaba
Bereczki1
1Department of Paediatrics; 2Department of Rheumatology and Immunology, University
of Szeged, Szeged, Hungary
Correspondence: Péter Blazsó
Introduction: Hyperzincaemia/hypercalprotectinaemia (Hz/Hc) is a recently discovered
autoinflammatory disorder showing monogenic, autosomal dominant inheritance pattern.
Until now the p.E250K and p.E257K missense mutations of PSTPIP1 gene have been found
in the background. These result in the extreme overproduction of the pro-inflammatory
cytokine IL-1β leading to the striking elevation of serum calprotectin and zinc through
positive feedback loops. Uncontrolled inflammation elicited by the continuous activation
of these danger signals end up in the classical constellation of systemic and cutaneous
inflammation, hepatosplenomegaly, arthritis, pancytopenia, and failure to thrive.
Objectives: We aimed to characterize the clinical phenotypes accompanied the mutations
of PSTPIP1 gene found in two unrelated Hungarian male patients. These data were compared
to the clinical presentations of the already published cases and novel symptoms were
demonstrated.
Methods: Clinical cases of both boys were investigated thoroughly. In order to clarify
the diagnosis targeted exome sequencing panel (Illumina TruSight One) was applied
in each case to pre-screen for possible mutations. Nucleotide variants in the probands
and in their parents were confirmed by Sanger sequencing.
Results: A p.E250K mutation was detected in one patient and a p.E257K in the other.
Both variants were de novo and heterozygous. p.E250K in the 2,5-year-old boy was associated
with additional recurrent non-infectious diarrhea, macrocephaly and pericardial fluid
on the top of the classical signs. p.E257K in the 7-year-old boy was joined with haemangiomatosis,
mental retardation, autism and overweight besides the already known manifestations
of Hz/Hc.
Conclusion: Atypical and potentially misleading clinical findings in Hz/Hc underline
the importance of genetic testing in order to get to the proper diagnosis. The presented
cases might extend our knowledge of the phenotypic traits observable in Hz/Hc.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1010 Identification of novel NLRC4 and IL2RA variants in a family cohort with juvenile-onset
arthritis and rash
Jessica L. Bloom1, Megan L. Curran1, Scott Canna2, Harold Hoffman3, Elena Hsieh4
1Department of Pediatrics, University of Colorado, Aurora; 2Departments of Pediatrics
and Immunology, University of Pittsburgh, Pittsburgh; 3Departments of Pediatrics and
Medicine, University of California San Diego, San Diego; 4Departments of Pediatrics
and Immunology and Microbiology, University of Colorado, Aurora, United States
Correspondence: Jessica L. Bloom
Introduction: Identification of genetic etiologies of autoinflammatory syndromes can
inform targeted therapy to improve outcomes.
Objectives: We aimed to identify a genetic etiology for an underlying autoinflammatory
syndrome in a 3-year-old boy presenting with failure to thrive, rash, and polyarthritis
since infancy without significant fevers. The patient’s mother and maternal aunt also
had similar symptoms since infancy.
Methods: We obtained a history, exam, routine laboratory evaluation, chromosomal microarray,
immune phenotyping and functional assays, and genetic sequencing of familial autoinflammatory
syndromes via INVITAE.
Results: The patient’s first examination showed small and large joint polyarthritis
and maculopapular rash. Laboratory results included anemia, positive ANA, negative
RF and anti-CCP, mildly raised ferritin, and very elevated platelet level, LDH, ESR,
CRP and IgG. He had recurrent diarrhea and tested positive for Campylobacter. INVITAE’s
autoinflammatory panel showed two heterozygous variants of unknown significance (VUS):
NLRC4, exon 4, c.741_742insAlu (p.Leu247fs) and IL2RA, exon 2, c.76G>C (p.Asp26His).
Genetic testing revealed the same two variants in the patient’s mother and aunt, while
unaffected relatives had one or the other (see Table 1). The patient and mother are
HLA-B27+ and have the same 2.8 Mb duplication from 3q28 to 3q29 on chromosomal microarray
including IL1RAP. Signal transducer and activator of transcription phosphorylation
(pSTAT5) studies showed increased baseline pSTAT5 induction without IL-2 stimulation
in patient compared to control.
The patient’s arthritis improved partially with naproxen and steroid joint injections.
Given genetic results, subcutaneous anakinra was initiated at 10 mg/kg daily with
significant improvement in arthritis, rash, and fatigue. Labs after one month showed
resolved anemia, normal inflammatory markers, and high IL-18 (7,824 pg/mL, normal
89-540). He switched to 4.29 mg/kg of canakinumab monthly. After one month, he had
mildly active arthritis, occasional fatigue, and stable labs apart from an increase
of IL-18 to 15,329 pg/mL. The mother, who is poorly controlled off therapy, has elevated
IL-18 (7,176 pg/mL)
Conclusion: We present a family cohort with juvenile-onset arthritis and rash, found
to have elevated IL-18, VUS in both NLRC4 and IL2RA, and a chromosomal duplication
consistent with a heritable autoinflammatory syndrome. While it appears that both
variants are required for symptomatology, his presentation is most consistent with
an unrecognized gain of function NLRC4 mutation despite lack of recurrent fevers or
enterocolitis. Genetic evaluation led to targeted therapy and improved outcomes, with
additional testing underway to further personalize therapy.
The patient's family consented for publication.
References
1. Canna SW, et al. An activating NLRC4 inflammasome mutation causes autoinflammation
with recurrent macrophage activation syndrome. Nature Genetics. 2014;46(10):1140-6.
2. Romberg N, et al. Mutation of NLRC4 causes a syndrome of enterocolitis and autoinflammation.
Nature Genetics. 2014;46(10):1135-9.
Disclosure of Interest
None Declared
Table 1 (abstract P1010).
INVITAE Panel Results
Relation to Patient
Symptoms?
VUS
Patient*
Yes
NLRC41, IL2RA2
Sister
No
NLRC41
Mother*
Yes
NLRC41, IL2RA2, ADAM173
Father
No
-
Maternal Aunt
Yes
NLRC41, IL2RA2
Maternal Half-Aunt
No
-
Maternal Grandfather
No
IL2RA2
Maternal Grandmother
No
NLRC44
1c.741_742insAlu (p.Leu247fs), heterozygous, ExAC 0
2c.76G>C (p.Asp26His), heterozygous, ExAC 0.1%
3c.179T>C (p.Leu60Pro), heterozygous, ExAC 0
4c.741_742insAlu (p.Leu247fs), possibly mosaic, ExAC 0
*2.8 Mb duplication from 3q28 to 3q29 on chromosomal microarray (maternal aunt's is
in process)
P1011 Discontinuation of colchicine therapy in children with familial Mediterranean
fever
Yonatan Butbul1, Rawan Silman1, Shafe Fahoum2, Yackov Berkun3
1Department of Pediatrics B, , Rappaport Children's Hospital, Rambam Medical Center,
Haifa; 2Department of Pediatrics B, Rappaport Children’s Hospital, Rambam Medical
Center, Haifa; 3Department of Pediatrics and FMF Clinic, Hadassah-Hebrew University
Medical Center, Mount Scopus, Jerusalem, Israel
Correspondence: Yonatan Butbul
Introduction: Clinical phenotype of FMF exists in some carriers of MEFV mutation.
These patients tend to have a mild disease. Prolonged colchicine free remission was
reported in a small group of FMF patients.
Objectives: To describe and characterize a group of children with FMF in whom colchicine
was discontinued.
Methods: The study cohort consisted of all children with FMF followed at 2 referral
centers in Israel in whom colchicine was discontinued following prolonged attack free
period.
Clinical presentation, mutations in MEFV gene and disease outcome of patients who
successfully ceased colchicine therapy were compared with patients with relapse of
FMF attacks.
We performed a retrospective study in two referral centers in Israel of 43patients
with FMF with 1 or non-mutated MEFV allele who ceased colchicine therapy following
prolonged attack free period. The phenotype of the patients was investigated in detail,
and the MEFV mutations, laboratory findings, clinical picture and outcome of 30 (70%)
patients that successfully ceased colchicine therapy were compared to 13 (30%) patients
whofailed.
Results: 47 patients (55% males), mean age 6±3.2 years at the diagnosis, were enrolled
in the study, of them 4patients were excluded due to poor follow up. Fever (93%),
abdominal pain (79%), arthralgia (19%) and arthritis (12%) were the most common symptom
at attack.The average period free of attacks before enrolment was 11.3±9.2 months.
The average follow-up after ceasing colchicine was 5.1± 2.9 years. Thirteenpatients
(30.2%) had anattack during follow up with most common symptomsof fever (92%) and
abdominal pain (77%) and colchicine therapy was restarted within 10.1 months (1.1-36.4months).
There were no differences between the groups of patients that were able to stop colchicine
and the group that needed to renew therapy in demographic, genetic and most clinical
parameters, including the age (13.4±3.9 vs 11.9±3.7p-0.26), level ofSAA at enrolment
(4±3.6 vs 3.3±2.4p-0.7) and time of last attackprior to enrolment (12.6±9.6 vs 8.6±8.2
monthsp-0.08). Myalgia and arthritis were more common among children that required
to renew therapy compared to the group that didn’t (31% vs 6.7% p-0.058 and 31% vs
3% p-0.024 respectively).
Conclusion: Cessation ofcolchicine therapy following prolonged remission in selected
group of patients who are not homozygous for MEFV mutation could be considered. Patients
with arthritis or arthralgia are more likely to have an attack after ceasing colchicine
therapy.
Disclosure of Interest
None Declared
P1012 Long-term follow up of a mevalonate deficiency kinase patients cohort
Inmaculada Calvo Penades, Berta Lopez Montesinos, M. Isabel Gonzalez Fernandez, Miguel
Marti Masanet, Elena Fernandez De La Puebla
Pediatric Rheumatology Unit, HUIP la Fe, Valencia, Spain
Correspondence: Inmaculada Calvo Penades
Introduction: The syndrome mevalonate kinase deficiency (MKD) is part of the syndromes
of periodic fever. With typical clinical manifestations and good response to treatment
with IL-1 blockade, but the long-term manifestations are little known
Objectives: To assess the clinical features, treatment and evolution of 11 patients
diagnosed with Mevalonate Kinase Deficiency (MKD).
Methods: Baseline demographic and clinical characteristics of the patients were considered,
including age at symptoms onset, age at diagnosis, time to follow up, clinical features,
laboratory data, results of the MVK gene sequencing study, administered treatments
and evolution.
Results: Overall, 11 patients. Gender: M/W 7:4. Onset age: 0.8 m (0-15 years). Age
at diagnosis: 9.6 years (4m-15 years), time of follow up: 9.8 years (4m-11 years).
Clinical features: Fever 93% of the patients, adenopathy 93%, abdominal pain 66%,
oral aphtha 66%, diarrhea 60%, arthritis 60%, amygdalitis 60%, other symptoms: skin
rash 34%, headache, 34%, hepatomegaly 27%, splenomegaly 20% and serositis 10%. Three
patients presented atypical manifestations: intestinal obstruction (6 episods), intestinal
invagination (4 episodis), orquitis (3 episodis) and chylothorax. All patients showed
IgD levels > 100 U/mL (100-1500). MVK mutations: 6 patients homozygotes (2: V250I,
4: V377I) and 5 patients double heterozygotes: 4(I268T, V377I), 1(N205D, R388X). The
genetic study of the whole family was performed in 7 families. Corticoid treatment
used for 100% of the patients. Anakinra in 45% (parcial-complete response), Canakinumab
82% (complete response), Etanercept 9% (no response) and adalimumab 9% (hydradenitis).
Long-term manifestations: 2 patients with cutaneous abscess and 1 patient with hydradenitis
suppurativa.
Conclusion: In this cohort the high response to canakinumab treatment is shown and
late clinical manifestations are described, to our knowledge, for the first time in
literature.
Disclosure of Interest
None Declared
P1013 Novel assay to diagnose and monitor cryopyrin associated periodic syndromes
(CAPS)
Fortunata Carbone1,2, Luca Cantarini3, Teresa Micillo4, Maria Alessio5, Alma Nunzia
Olivieri6, Maria Francesca Gicchino7, Antonella Insalaco8, Maria Cristina Maggio9,
Orso Maria Lucherini3, Roberto Scarpioni10, Matteo Piga11, Maria Maddalena Angioni11,
Laura Obici12, Antonella Simpatico3, Pietro Leccese13, Rita Consolini14, Raffaele
Manna15, Paolo Sfriso16, Sara Bindoli16, Paola Galozzi16, Ida Orlando3, Sabrina Chiesa17,
Marco Gattorno17, Giuseppe Matarese18,19
1Istituto per l'Endocrinologia e l'Oncologia Sperimentale-Consiglio Nazionale delle
Ricerche (IEOS-CNR), Napoli; 2Unità di Neuroimmunologia, IRCCS Fondazione Santa Lucia,
Roma; 3Research Centre of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic
and Rheumatology-Ophthalmology Collaborative Uveitis Centre, Department of Medical
Sciences, Surgery and Neurosciences, University of Siena, Siena; 4Dipartimento di
Biologia, Università di Napoli “Federico II”; 5Department of Translational Medical
Sciences, Section of Pediatrics, Federico II University; 6Dipartimento della Donna,
del Bambino e di Chirurgia Generale e Specialistica; 7Dipartimento della Donna, del
Bambino e di Chirurgia Generale e Specialistica, Università degli Studi della Campania
“Luigi Vanvitelli”, Napoli; 8Department of Pediatric Medicine, Division of Rheumatology,
Bambino Gesù Children's Hospital, Roma; 9Ospedale dei Bambini “Di Cristina” , Palermo;
10Ospedale AUSL “Guglielmo da Saliceto” , Piacenza; 11Reumatologia, Policlinico Universitario,
Cagliari; 12Centro per lo Studio e la Cura delle Amiloidosi, Fondazione IRRCS, Policlinico
San Matteo, Pavia; 13Rheumatology Institute of Lucania (IReL), Rheumatology Department
of Lucania, “San Carlo” Hospital of Potenza and “Madonna delle Grazie” Hospital of
Matera, Potenza; 14Laboratory of Immunology, Division of Pediatrics, Department of
Clinical and Experimental Medicine, University of Pisa, Pisa; 15Centro delle febbri
periodiche e malattie rare, Policlinico Gemelli, Università Cattolica Roma, Roma;
16Unità di Reumatologia, DIMED, Policlinico Universitario, Padova; 17Dipartimento
di Scienze Pediatriche Generali e Specialistiche, IRCCS Istituto Giannina Gaslini,
Genova; 18Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università
di Napoli Federico II; 19Istituto per l'Endocrinologia e l'Oncologia Sperimentale,
Consiglio Nazionale delle Ricerche (IEOS-CNR), Napoli, Italy
Correspondence: Fortunata Carbone
Introduction: Cryopyrin associated periodic syndromes (CAPS) are rare autoinflammatory
disorders associated with dominantly gain-of-function mutations in the NLRP3 gene
that result in overactivation of the inflammasome, increased secretion of interleukin
(IL)-1beta and IL-18, and systemic inflammation. It has been reported that oligomeric
particles of the adaptor ASC (apoptosis-associated Speck-like protein with a caspase-recruitment
domain) are released together with IL-1beta and active caspase-1 subunits after activation
of the inflammosome complex and that patients with CAPS show an increased serum concentration
of ASC+ particles.
Objectives: The diagnosis of CAPS is a critical factor due to both the lack of specific
laboratory results and the sharing of similar clinical manifestations with other autoinflammatory
diseases, our aim is to develop a simple assay to evaluate the levels of ASC particles
in the serum of CAPS patients to provide novel biomarkers facilitating early disease
diagnosis and able to monitor treatment responses.
Methods: We developed an ELISA for the quantification of ASC particles in serum and
plasma of normal and pathological subjects. We analysed samples from CAPS patients
and from patients with autoimmune disorders (Multiple Sclerosis (MS), Type 1 Diabetes
(T1D) and juvenile idiopathic arthritis), to confirm that ASC presence in the serum
is not due to other chronic inflammatory processes characterizing autoimmunity. In
addition, we also evaluated the concentration of ASC in the sera of TNF receptor–associated
periodic syndrome (TRAPS) patients to reinforce the concept of specificity of this
biomarker in CAPS patients and not in individuals suffering from others inflammatory
disorders.
Results: We observed that untreated CAPS patients are characterized by the presence
of a significant higher amount of ASC particles when compared with healthy controls
(HS) and with patients suffering from MS and T1D. This tendency was also evident in
patients with arthritis and TRAPS even if the difference was not statistically significant
due to the small number of samples. In addition there is a tendency through a reduction
of ASC levels in CAPS patients after pharmacological treatment, which require future
investigations.
Conclusion: These data suggest that ELISA quantitation of ASC protein could represent
a novel and additional strategy for the diagnosis and monitoring of CAPS.
Disclosure of Interest
F. Carbone: None Declared, L. Cantarini: None Declared, T. Micillo: None Declared,
M. Alessio: None Declared, A. N. Olivieri: None Declared, M. F. Gicchino: None Declared,
A. Insalaco: None Declared, M. C. Maggio: None Declared, O. M. Lucherini: None Declared,
R. Scarpioni: None Declared, M. Piga: None Declared, M. M. Angioni: None Declared,
L. Obici: None Declared, A. Simpatico: None Declared, P. Leccese: None Declared, R.
Consolini: None Declared, R. Manna: None Declared, P. Sfriso: None Declared, S. Bindoli:
None Declared, P. Galozzi: None Declared, I. Orlando: None Declared, S. Chiesa: None
Declared, M. Gattorno: None Declared, G. Matarese Grant / Research Support from: Giuseppe
Matarese reports research grants from Merck-Serono, Biogen Idec, Novartis and IBSA.
P1014 An Italian family with FCAS
Maria Carrabba1, Marina Zarantonello2, Isabella Ceccherini3, Giovanna Fabio1
1Internal Medicine - Rare Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico; 2Department of Clinical Sciences and Community Health , Università degli
Studi, Milan; 3UOC Genetica Medica, UOS Diagnostica Molecolare e Malattie Ereditarie,
Istituto Giannina Gaslini, Genoa, Italy
Correspondence: Maria Carrabba
Introduction: The prevalence of Cryopyrin-Associated Periodic Syndrome (CAPS) is estimated
at about one per million. The Familial Cold Autoinflammatory Syndrome (FCAS) presents
in about 95% of the patients by 6 months with cold-induced, urticaria-like rash, fever,
and arthralgia. FCAS causes lifelong debilitating effects that restrict patients’
daily activities. Diagnostic delay related to lack of knowledge in Autoinflammatory
Diseases is still an important problem.
Objectives: To report an Italian family with FCAS successfully treated with anti-IL1.
Methods: Three subjects, members of the same family, were screened by an experienced
doctor. Clinical and laboratory variables, Brain-CT scan, X-ray, audiometry and lung
function tests were performed. A targeted review of clinical feature for Autoinflammatory
diseases and standardized questioning for CAPS-associated symptoms was conduct. Genetic
testing for the NLRP3 mutation was performed.
Results: A 51 years old woman presented with a long history of maculopapular rash
after cold exposure starting in early childhood associated with low-grade fever, higher
during childhood. During cold months, she needed daily FANS because of fever, and
topical steroids for skin rash, prescribed by dermatologists. The patient was in chronic
therapy with local steroids because of recurrent ulcerative keratitis. Some corneal
scars are present as outcomes. She experienced ocular manifestation on exposure to
cold and summertime in contact with air conditioning. She has a 18-years daughter
and a 15-years son with a long history of maculopapular rash after cold exposure starting
in childhood associated with low-grade fever, fatigue, headache and arthralgia (more
severe in the son) lasting less than 24hours. The two children had the same ocular
manifestations of the mother and underwent local steroids therapy 4-5 times per year.
They all carried the A439V mutation on NPLR3 gene exon 3. Patients were vaccinated
(Pneumococcus, HBV, HAV) before starting treatment for anti-IL1 (canakinumab, a fully
human anti-IL-1β monoclonal antibody, at a dose of 150 mg subcutaneous every 8 weeks).
The Auto-Inflammatory Disease Activity Index (AIDAI, the simplified items scored 0–1
(CAPS range 0–155)) and the Autoinflammatory Disease Damage Index (ADDI) scores were
assessed before every treatment. Before treatment, the AIDAI score calculated during
a winter and summer month was respectively 59 and 5 for the mother, 30 and 3 for the
daughter and 40 and 3 for the son. After 12-months of treatment, the AIDAI score is
zero for the mother and the daughter as well as the ADDI score. During treatment mother
experienced a urinary tract infection and the daughter two distinct infectious episodes:
one of pharyngitis and one of diarrhoea. The son delayed his treatment because of
a severe chronic sinusitis that needed surgical treatment. He just received his first
dose last month.
Conclusion: The NLRP3 mutation A439V was first entered into the Infevers database
in 2002 by Hal Hoffman. It is one of the most common mutations in multiplex families
with CAPS and it is considered a CAPS disease-causing mutation, although the overall
clinical phenotype is rather mild. Most of the patients reported with FCAS carrying
A439V have ocular manifestations (conjunctivitis, keratitis, uveitis) that causes
lifelong debilitating effects that restrict patients’ daily activities, as well as
rash or low-grade fever or myalgia/arthralgia.FCAS-associated ocular manifestations
need treatment with anti-IL1, which typically results in dramatic improvement in clinical
and laboratory measures of inflammation, and is well tolerated. Unfortunately, ophthalmologists,
dermatologist as well as other specialists do not recognise FCAS and do not appropriately
treat this disease nor send patients to Autoinflammatory Diseases experienced Centres.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1015 Scores assessment for clinical management of familial Mediterranean fever
Maria Carrabba1, Marina Zarantonello2, Giovanna Fabio1
1Internal Medicine - Rare Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico; 2Department of Clinical Sciences and Community Health, Università degli
Studi, Milan, Italy
Correspondence: Maria Carrabba
Introduction: Clinical spectrum of Familial Mediterranean fever (FMF) is heterogeneous,
ranging between minimal activity of few affected sites and excellent response to colchicine
and large number of frequent, intolerable, treatment-resistant attacks. Frequent and
severe FMF attacks may result in serious complications. Severity scoring systems for
FMF have been developed and validated in adults (1998 Pras et al., 2005 Mor et al.)
to objectively quantify the disease severity for both therapeutic and prognostic purposes.
In 2016 the ISSF score has been developed with a consensus-driven methodology by paediatricians
and internists, with expertise in this disease, and validated in a large database
comprising both children and adults with FMF. Recently, the ADDI score, which was
developed based on consensus building, purposes to measure the chronic damage by Autoinflammatory
Diseases.
Objectives: This study aims to assess the performance of the existing severity scores
(Mor 2005 and ISSF 2016) for FMF in predicting the therapeutic outcome (colchicine
dosage and residual attacks); and to assess the relation between the above scores
and the ADDI score.
Methods: All the patients with FMF in charge since 2003 have been enrolled. Severity
scores have been calculated at the diagnosis and ADDI has been calculated at the latest
visit. ROC curves and statistical analysis have been performed.
Results: Forty-five consecutive patients affected by FMF (follow-up 1-41 years) with
a median age of 39 years (range 9-89) have been evaluated. Ten patients were diagnosed
for FMF in childhood and 35 in adulthood, with a median of diagnostic delay of 12
years (range 1-45). Eight patients are homozygous carries of one mutation on MEFV
gene exon 10, twelve patients are heterozygous carriers of two mutations on MEFV gene
exon 10, and twenty patients are heterozygous carriers of one mutation on MEFV gene
exon 10.
All patients except four are under therapy with colchicine. Nine patients need more
than 1mg per day of colchicine. Ten patients reported one or two mild FMF attacks
during the year before the last visit. According to the severity score of Mor et al.,
15 patients were stratified as mild disease, 20 as intermediate and 10 as severe.
According to the ISSF score, 37 patients had a mild disease, eight intermediate and
no one severe. Sixteen patients have a positive ADDI score (range 0-4). The ROC analysis
shows that the score of Mor performed better than the ISSF (AUC 0.903vs0.661) to identify
patients needing more than 1mg of colchicine per day. The ISSF has a good performance
(AUC 0.694) to identify patients referring one or two mild attacks in the year before
the last visit. The ROC curves analysis shows that both the Mor (AUC 0.677) and the
ISSF (AUC 0.657) scores can identify patients with chronic damage (positive ADDI score).
ROC analysis of Mor, ISSF and ADDI scores for FMF genetic pattern, showed that only
ADDI has a good performance (AUC 0.811) to discriminate the FMF homozygous patients.
Conclusion: The score of Mor et al. can be useful for prediction of FMF patients needing
higher colchicine dosage. The ISSF score seems to predict better patients with one
or two mild attacks per year. The most of homozygous FMF patients have a positive
ADDI score despite therapy.
Disclosure of Interest
None Declared
P1016 Single center experience with 402 familial Mediterranean fever patients
Ozlem Ozdemir Isik, Senem Tekeoglu, Duygu Temiz Karadag, Ayten Yazici, Ayse Cefle
Department of Internal Medicine Division of Rheumatology, Kocaeli University Faculty
of Medicine, Kocaeli, Turkey
Correspondence: Ayse Cefle
Introduction: Familial Mediterranean Fever (FMF) is an autosomal recessive genetic
disorder that causes recurrent episodes of fever, poliserositis, arthritis, skin eruptions.
Objectives: In this study, we aim to present clinical and demographic features of
FMF patients followed in our clinic.
Methods: The clinical, demographic, genetic features and management of 402 FMF patients
(fulfilling Tel-Hashomer Diagnostic Criteria) were analyzed.
Results: The mean age was 36,8±11,2 (10-71), the mean diagnosis age was 28±11,9 (3-66)
years, and mean duration of disease was 189±125 months. Mean duration between disease
onset and treatment was 93.6±104 months. 43% (174) of the patients had positive family
history for FMF, 7% (29) had consanguineous marriage in family. 24% of the patients
had appendectomy. Fever and abdominal pain both were initial symptoms in 72% of the
patients, while 7% of them had chest pain, 4% had only fever, 15% had arthritis, 1%
had erysipelas like erythema (ELE) as the first symptom of FMF.
Fever was observed 76% of the patients, abdominal pain in 86%, ELE in 13%, chest pain
in 21%, and arthritis in 32%. The frequency of monoarthritis was 21%, oligoarthritis
10,5% and polyarthritis was identified 0,5% of the patients. Ankle arthritis was the
most frequent(20%) one among the patients who had monoartritis. 16% of the patients
had inflammatory back pain, while 11% of the patients were identified with sacroiliitis.
8 patients (2%) suffered from chronic kidney disease and 2 of them were on dialysis
programme. Amyloidosis (diagnosed with biopsy) was identified among 14 patients (3,5%).
At least one mutation of MEFV gene was identified in 78% of the patients. No mutation
could be identified in 8%. MEFV gene analyses was not performed in 14% of the patients.
The most frequent mutation was M694V mutation and its allel frequency was found to
be 54%. For V726A, M680I, E148Q, R761H and A744S allels, mutation frequency were in
order of 11%, 7%, 7%, 2%, 1%. The frequency of compound heterozygositywas 38% and
the most common genotype wasM694V/R202Q (11%).
There was a significant relationship between M694V mutation and arthritis, ELE, amyloidosis
and sacroiliitis (p<0.001). Amyloidosis was more frequent in patients with M694 homozygous
mutation. Mean age of disease onset was lower in patient who had M694V homozygous
mutation than M694V heterozygous mutation (p<0.001).
Conclusion: The most common mutation in our patients is M694V mutation and it is significantly
associated with arthritis, ELE, sacroiliitis, and amyloidosis. Tight control and regular
treatment are important in FMF patients to protect from amyloidosis.
Disclosure of Interest
None Declared
P1017 Testicular ischemia in deficiency of adenosine deaminase 2 (DADA2)
Katherine Clarke, Cathy Campbell, Ebun Omoyinmi, Ying Hong, Muthana Al Obaidi, Neil
Sebire, Paul Brogan
Paediatric Rheumatology, Great Ormond Street Hospital, London, United Kingdom
Correspondence: Katherine Clarke
Introduction: Deficiency of adenosine deaminase 2 (DADA 2) is a rare autosomal recessive
autoinflammatory condition. Recognised features include vasculitis predominantly affecting
medium sized vessels, livedoid skin rash, central and peripheral nervous system involvement,
variable degrees of immunodeficiency, and marrow failure amongst other clinical presentations.
We present the case of a six year old male with DADA 2 who presented with acute testicular
ischaemia secondary to vasculitis, the first such description in DADA2.
Objectives: We wish to highlight the ever-expanding phenotype of DADA2, and to emphasise
the ongoing controversies regarding management of this lifelong genetic disease. Improvements
in our understanding of the pathogenesis will ultimately lead to better biomarkers,
better treatments, and ultimately even cure using gene therapy based on the favourable
clinical outcomes of patients undergoing allogeneic HSCT thus far.
Methods: A six year old male presented acute right-sided testicular pain. His history
included transient infantile neutropenia, resolved hepatosplenomegaly, and longstanding
livedo racemosa, leading to screening and confirmation of DADA2 caused by homozygous
c.139G>C(p.G47R) mutation of ADA2. As his only clinical feature was that of mild livedo
racemosa with normal laboratory parameters at diagnosis, he was being actively monitored
prior to starting any treatment. At a routine clinic follow-up a 24 hour history of
testicular pain was noted on systems review; he was afebrile, and his only physical
signs were that of moderate livedo racemosa, and tenderness of the right testicle.
Laboratory parameters revealed C-reactive protein 8mg/L (reference range [RR]<20mg/L);
erythrocyte sedimentation rate 28 mm/hr (RR<10); and serum amyloid A 5mg/L (RR<10).
Ultrasound-scan of the scrotum revealed significantly reduced perfusion of the right
testes, without torsion; and surgical scrotal exploration confirmed testicular ischaemia
without torsion. Histology demonstrated ischaemic seminiferous tubules with intervening
haemorrhage and acute inflammatory cells, consistent with vasculitis of the testis
as the cause. He was treated with high dose intravenous methyl-prednisolone followed
by a weaning course of oral prednisolone, and subcutaneous adalimumab (anti-tumour
necrosis factor alpha, anti-TNFα). Repeat ultrasound-scan 3 weeks later revealed good
testicular perfusion, with a small area of focal infarction. At last follow-up (11
months post-event) he remained asymptomatic, on treatment with adalimumab.
Results: Figure 1: Livedo racemosa noted on both lower limbs.
Figure 2: Doppler study of both testes (transverse views) showing globally reduced
(but not absent) perfusion in the right testes compared to the left.
Figure 3: Photomicrograph of testicular biopsy showing patchy areas of tubular necrosis
with loss of cellular and nuclear detail and nuclear ‘smudging’ (Right side) with
more normal, viable tubules (Left side); H&E original magnification x100
Figure 4: Acute phase markers before, during, and after acute testicular infarction
in DADA2. Acute phase responses were completely normal prior to testicular infarction.
C-reactive protein (CRP) and serum amyloid A (SAA) remained within the normal range
throughout the episode and follow-up. Erythrocyte sedimentation rate (ESR) was normal,
but was transiently modestly elevated on the day of tissue infarction (arrowed), remaining
normal at follow-up.
Conclusion: The phenotype of DADA2 continues to expand, and we add testicular infarction
to the features of DADA2. CRP and SAA cannot be relied on as reliable biomarkers to
predict tissue ischaemia and hence who to target for anti-TNFα therapy in DADA2, since
these remained steadfastly normal before, during, and after testicular infarction
in this case
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1018 A novel duplication in the X-linked inhibitor of apoptosis protein gene leading
to recurrent hemophagocytic lymphohistiocytosis that is responsive to interleukin-1
blockade
Dilan Dissanayake1, Rebecca Marsh2, Ahmed Naqvi3, Michael Jordan2, Rae Yeung1, Ronald
Laxer1
1Paediatric Rheumatology, The Hospital for Sick Children, Toronto, Canada; 2Bone Marrow
Transplantation and Immune Deficiency, Cincinnati Children's Hospital, Cincinnati,
United States; 3Paediatric Haematology/Oncology, The Hospital for Sick Children, Toronto,
Canada
Correspondence: Dilan Dissanayake
Introduction: We present here a 9 year-old male with recurrent episodes of hemophagocytic
lymphohistiocytosis (HLH), characterized by fever, cytopenias, transaminitis, hyperferritinemia,
hypofibrinogenemia, and elevated levels of soluble CD25 and soluble CD163, in whom
we investigated for an underlying genetic defect.
Methods: Peripheral blood samples were obtained from the patient and his family members
for analysis using next generation sequencing by gene panels commonly associated with
HLH and recurrent fever syndromes, followed by whole exome and whole genome sequencing.The
patient’s blood was also assessed using an enzyme-linked immunosorbent assay for serum
interleukin (IL)-18. Intracellular X-linked Inhibitor of Apoptosis Protein (XIAP)
levels were measured by flow cytometric analysis of peripheral blood mononuclear cells
(PBMC).The function of XIAP was assessed by a previously established assay that measures
intracellular cytokine staining for tumor necrosis factor alpha (TNFa) production
following stimulation of PBMC by muramyl dipeptide (MDP), the ligand for the Nucleotide-binding
Oligomerization Domain-containing protein 2 (NOD2) receptor.
Results: The HLH and recurrent fever syndrome gene panels, as well as whole exome
sequencing were initially unable to identify a contributory variant in this patient.However,
we strongly suspected a primary form of HLH after having measured persistently elevated
levels of serum IL-18 to 2524 pg/ml in between episodes of HLH.Furthermore, we discovered
a family history of recurrent fevers in the maternal grandfather, which was suspicious
for an X-linked condition, such as XIAP deficiency. While awaiting results of whole
genome sequencing, we performed flow cytometry for XIAP, which demonstrated reduced
protein levels in the patient’s T-lymphocyte, B-lymphocyte and natural killer cell
populations.Subsequent results from whole genome sequencing demonstrated a large duplication
spanning three exons within the XIAP gene, which was present in the patient, his asymptomatic
mother, and his maternal grandfather. In addition to decreased protein expression,
MDP stimulation of the patient’s PBMC confirmed a significant functional defect in
XIAP function downstream of the NOD2 receptor.While the above testing was being completed,
the patient was started on anakinra and successfully weaned off steroids, with no
further recurrences of HLH to date.
Conclusion: This case describes the identification of a previously undescribed large
duplication within the XIAP gene, which was initially not identified on gene panels
and whole exome sequencing.This genetic variant is associated with reduced expression
of XIAP in peripheral blood mononuclear cells, as well as decreased function downstream
of the NOD2 receptor.Interestingly, while patients with XIAP deficiency are typically
treated with hematopoietic stem cell transplantation, this patient has been successfully
maintained on anakinra, suggesting an IL-1 dependent link between XIAP and recurrent
HLH. We thereby illustrate the utility of combining genetic and molecular tools for
the identification of contributors to unexplained autoinflammatory presentations,
and present IL-1 blockade as a potential safe and effective alternative for some patients
with XIAP deficiency.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1019 10 year prognosis of patients diagnosed with familial Mediterranean fever
Serdal Ugurlu1, Bugra H. Egeli2, Asli E. Soykut2, Bilgesu Ergezen2
1Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty;
2University of Istanbul - Cerrahpasa, Istanbul, Turkey
Correspondence: Bugra H. Egeli
Introduction: In Familial Mediterranean Fever (FMF), other than amyloidosis factors
affecting mortality are being debated. In our previous study, we did not observe any
atherosclerotic plaque formation in carotid or femoral artery. We thought that the
risk of atherosclerosis did not increase in patients diagnosed with FMF.
Objectives: The aim of this study was to assess the 10 year prognosis and comorbidity
of patients diagnosed with FMF who have been treated in our rheumatology clinic.
Methods: The sample group is a subset of 2009 study. In 2009, the patients who already
had myocardial infarction or cancer diagnosis were excluded. The patients were interviewed
with polar questions of whether they were diagnosed with acute myocardial infarction
(AMI), cerebrovascular events, cancer, diabetes, and hypertension.
Results: We studied 71 patients (37 males, 34 females; mean age: 49.66±6.91) with
FMF, and 59 patients (24 males, 35 females) in healthy control (HC) group. The gender
and age difference between two groups was not found significant.
During 10 year follow-up, 8% of FMF patients had either a cardiovascular or cerebrovascular
event comparing to 5% in HC (p>0.05). 3% of FMF patients had a cancer diagnosis comparing
to 3% in HC (p>0.05). Even though diabetes mellitus diagnosis rate was higher in FMF
patients (15% to 10%), results were still not significant (p>0.05). Hypertension diagnosis
was 5% higher in FMF group (p<0.05)
Conclusion: Even though there was a significant increase in hypertension, increased
diabetes, cancer, and AMI/Stroke ratio was not found significant when compared to
the HCs. Therefore, any cardiovascular and malignancy related comorbidities are not
associated with FMF.
Disclosure of Interest
None Declared
Table 1 (abstract P1019).
Prognostic Factors of FMF patients compared with Healthy Controls
FMF 2018, n(%)
HC 2018, n(%)
p value
Female
34 (47.89)
35 (59)
0,193
Age
49±6.91
51±5.59
0,076
AMI/Stroke
6 (8.45)
3 (5.08)
0,45
Cancer
2 (2.82)
2 (3.39)
0,85
DM
9 (14.86)
6 (10.17)
0,198
Hypertension
25 (33.78)
10 (16.95)
0,019*
Total
71
59
P1020 In a familial Mediterranean fever prevalent region, are familial Mediterranean
fever and Behçet’s disease associated?
Ozgur Alparslan1, Bugra H. Egeli2, Yeltekin Demirel3, Serdal Ugurlu4
1Gaziosmanpasa University, Tokat; 2university of Istanbul- Cerrahpasa, Istanbul; 3Sivas
Cumhuriyet University, Sivas; 4Division of Rheumatology, Department of Internal Medicine,
Cerrahpasa Medical Faculty, University of Istanbul- Cerrahpasa, Istanbul, Turkey
Correspondence: Bugra H. Egeli
Introduction: The co-existence of Familial Mediterranean Fever (FMF) and Behçet’s
Disease (BD) has been questioned. There have been a variety of claims on a common
pathogenesis.
Objectives: We intended to report the prevalence of Familial Mediterranean Fever (FMF)
and Behçet’s disease (BD) and comorbidity ratio of these two diseases in Sivas, Turkey,
a city where FMF is known to be very high.
Methods: Seventy-two primary schools in the center of Sivas participated in the study.
A total of 14881 randomized sample children from 6th, 7th, and 8th grades, and also
985 of them with their parents (n: 978) were interviewed. During these interviews,
the family tree up to second degree relatives was drawn. The presence of a diagnosis
of FMF or BD was questioned. The ones who have a diagnosis were confirmed by contacting
the medical centers. The ones who were suspected of a disease were further investigated
at Sivas Cumhuriyet University Medical Faculty, Family Medicine Outpatient unit. For
each disease a disease related history, physical examination, eye examination and
pathergy test for BD were performed when needed.
Results: 985 students, 978 mothers, 953 fathers and 1876 relatives (4792 in total)
were included in the study. Only 30 (0.6%) of the sample was diagnosed with FMF, and
3 (%0.06) was diagnosed with BD. One of them had concomitant FMF diagnosis.
Conclusion: The prevalence of FMF in Sivas is higher than Turkey’s prevalence; however,
BD prevalence was found very low. According to these findings, it is not easy to conclude
that these two diseases share a similar background of pathogenesis.
Disclosure of Interest
None Declared
Table 1 (abstract P1020).
FMF symptoms within the last year
Symptoms
N
%
Abdominal Pain
20
66.7
Fever
23
76.7
Joint Pain
8
26.7
Chest Pain
10
33.3
Muscle Pain
7
23.3
Erysipelas like erythema
5
16.7
P1021 Does testing for SAA is more beneficial than CRP for the follow-up of patients
with FMF?
Oguzhan Selvi, Serdal Ugurlu, Bilgesu Ergezen, Huri Ozdogan
Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty,
University of Istanbul - Cerrahpasa, Istanbul, Turkey
Correspondence: Bilgesu Ergezen
Introduction: In order to follow subclinical inflammation and adjust the therapy for
an optimal disease control, clinicians seek for readily accessible, affordable and
reproducible markers. C reactive protein (CRP) is widely used for this purpose. Some
suggest that CRP measures are not conclusive in all cases, especially in initial stages
of inflammation. It is suggested that Serum Amyloid A (SAA) may be more reliable and
sensitive in predicting an ongoing inflammation.
Objectives: It is aimed to evaluate if SAA and CRP is correlated in M694V homozygous
FMF cases and if one is superior to the other with regards to early sensitivity.
Methods: In order to evaluate and to compare the sensitivity of SAA and CRP, 234 measurements
from 40 FMF patients with M694V homozygous mutation were obtained during a mean follow-up
of 5 months.For the analysis, the folds of normal CRP and SAA values were used for
correlation.Serum levels of the given markers were measured with nephelometric kits
(normal CRP levels <5 mg/L and SAA levels <6,8 mg/L).
Results: All patients were on prophylactic colchicine. Among 40 patients 1 patient
was being treated with tocilizumab, 2 patients with adalimumab, 19 patients with anti-IL-1
regimens. There were a total of 234 measurements of CRP and SAA from 40 patients.A
similar significant correlation was found when we tested only the values obtained
during 202 attack-free occasions (r = 0,863, p < 0,01). Both acute phase reactants
were increased in 169 measurements, while in 15 CRP was high but SAA was normal and
in 40 SAA was high however CRP was within normal limits. 13 patients has amyloidosis.
A number of 86 CRP and SRR measures, these two parameters were correlated in patients
with FMF Amyloidosis (r = 0,818, p < 0,01). The mean increase in CRP of the population
was 2,82 ± 4,52 fold, whereas mean increase in SAA was 8,47 ± 15,15 fold of the normal.
Conclusion: According to these results, serial testing of SAA does not provide any
additional advantages over CRP. Follow-up with CRP measures particularly in patients
with amyloidosis might be adequate when it is considered that SAA is not superior
to CRP. Readily accessible and affordable bio-marker CRP seems to be sufficient for
follow-up of patients with FMF.
Disclosure of Interest
None Declared
P1022 The pregnancy outcomes in FMF patients who are exposed to IL-1 blockade with
anakinra
Bilgesu Ergezen, Serdal Ugurlu, Huri Ozdogan
Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty,
University of Istanbul - Cerrahpasa, Istanbul, Turkey
Correspondence: Bilgesu Ergezen
Introduction: Some colchicine resistant and/or intolerant FMF cases as well as some
patients who experience severe FMF episodes during pregnancy may require alternative
therapies during their pregnancies. An Anti-IL-1 agent, Anakinra is being used for
this purpose although is still under investigation of researchers.
Objectives: To assess the safety of anakinra in pregnant FMF patients and its effect
on fetal and maternal outcomes.
Methods: Thirteen patients who were exposed to anakinra during their pregnancies were
monitored closely for disease activity, side effects, fetal USG and pregnancy outcome.
Results: A total of 13 FMF cases followed in our clinic were exposed to Anakinra during
the course of their pregnancies due to severe protracted febrile myalgia in 4, thrombocytopenia
in 1 and amyloidosis in 1 and severe attacks during pregnancy in 6. One patient had
a single injection of anakinra due to pericarditis at 2nd GW and had a spontaneous
abortus at 4th GW. Among 13 patients, 2 are still pregnant and both at 8th GW, one
started Anakinra at 5th GW, while the other concieved on Anakinra. One of our patients
was reported previously by Lachman et al1. We represent detailed data of 9 pregnancies
which we have conclusive data regarding the whole pregnancy as well as the follow
up period after birth. The relation of the use of the drug and pregnancy are represented
in Table 1.
Conclusion: Anakinra seems to be a very effective alternative in the treatment of
protracted febrile myalgia non-responsive to colchicine and corticosteroid therapy,
even in pregnant FMF patients who have active disease despite colchicine or intolerant
and also can be given transiently during pregnancy and successfully stopped after
delivery
Reference
1) Lachman HJ, et al. Anti IL-1 therapies and pregnancy outcome. Pediatric Rheumatology
2013, 11 (Suppl 1):A269
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P1022).
See text for description
Case
Maternal Age at pregnancy
Anakinra Relation to pregnancy
USGs
Weeks at delivery
Gender of the baby/fetus
Mode of the delivery
1st minute APGAR
Follow-up duration after birth (months)
Complications after birth
1
28
started at 12th Gestational Week (GW) and used until birth
normal
Birth at 40th GW
girl
vaginal
10
34 mo
No
2
31
Conceived on Anakinra (have been on Anakinra since 2012), discontinued at 29th GW,
reintroduced at 33th GW due to symptom flare.
normal
Birth at 38th GW
boy
C/S
6
48 mo
Methicillin-Sensitive Staphylococcus Aureus incision-site infection (treated with
Tygecycline) in mother
3
24
started at 15th GW and useduntil birth
normal
Birth at 38th GW
boy
Vaginal
8
48 mo
thrombocyte count of the baby was low (23,000/mm3) (After three courses of IVIG, it
was increased to 95,000/mm3 and a month later to 269,000/mm3)
4
32
started at 16th GW, continued for 6 months following the birth at 31th GW
normal
Birth at 31th GW
2 girls
C/S
8 for both babies
42 mo
No
5
25
Started at 23th GW used until birth at 37th GW
normal
Birth at 37th GW
girl
C/S
7
42 mo
Injection site reaction
6
29
Started at 32nd GW, used until birth 40 th GW
normal
Birth at 40th GW
Girl
C/S
?
37 mo
No
7
33
Started at 2013, conceived under Anakinra. Anakinra was stopped at the first month
of pregnancy, she flared and it was reintroduced.
Normal
Birth at 38th GW
Girl
C/S
8
42 mo
No
8
30
Started at 34th GW, used until still birth at 37th GW
Intrauterine death at 37th GW
Pregnancy terminated at 37th GW
Boy
Normal
0
10 mo
No
9
Zeynep
Started at 6th GW, still using after birth
Normal
Birth at 36th GW
Girl
C/S
9
9 mo
No
P1023 Clinical picture of 7 PAPA patients followed in a single pediatric rheumatologic
center
Silvia Federici1, Camilla Celani1, Virginia Messia1, Giulia Marucci1, Christoph Kessel2,
Fabrizio De Benedetti1, Antonella Insalaco1
1Division of Rheumatology, IRCCS, Ospedale Pediatrico Bambino Gesu’, Rome, Italy;
2Department of pediatric Rheumathology & immunology, University Children’s Hospital,
Muenster, Germany
Correspondence: Silvia Federici
Introduction: Pyogenic sterile arthritis, pyoderma and acne (PAPA) syndrome is an
autosomal dominant inflammatory disorder caused by mutations in the PSTPIP1 gene primarily
affecting joints and skin. The E250K mutation cause the hyperzincaemia/hypercalprotectinemia
syndrome termed PSTPIP1-associated-related proteinemia inflammatory (PAMI) syndrome
in which a bone marrow involvement is reported
Objectives: To describe the clinical presentation of 7 PAPA patients followed at a
single pediatric rheumatology center
Methods: For each patient clinical and laboratory data were collected from medical
charts. PSTPIP1 was sequenced through Sanger Sequencing or targeted resequencing using
a customized panel and analyzed with the NextSeq® platform (Illumina)
Results: We describe 7 patients from 4 unrelated families with the E250K mutation
in a mother and 2 siblings, the A230T variant in a father and his son and the R405C
and D266N respectively in the last 2 unrelated patients. Disease onset occurred within
the 7thyear of life in all patients. Patients 3 and 4 (table) presented since the
1st year of life recurrent episodes of fever without any cutaneous or articular symptoms.
In both patients inflammatory markers were elevated during fever episodes but persistently
negative during well-being not requiring any therapy. The variants described in these
patients were not previously reported. However their pathogenic role is supported
by the detection of markedly high serum calprotectin levels (>10.000 microg/ml). The
predominant feature of patients 1 and 2 was articular involvement with recurrent episodes
of arthritis associated to acne. Patient 1 was initially treated with prednisone with
good clinical response but relapse of arthritis at discontinuation followed bythe
development of a sterile muscle abscess. An anti-TNF drug was started in both patients
with complete clinical response. Patient 5 reported severe acne and psoriasis, and
recurrent episodes of sterile arthritis. She presented a persistent elevation of acute
phase reactants with severe anemia and leukopenia not resolving after splenectomy.
His son (pts 6) presented with recurrent episodes of sterile arthritis, hepato-splenomegaly,
anemia and neutropenia. Zinc and calprotectin serum levels resulted respectively 728
micromol/l and 2600 microg/ml. IL-1 inhibition determined a complete normalization
of inflammatory parameters with no effects on anemia and neutropenia. In patient 6
zinchemia decreased to almost normal value after 4 months of therapy. Patient 7 presented
at the age of 4 years a sterile lymphnode abscess. She also presented with splenomegaly
and neutropenia with persistent elevation of acute phase reactants. Anakinra was proposed
but not administered for poor compliance
Conclusion: The clinical picture of patients carrying PSTPIP1 mutation may be heterogeneous.
In our cohort TNF-inhibitors were successfully used in PAPA patients preventing new
arthritis episodes and resolving cutaneous manifestation where present. In 2 patients
the clinical picture was mild not requiring continuous treatment. One PAMI patient
had a good response to IL-1 inhibition, which however, had no effect on hematological
manifestations
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P1023).
See text for description
Patients
Mutation
Clinical features
Laboratory features
Response to therapy
1
A230T
Recurrent fever, acne, cutaneous abscesses, pyogenic arthritis
←CRP,ESR,SAA
Anti-TNF
2
A230T
Acne, pyogenic arthritis
←CRP,ESR,SAA
Anti-TNF
3
R405C
Recurrent fever
← CRP,ESR,SAA, Zinc
/
4
D266N
Recurrent fever
←CRP,ESR,SAA, Zinc
/
5
E250K
Acne, psoriasis, pyogenic arthritis, hepatosplenomegaly
←CRP,ESR,SAA, Zinc, serum calprotectin
/
6
E250K
pyogenic arthritis,hepato- splenomegaly
←CRP,ESR,SAA, Zinc, serum calprotectin
IL-1 inhibition
7
E250K
Limphnode abscess, hepatosplenomegaly
←CRP,ESR,SAA
/
P1024 Clinical presentation, genetic analysis and IFN-score in patients with undefined
interferonopathies
Silvia Federici1, Gianmarco Moneta1, Chiara Passarelli1, Claudia Bracaglia1, Luana
Raffaele1, Fabrizio De Benedetti2, Antonella Insalaco1
1Division of Rheumatology; 2Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Silvia Federici
Introduction: A group of genetic disorders with a disturbance of the homeostatic control
of IFN-mediated immune responses, have been identified (type I interferonopathies).
An increased expression of type I IFN regulated genes, IFN signature (IS), is reported
Objectives: To evaluate the correlation between clinical presentation, genetic analysis
and IFN-score in 10 pts with undefined interpheronopathies
Methods: Patients with suspected interferonopathy based on the presence of typical
clinical manifestations (neurological, muco-cutaneous symptoms), laboratory parameters
(complement deficiency, low platelet count, presence of autoimmunity), instrumental
abnormalities (cerebral calcification), were screened for the IFN-score. Defined IFN-mediated
diseases were excluded. Patients with IFN-score above 10 underwent genetic screening
by running a panel of 24 genes involved in interferonopathies
Results: 10 pts followed in a pediatric rheumatology center were included. 7/10 presented
with recurrent fever (table). Pts 2, 3 and 7 displayed neurological manifestation,
respectively epilepsy, epilepsy and mental retardation and progressive hemiplegia.
To note epilepsy in pts 2 might be due to a bilateral intraventricular hemorrhage
presented at birth. In pts 1,4 gastrointestinal manifestation resembling inflammatory
bowel diseases were described while pts 5,7 and 10 suffered from recurrent abdominal
pain, diarrhea and patient 10 from hypertransaminasemia. Half of the patients complained
arthromyalgia; arthritis developed in pts 2. Cutaneous involvement presented in pts
1,3,6 respectively with widespread panniculitis of trunk and limbs, aspecific vasculitis
and Schonlein Henoch purpura (HSP). Other cutaneous manifestation were urticarial
rash (pts2) and an erythematous, desquamative confluent eczema (pts 4). Autoimmunity
was detected in 2/10 pts. Pts 4 8 had an immunological defect with recurrent infections.
The genetic analysis resulted negative in pts 1 and 7 and is ongoing in patients 5,6
and 8. Patients 2,3,4,9 and 10 carried one mutation in at least one IFN correlated
gene not confirming the diagnosis. All patients presented an increased IS ranging
from 14 to 172.
Conclusion: An elevated IFN-score represent a useful instrument in clinical practice
to classify patients with suspected interferonopaties. It may be an important tool
to select pts to be genetically screened with a defined panel of interferonopathies
correlated genes. In pts in which the genetic analysis results negative, the presence
of a positive IFN-score, may guide clinicians in the management of these patients
and may support therapeutic decisions
Disclosure of Interest
None Declared
Table 1 (abstract P1024).
See text for description
Pts
1
2
3
4
5
6
7
8
910
Systemic symptoms
Fever
Fever
Fever
Fever
Fever
FeverFever, Hemophagocytic
lymphohistiocytosis
CNS
Cerebral calcification
Epilepsy
Epilepsy, mental retardation
/
Hemiplegia
Gastrointestinal
Epatosplenomegaly, aspecific IBD
IBD simil-RCU
Abdominal pain, diarrhoea
Abdominal pain
/
Hypertransaminasemia
Skin/osteoarticular
Arthro-myalgia, , panniculitis
Arthro-myalgia, arthritis, urticarial rash
Arthro-myalgia, vasculitis
Eczema
Arthro-myalgia
erythema polymorphe, HSP
Arthro-myalgia
/
9783
28 16
C3
(90-180 mg/dl)
144
127
81
133
53
137
96
203
C4
(10-40 mg/dl)
34
24
6
23
20
54
17
38
Immunodeficit
autoimmunity
ANA 1:2.560
Anti ds-DNA 1:640
ANA 1:10.240
Anti dsDNA 1:1280
Immunodeficit
ANA neg
Neg
Neg
Neg
Immuno
Deficit
/
WBC/ mmc3
5,2
4,4
9,8
3,9
4,6
8,1
6,4
4,4
3,51,7
Hb g/dl
10,4
12
12,9
10,2
13
11.1
14,1
12,1
16,5 9,7
PLT/mmc3
199
381
194
86
110
277
214
358
150 56
IS
14,2
171,5
54,73
60,09
27,8
17,2
53,9
40,6
32,618,19
Genetic analysis
Neg
PSMB9:p.Arg60Cys
OTULIN:p.Gln115His
CARD8:p.Leu426Phe
IFIH1: p.Arg374His
Neg
ACP5:DNASE2:
p.Arg269p.Ala45Gly
Tr
P1025 Lesson from eurofever registry after the first ten years of enrollment
Martina Finetti, Ilaria Gueli, Joost Frenkel, Seza Ozen, HelenLachmann, Fabrizio De
Benedetti, Isabelle Koné-Paut, Carine Wouters, Paul Brogan, Hermann Girschick, Benedicte
Neven, Alberto Martini, Nicola Ruperto, Marco Gattorno, on behalf of the Paediatric
Rheumatology International Trials Organisation (PRINTO) and the Eurofever Project
UOSD Centro Malattie Autoinfiammatorie e Immunodeficienze, on the behalf of the Paediatric
Rheumatology International Trials Organisation (PRINTO) and the Eurofever Project,
IRCCS Istituto Giannina Gaslini, Genoa, Italy
Correspondence: Martina Finetti
Introduction: In 2008 the Paediatric Rheumatology European Society (PReS) promoted
an International Project for the study of Autoinflammatory Diseases (AIDs) named Eurofever,
whose main purpose is to create a web-based registry for the collection of information
in AIDs patients.
Objectives: To assess the impact of the Eurofever Registry on scientific community
with particular interest in the geographical coverage, diagnostic delay, access to
treatment and pubblications.
Methods: The data analyzed in the study were extracted from the Eurofever registry,
which is hosted in the PRINTO website.
Results: Up to date 4175 patients have been enrolled from 62 countries (3843 of them
with complete demographic data). Most of patients (72%) are resident in Western Europe,
8% in Central-Eastern Europe, 11% in Southern-Eastern Mediterranean, 2% in South America
and 7% in other countries. Compared to the first Eurofever report (Toplak et al, 2012)
we have observed an increase of enrolled patients from 1388 to 2651 in Western Europe,
from 106 to 313 in Central-Eastern Europe, from 294 to 406 in Southern-Eastern Mediterranean.
The median onset age is 4 years (range 1 month – 75 years), the median diagnosis age
is 8 years (range 1 month – 78 years). The median diagnostic delay observed in 2012
was 7.3 years (range 0.3–76), from patients enrolled after 2012 it was 1.9 years (range
0-57). Comparing the mean diagnostic delay from 1980 to 2018, we have observed an
encouraging constant reduction of period between AIDs onset e diagnosis (from a mean
diagnostic delay value of 20 years for patients born before 1980, to a mean value
of 1 year for patients born after 2011). Complete information on access to treatment
were available in 2430 patients. DMARDs were used in 1031 (42%), biologics in 396
(16%) patients. According to the number of enrolled patients, biologics were used
in 361/1782 (20%) of Western europeans, 17/342 (5%) of Central-Eastern europeans,
6/259 (2%) of Southern-Eastern Mediterranean patients. Regarding Eurofever impact
on Scientific Community, during this first 10 years the Registry provided 12 papers
with more than 800 citations. Detailed analysis of clinical features collected in
Eurofever database allowed to perform studies with large cohort of patients, to purpose
new classification criteria (Federici et al, 2015), to validate damage and activity
score (Piram et al, 2014 and N Ter Haar et al, 2017) and to evaluated genotype/phenotype
correlation (Papa et al, 2017).
Conclusion: In the last years we have observed an encouraging increase of involved
Countries, with a greater number of patients coming from geographic area poorly represented
in the first epidemiologic study of Toplak et al. Eurofever data analysis has confirmed
an improvement of diagnostic ability during the last years, with a significant reduction
of mean diagnostic delay. Long-term studies will help understand the efficacy and
safety of different treatments used in these rare conditions.
Disclosure of Interest
M. Finetti: None Declared, I. Gueli: None Declared, J. Frenkel: None Declared, S.
Ozen: None Declared, H. Lachmann: None Declared, F. De Benedetti: None Declared, I.
Koné-Paut: None Declared, C. Wouters: None Declared, P. Brogan: None Declared, H.
Girschick: None Declared, B. Neven: None Declared, A. Martini Grant / Research Support
from: The Gaslini Hospital, which is the public Hospital where AM worked till 31/dec/2018as
a full time public employee, has received contributions from the following industries:Abbvie,
Ablynx, Aim Group, Amgen, Astrazeneca, Biogen, BMS, Boehringer, Celgene, Emd Serono,
GSK, Janssen, Novartis, Pfizer, R-Pharm. This money has been reinvested for the research
activities of the hospital in a fully independent manner without any commitment with
third parties., N. Ruperto Grant / Research Support from: The Gaslini Hospital, where
NR works as full-time public employee, has received contributions (> 10.000 USD each)
from the following industries in the last 3 years: BMS, Eli-Lilly, GlaxoSmithKline,
F Hoffmann-La Roche, Janssen, Novartis, Pfizer, Sobi. This funding has been reinvested
for the research activities of the hospital in a fully independent manner, without
any commitment with third parties.,Speaker Bureau of: NR has received honoraria for
consultancies or speaker bureaus (< 10.000 USD each) from the following pharmaceutical
companies in the past 3 years: Ablynx, AbbVie, Astrazeneca-Medimmune, Biogen, Boehringer,
Bristol Myers and Squibb, Eli-Lilly, EMD Serono, Glaxo Smith and Kline, Hoffmann-La
Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, SanofiServier, Sinergie, Sobi and
Takeda., M. Gattorno Grant / Research Support from: MG has received unrestricted grants
from Sobi and Novartis
P1026 Clinical study of Japanese patients with fever of unknown origin: investigation
of mutations in 22 genes related to autoinflammatory diseases
Kyoko Fujimoto1, Yukiko Hidaka1, Yumi Yoshida1, Makiko Hayashi1, Takuma Koga1, Shinjiro
Kaieda1, Satoshi Yamasaki2, Tomoaki Hoshino1, Hiroaki Ida1
1Division of Respirology, Neurology and Rheumatology, Department of Medicine, Kurume
University School of Medicine; 2Center for Rheumatology, Kurume University Medical
Center, Kurume-shi, Fukuoka, Japan
Correspondence: Kyoko Fujimoto
Introduction: Autoinflammatory diseases cause systemic inflammation mainly by innate
immune abnormality. It is important to have a diagnosis of autoinflammatory diseases
in patients with fever of unknown origin. Examining gene mutations is valuable for
the diagnosis of autoinflammatory diseases; however, the frequency of genetic mutations
in patients with fever of unknown origin is not reported in Japan.
Objectives: We comprehensively analyzed genetic mutations related to autoinflammatory
diseases and clinical features in patients with fever of unknown origin.
Methods: We analyzed mutations of 22 genes related to autoinflammatory diseases as
follows: TNFRSF1A, MEFV, NLRP3, MVK, NOD2, IL1RN, NLRP12, PSTPIP1, PSMB8, PSMB9, PSMA3,
PSMB4, POMP, NLRC4, PLCG2, HMOX1, CECR1, COPA, TNFAIP3, FAM105B, RNF31, RBCK1,in 84
patients with fever of unknown origin who introduced to our hospital from May 2017
to June 2018. Genetic analysis was performed by the next generation sequencer. Furthermore,
we investigated precise clinical features in 53 cases.
Results: Fifteen genes were identified as having novel or rare variants. The most
frequent variants were determined in NLRP12 (8 cases, 6 sites) and NLRP3 (8 cases,
4 sites). In addition, missense mutations including genetic polymorphisms were observed
in MEFV(66.7%). In 53 cases in which clinical symptomatic investigations were possible,
40 cases (75.5%) had definite periodic fever. Among cases with periodic fever, joint
symptoms were observed in 52.5%, and abdominal symptoms were in 35.0%. Colchicine
treatment was effective in 37.5%. Sixty-five percent of patients with periodic fever
had MEFVmutations, including genetic polymorphisms. Almost half of them had novel
or rare mutations in autoinflammatory diseases related genes other than MEFV. The
most frequent variants were determined in NLRP3.
Conclusion: Novel or rare variants in NLRP12and NLRP3were noted in patients with fever
of unknown origin. Sixty-five percent of patients with periodic fever had MEFVmutations
including genetic polymorphism.
Disclosure of Interest
None Declared
P1027 A case of adenosine deaminase 2 deficiency (DADA2) with an uncommon clinical
presentation and response to IV IG
Francesca Garbarino1, Roberta Caorsi2, Stefano Volpi2, Alice Grossi3, Isabella Ceccherini3,
Marco Gattorno2
1Università Degli Studi Di Genova; 2Clinica Pediatrica Reumatologica, UOSD Malattie
Autoinfiammatorie-Immunodeficienze; 3UOC Genetica Medica e UOSD Genetica e Genomica
delle Malattie Rare, Ist. Giannina Gaslini, Genova, Italy
Correspondence: Francesca Garbarino
Introduction: DADA2 is an autoinflammatory disease with autosomal recessive inheritance
characterized by a heterogeneous clinical phenotype ranging from multisystemic inflammation
(fever, polyarteritis nodosa, cerebral stroke, livedo reticularis, gastro-intestinal
involvement, peripheral neuropathy etc.) to immune-dysregulation and immunodeficiency
(lymphoproliferation, recurrent infections, cytopenia etc.).
Objectives: To extend the clinical spectrum of DADA2 reporting a case of isolated
nonspecific systemic inflammatory syndrome associated with slight signs of immune-dysregulation
in a patient with a novel ADA2 mutation.
Methods: In a patient with nonspecific inflammatory phenotype associated to susceptibility
to viral infections, Next Generation Sequencing (NGS) panel was performed; mutations
detected were confirmed by direct sequencing (Sanger analysis). ADA2 enzymatic activity
was analyzed in monocyte isolated from the patient and incubated with adenosine and
an ADA1 inhibitor.
Results: The girl, adopted and of Asian origin, began to suffer from nonspecific systemic
inflammatory symptoms (high persistent fever and arthralgias) at the age of 6 years.
In past history recurrent respiratory infections and impaired immunological response
to viruses (CMV related hepatitis, measles after vaccination) were reported. After
few months the patient developed clinical and laboratory findings of HLH (Hemophagocytic
Lympho-Histocytosis), confirmed on bone marrow samples; treatment with intravenous
(IV) high dose (HD) steroids was started, with prompt response. During steroids tapering
fever and systemic inflammation reappeared; anti-IL1 treatment (anakinra) was not
effective. Immunologic assessment demonstrated mild hypogammaglobulinemia and moderate
NK deficiency on lymphocyte subsets. HD IV Immunoglobulins (IG) (2 g/kg every month)
allowed to achieve a complete control of the clinical picture; the frequency of administration
was progressively reduced to every 4 months due to persistent wellbeing. At the age
of 9, after switching IG to the substitutive dosage, the patient experienced an Herpes
Zoster virus reactivation (requiring prolonged antiviral treatment), followed by the
reappearance of the inflammatory phenotype complicated by HLH with neurological involvement
(irritability and lethargy), responsive to HD steroids and IG. A later cerebral MRI
evidenced a small gliotic area in left Centrum Ovale. After steroids suspension, monthly
HD IV IG administrations maintained clinical remission. Further immunological studies
confirmed a reduction of NK cells with normal function. Hereditary HLH, Autoimmune
Lympho-Proliferative Syndrome (ALPS) and main primary immunodeficiencies were ruled
out. Given the clinical picture, a large NGS diagnostic panel (courtesy by K. Botzug,
Vienna) for autoinflammatory diseases and immunodeficiencies was performed revealing
the homozygous LEU141PRO ADA2 mutation, confirmed by Sanger analysis. Being this mutation
novel, an ADA2 enzymatic activity test was performed revealing a complete loss of
ADA2 activity. The parents refused anti-TNF treatment and the patient is still on
monthly HD IG with a complete wellbeing after 3 years of follow-up.
Conclusion: The current report enlarges the clinical spectrum associated with DADA2
to a persistent unspecific inflammatory syndrome, complicated by HLH. This case further
emphasizes the possibility that NGS could unravel unusual phenotypes of already known
inflammatory syndromes. Even if further reports are required, the response to high
doses IG observed in the present case it is of interest. Even if anti-TNF is the treatment
of choice HD IV IG could be a possible treatment in DADA2, especially during the acute
phase.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1028 Non-amyloid kidney diseases and autoinflammatory diseases: report of 20 cases
and literature review
Charlotte Borocco1,2, Isabelle Kone-Paut1,2, Alexandre Belot3, Marine Desjonqueres3,
Alexandre Karras4, Corinne Miceli-Richard5, Bruno Moulin6, Tim Ulinski7, Jean-Jacques
Boffa8, David Buob9, Gilles Grateau10,11, Sophie Georgin-Lavialle10,11
1Pediatric Rheumatology, Bicetre University Hospital; 2CeReMAIA, Le Kremlin-Bicêtre;
3Pediatric Rheumatology, Lyon University Hospital, Bron; 4Department of Nephrology,
Georges Pompidou European Hospital; 5Department of Rheumatology, Cochin University
Hospital, Paris; 6Department of Nephrology, Civil Hospital, Strasbourg; 7Pediatric
Nephrology, Trousseau University Hospital; 8Department of Nephrology; 9Department
of Pathology; 10Department of Internal Medicine, Tenon University Hospital; 11CeReMAIA,
Paris, France
Correspondence: Sophie Georgin-Lavialle
Introduction: Autoinflammatory diseases (AID) are associated with abnormalities of
innate immunity. Patients display recurrent fever and various signs including digestive
disorders, cutaneous rashes and joint features. One of the most severe complication
of AID is inflammatory amyloidosis (AA) including renal involvement, that can lead
to kidney failure. However, other nephropathies exist and can be misdiagnosed.
Methods: This study was a retrospective, multicentric French study carried out by
medical societies and national reference centers of AID. All patients with non-amyloid
kidney diseases (NAKD) occurring at pediatric or adult age with a genetically proven
or not AID were included.
Results: Twenty patients were included: 13 patients with familial Mediterranean fever
(FMF), 3 with mevalonate kinase deficiency (MKD), one with TNF-receptor associated
periodic syndrome (TRAPS) and 3 with unclassified AID (uAID). Among the 13 FMF patients,
8 displayed homozygous M694V MEFV mutation, the mean age at the occurrence of nephrological
symptoms was 28.6 years old. Renal diagnosis were: Henoch-Schönlein purpura (HSP)
nephritis (n=3), minimal change disease (n=3), IgA nephropathy (n=2), diabetic nephropathy
(n=2), nephroangiosclerosis (n=2) and idiopathic nephrotic syndrome (n=1). Renal treatments
were represented by angiotensin-converting enzyme inhibitors (ACEIs) (n=6), then colchicine
(n=4; dose adjustment or reinstatement of treatment), corticosteroids (n=4), antihypertensive
medication (n=4), dialysis (n=2), levamisol (n=1), kidney transplantation (n=1) and
anakinra (n=1). After treatment, 5 patients were in renal remission, 2 patients had
a transient proteinuria, 5 patients a persistent proteinuria, 2 patients had a renal
insufficiency, and 1 patient was in remission after kidney transplantation.
Among the 3 MKD patients, the mean age at onset of nephrological symptoms was 17.7
years. Renal biopsies found: pauci immune extra capillary glomerulonephritis (n=1),
HSP nephritis (n=1) and segmental focal hyalinosis lesions associated with nephrosclerosis
(n=1). One patient received a kidney transplant with a relapse after it, one was in
pre-transplant status, one was in remission under treatment. They all were treated
with anti IL1 agent.
The TRAPS patient displayed rapidly progressive glomerulonephritis and was treated
with steroids, etanercept and then anti IL1 agent.
The 3 uAID patients displayed: C3 depositional glomerulonephritis (n=1) an IgA nephropathy
(n=2) at a median age of 36 years old.
In our literature review including our cases, we found 124 cases of FMF with NAKD
biopsy proven, 4 MKD patients with NAKD, only 1 TRAPS patient and no cryopyrin associated
periodic syndrome.
Conclusion: Non-amyloid nephropathies can occur in AID; the most frequent ones being
IgA nephropathy and HSP nephropathy. Kidney biopsy is necessary in case of nephrological
signs to optimize the treatment and to limit the evolution towards kidney failure.
Disclosure of Interest
None Declared
P1029 The transition from pediatrics to adulthood in auto-inflammatory diseases: comparison
of 2 transition strategies among 72 patients
Sophie Georgin-Lavialle1, Pierre Quartier2, Brigitte Bader-Meunier2, Katia Stankovic
Stojanovic3, Virginie Avellino3, Samuel Deshayes3, Isabelle Melki4, Alexandre Belot5,
Isabelle Kone-Paut6, Gilles Grateau7, Véronique Hentgen8 on behalf of transition group
project, CEREMAIA, FAI2R and Transition Working Group, National Reference Center for
Autoinflammatory Diseases and AA Amyloidosis
1Internal Medicine, Tenon hospital, AP-HP, Paris; 2Pediatric Rheumatology, AP-HP,
Necker Hospital; 3Internal Medicine, Tenon Hospital; 4Pediatric Rheumatology, AP-HP,
PARIS; 5Pediatric Rheumatology, HCL, Hopital Mère Enfant, LYON; 6Pediatric Rheumatology,
AP-HP, Kremlin-Bicêtre hospital, Kremlin-Bicêtre; 7Internal Medicine, AP-HP, Tenon
hospital, PARIS; 8General pediatry, CH Versailles André mignot, Versailles, France
Correspondence: Sophie Georgin-Lavialle
Introduction: Transition is the period during which the young patient will move from
the pediatric team to the adult team for the follow-up of his or her chronic disease.
It requires perfect coordination between the two medical teams but also the active
involvement of the young person and his or her family. A specific transition program
increases the chances of good health and well-being and reduces mortality in this
age group. We experienced two different transition strategies from two different pediatric
wards to a single adult ward specialized in auto-inflammatory diseases (AIDs) and
compare the efficacy of the 2 strategies.
Objectives:To compare the effectiveness of the transition process in the two strategies,
evaluated by the lost of sight patients avec a median 5 years of follow up.
Methods: Children from 2 pediatric centers were addressed for transition in a single
adult ward. The first strategy concerned 53 patients that were to prepare since the
age of 14 years old and at the age of 18, they were presented for transition thru
a joint consultation with the pediatrician in the adult clinics. The second strategy
concerned 19 patients who came directly from pediatrics without the pediatrician for
an adult medical consultation; the pediatrician explained bye mail and/or phone the
case and sent the patient with his medical file.
Results: Seventy-two young people (29 girls, 43 boys) passed the 10-year transition
step between 2007 and 2017. The AIDs encountered were: familial Mediterranean fever
(n=46), PFAPA syndrome, mevalonate kinase deficiency (n=6 of each), Still's disease
(n=4), TRAPS syndrome (n=3) or another rare MAI (NRLP12 mutation, CAPS, or other rare)
(1 to 2 cases each time). A total of 81% young patients came regularly (about once
a year). Only 3 patients are currently out of sight (4%); none had a clearly identified
single gene MAI requiring very regular follow-up. The young people interviewed are
generally satisfied.
Conclusion: No difference was observed in the transition efficacy process when comparing
the two transition strategies (joint consultation or not). Joint consultation is experienced
as necessary, but our results show that this strategy is not mandatory for a successful
transition. When asked, young people are eager to have written documentation about
their illness and to have the telephone number and e-mail address of the doctor to
contact in case of problems.
These positive results of the effectiveness of a transition program require close
collaboration between the pediatrician and the adult physician regardless of the transition
strategy chosen. The adult doctor must invest in taking care of young people who are
very connected and in case of problems expect a quick response by email most often.
Indeed, more than a joint consultation, the involvement of the adult physician seems
essential to the successful transition from pediatrics to adult service.
Disclosure of Interest
None Declared
P1030 The longitudinal eurofever project: an update on enrollment
Ilaria Gueli, Martina Finetti, Fabrizio De Benedetti, Jordi Anton Lopez, Maria Alessio,
Joost Frenkel, Luca Cantarini, Romina Gallizzi, Judith Sanchez Manubens, Marco Cattalini,
Efimia Papadopoulou-Alataki, Rolando Cimaz, Donato Rigante, Alma Nunzia Olivieri,
Pavla Dolezalova, Alberto Martini, Nicola Ruperto, Marco Gattorno, on behalf of the
Paediatric Rheumatology International Trials Organisation (PRINTO) and the Eurofever
Project
UOSD Centro Malattie Autoinfiammatorie e Immunodeficienze, on the behalf of the Paediatric
Rheumatology International Trials Organisation (PRINTO) and the Eurofever Project,
IRCCS Istituto Giannina Gaslini, Genoa, Italy
Correspondence: Ilaria Gueli
Introduction: In 2008 the Paediatric Rheumatology European Society (PReS) promoted
an International Project for the study of Autoinflammatory Diseases (AIDs) named Eurofever,
whose main purpose is to create a web-based registry for the collection of information
in AIDs patients
Objectives: To implement the Registry with the new recently described AIDs and to
increase the collection of longitudinal data
Methods: The data were extracted from the Eurofever registry, which is hosted in the
PRINTO website (http://www. printo.it). From February 2015 we started the longitudinal
collection of follow-up data with particular focus on treatment, modification of the
clinical picture, onset of complication/adverse events. We have enrolled patients
included in the registry up to 28 September 2018.
Results: Up to date 4175 patients have been enrolled (3843 of them with complete demographic
information, 1903 M and 1940 F) from 62 countries. For 3356 (87%) patients also clinical
data from onset to diagnosis, collected during the first visit performed at referred
pediatric or adult center, are available. For each disease the number of enrolled
patients is: FMF 1086 pts (951 with complete clinical data); TRAPS 273 pts (256 complete);
CAPS 298 pts (279 complete); MKD 205 pts (190 complete); Blau’s disease 49 pts (26
complete); PAPA 42 pts (41 complete); NLRP-12 mediated periodic fever 13 pts (11 complete);
DADA2 14 pts (9 complete); DIRA 3 pts (all complete); SAVI 3 pts (all complete); CANDLE
1 pt (complete) and Majeed 4 pts (all complete). Among multifactorial autoinflammatory
diseases: PFAPA 676 pts (551 complete); CNO 581 pts (540 complete); Behcet 214 pts
(186 complete), undefined periodic fever 368 pts (292 complete) and Schnitzler syndrome
13 pts (all complete). The median onset age is 4 years (range 1 month – 75 years),
the median diagnosis age is 8 years (range 1 month – 78 years). Most of patients (3509,
91%) presented disease onset during pediatric age (<16 years), 334 (9%) during adult
age (81 FMF, 31 CAPS, 53 TRAPS, 40 CRMO, 12 Schnitzler syndrome and 90 unknown fever).
405 of 3509 (12%) patients with pediatric onset received diagnosis during adult age.
The median diagnostic delay is 5 years; diseases with longer diagnostic delay are:
NLRP12 (24 years, range 4-76), CAPS (15 years, range 0-77), PAPA (14 years, range
2-57), TRAPS (12 years, range 0-77). 396 patients have been treated with at least
one biologic drug, 1031 with DMARDs, 427 with systemic steroid and 686 with others
drugs. The most frequent diseases treated with biologic drugs are: CAPS (38%), multifactorial
diseases (22%), TRAPS (14%), MKD (11%), rare monogenic (8%: 1 CANDLE, 2 DIRA, 2 NLRP12,
3 Majeed, 8 DADA2 and 14 PAPA), and FMF (7%). Since February 2015, longitudinal visits
have been inserted for 477 (12%) patients, with detailed data on treatment and safety.
Conclusion: The enrollment in Eurofever Registry is still ongoing. The analysis of
data will improve our knowledge both on the natural history of the single disease
and on the efficacy/safety of treatment commonly used in the clinical practice.
Disclosure of Interest
I. Gueli: None Declared, M. Finetti: None Declared, F. De Benedetti: None Declared,
J. Anton Lopez: None Declared, M. Alessio: None Declared, J. Frenkel: None Declared,
L. Cantarini: None Declared, R. Gallizzi: None Declared, J. Sanchez Manubens: None
Declared, M. Cattalini: None Declared, E. Papadopoulou-Alataki: None Declared, R.
Cimaz: None Declared, D. Rigante: None Declared, A. N. Olivieri: None Declared, P.
Dolezalova: None Declared, A. Martini Grant / Research Support from: The Gaslini Hospital,
which is the public Hospital where AM worked till 31/dec/2018as a full time public
employee, has received contributions from the following industries:Abbvie, Ablynx,
Aim Group, Amgen, Astrazeneca, Biogen, BMS, Boehringer, Celgene, Emd Serono, GSK,
Janssen, Novartis, Pfizer, R-Pharm. This money has been reinvested for the research
activities of the hospital in a fully independent manner without any commitment with
third parties., N. Ruperto Grant / Research Support from: The Gaslini Hospital, where
NR works as full-time public employee, has received contributions (> 10.000 USD each)
from the following industries in the last 3 years: BMS, Eli-Lilly, GlaxoSmithKline,
F Hoffmann-La Roche, Janssen, Novartis, Pfizer, Sobi. This funding has been reinvested
for the research activities of the hospital in a fully independent manner, without
any commitment with third parties.,Speaker Bureau of: NR has received honoraria for
consultancies or speaker bureaus (< 10.000 USD each) from the following pharmaceutical
companies in the past 3 years: Ablynx, AbbVie, Astrazeneca-Medimmune, Biogen, Boehringer,
Bristol Myers and Squibb, Eli-Lilly, EMD Serono, Glaxo Smith and Kline, Hoffmann-La
Roche, Janssen, Merck, Novartis, Pfizer, R-Pharma, SanofiServier, Sinergie, Sobi and
Takeda., M. Gattorno Grant / Research Support from: MG has received unrestricted grants
from Sobi and Novartis
P1031 Digital brachial index testing as a noninvasive tool in diagnosing peripheral
vascular disease in DADA2
Patrycja M. Hoffmann1, Deborah L. Stone1, Karyl Barron2, Cornelia Cudrici3, Alessandra
Brofferio3, Anne Jones1, Tina Romeo1, Ivona Aksentijevich1, Daniel L. Kastner1, Amanda
K. Ombrello1
1NHGRI; 2NIAID; 3NHLBI, National Institutes of Health, Bethesda, MD, United States
Correspondence: Patrycja M. Hoffmann
Introduction: Deficiency of adenosine deaminase 2 (DADA2), is an autosomal recessive
disease caused by biallelic loss-of-function mutations in the ADA2 gene. Deficiency
of ADA2 is the first molecularly described monogenic vasculitis syndrome. In some
cases, DADA2-associated peripheral vascular disease (PVD) can be severe enough to
require amputation.
Objectives: To examine the results of upper and lower digital brachial index (DBI)
and to compare upper and lower DBI tests to corresponding upper and/or lower extremity
MRA tests in patients with DADA2 who have clinical features of PVD.
Methods: Three out of 45 patients with DADA2 seen at the NIH were found to have moderate
to severe PVD. Complete histories were obtained and physical exams were performed.
Upper and/or lower extremity DBI tests and MRA exams were performed.
Results:
28 yo male with DADA2 who had triphasic Raynaud’s syndrome and pustular-like lesions,
bone resorption, and necrotic tissue of various digits, three of which eventually
required partial amputation. DBI of upper and lower extremities showed decreased waveform
and pressure in 1st-5th left upper digits, 1st, 3rd-5th right upper digits, 2nd-5th
left lower digits and 2nd-5th right lower digits. MRA findings showed a single patent
common artery, supplying blood to 2nd-3rd left upper digits, adequate blood flow in
right upper 2nd digit and little to no blood flow in right 1st, 3rd-5th digits. Right
and left lower 1st digit blood flow was patent. There were numerous collaterals to
all lower extremity digits. Thus DBI and angiography were in agreement. DBI results
demonstrated a lack of waveform or pressure in digits that showed poor flow on angiography.
Based on this data, DBI can be considered as an alternative to MRA if cost or renal
insufficiency is a concern.
26 yo female with DADA2 with polyarteritis nodosum and intermittent bilateral 1
st
toe swelling and pain. Right and left lower DBI showed no waveform or pressure in
1st-5th digits. MRA of lower extremity was limited to medium vessel arteries which
were patent bilaterally. Small vessels of the feet were not well visualized because
of MRA limitations so digital blood flow could not be analyzed or compared to abnormal
DBI results.
39 yo female with DADA2 with multiple chronic ankle ulcerations and Raynoud’s syndrome.
Bilateral lower DBI waveform and pressure was normal in the 1st digits bilaterally
but there was decreased pressure and waveform in the 2nd-5th digits bilaterally. MRA
of lower extremity was limited to medium vessel arteries which were patent bilaterally.
Small vessels were not well visualized because of MRA limitations so digital blood
flow could not be analyzed or compared to abnormal DBI results.
Conclusion: The complexity of DADA2 increases the need for expanding diagnostic tests,
some of which can be long and invasive. In the NIH cohort of 45 patients, 3 were found
to have clinical findings of PVD. The upper and lower extremity DBI test helped diagnose
patients with moderate to severe PVD. In our 2nd and 3rd patient, the MRA exam was
limited to medium vessel blood flow testing and therefore blood flow in the small
vessels of the feet were not well visualized.Based on the noninvasive less expensive
DBI diagnostic testing, patients with DADA2 can be screened effectivey and in a timely
manner and avoid exposure to contrast, especially in the setting of renal deficiency.
The additional close monitoring can help expedite diagnosis and treatment to possibly
avoid future amputation as was the case in Patient 1.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1032 The expanding clinical and laboratory spectrum of PAPA syndrome: the NIH cohort
Patrycja Hoffmann1, Amanda K. Ombrello1, Deborah L. Stone1, Karyl Barron2, Anne Jones1,
Tina Romeo1, Michele Nehrebecky1, Jae Chae1, Ivona Aksentijevich1, Daniel L. Kastner1
1NHGRI; 2NIAID, National Institutes of Health, Bethesda, MD, United States
Correspondence: Patrycja Hoffmann
Introduction: The dominantly inherited PAPA syndrome is caused by mutations in PSTPIP1.
It is one of the least understood of the known monogenic autoinflammatory diseases,
both from a pathogenic and treatment perspective. Symptoms include arthritis, cystic
acne, and pyoderma gangrenosum. Therapy includes corticosteroids, interleukin-1 receptor
antagonists, and tumor necrosis factor inhibitors.
Objectives: To review noninfectious epiglottis and sterile osteomyelitis, rare complications
not previously published in PAPA syndrome, and to compare LDH and aldolase levels
in patients with PAPA syndrome vs patients with mutation-negative PAPA-like phenotype.
Methods: The NIH cohort of 20 patients with PAPA syndrome and 10 patients with PAPA-like
phenotype were reviewed. Comprehensive evaluation was performed. MRI, CBC with differential,
LDH, aldolase, CK, CRP and ESR were examined. Patients’ labs were drawn during times
of flare and no flare. CK was drawn to ensure there was no inflammatory muscle involvement.
Results: One patient with PAPA syndrome developed severe sore throat. Clinical and
radiographic evaluation showed piriform sinus swelling consistent with supraglottitis.
CRP and ESR were elevated. WBC was normal. Treatment was started with IV clindamycin
and ceftriaxone; doxycycline was added later. Severe sore throat continued and repeat
radiographic findings showed ongoing swelling. Clindamycin was stopped.Methylprednisolone
and a scheduled dose of golimumab were initiated with significant symptomatic improvement
and normalization of radiographic findings, CRP and ESR.
A second patient with PAPA syndrome developed severe right wrist pain and swelling.
MRI revealed distal right radial epiphyseal marrow abnormalities consistent with osteomyelitis
without synovitis. ESR and CRP were elevated. WBC was normal. The patient was treated
with clindamycin without symptomatic benefit or improvement in MRI findings. Clindamycin
was discontinued. Methylprednisolone and anakinra were initiated which resulted in
decreased pain and improvement in marrow inflammation on MRI. CRP and ESR improved.
Of the 20 patients with PAPA syndrome, LDH, aldolase, and CK levels were drawn. LDH
was elevated in 19/20 patients. Aldolase was elevated in 19/19 patients. CK was elevated
in 5/20 patients. Of the 10 patients with PAPA-like phenotype, LDH was elevated in
1/10 patients. Aldolase was elevated in 2/10. CK was elevated in 1/10. MRIs done on
two patients with PAPA syndrome did not show muscle inflammation during a flare.
Upon further analysis of LDH isoenzymes I-V tested in 12/20 patients with PAPA syndrome,
12/12 had elevated LDH isoenzyme V, a skeletal muscle isoenzyme.
Conclusion: Our findings indicate an expanding clinical spectrum in PAPA syndrome
that includes aseptic supraglottitis and non-bacterial osteomyelitis. Improvement
in clinical symptoms, MRI findings, and acute phase reactants as well as a normal
WBC on methylprednisolone support an inflammatory rather than infectious process.
We do not have a clear understanding as to the relevance of elevation in LDH and aldolase
in patients with PAPA syndrome and overall normal LDH and aldolase in the PAPA-like
phenotype during periods of flare and no flare. LDH isoenzyme V and aldolase are markers
of skeletal muscle involvement. In looking at muscle MRIs and obtaining CK levels,
we did not see any muscle inflammation. Therefore, in addition to pursuing further
testing to rule out muscle damage, additional etiologies for elevation of LDH and
aldolase should be considered.
Disclosure of Interest
None Declared
P1033 Pseudodominant inheritance of Behçet-like autoinflammatory disease associated
with TNFAIP3 (A20) and MEFV mutations in a Turkish family with familial Mediterranean
fever
Nobuyuki Horita1, Ahmet Gul2, Ivona Aksentijevich1, Daniel Kastner1, Elaine Remmers1
1NIH, Bethesda, United States; 2Istanbul University, Istanbul, Turkey
Correspondence: Nobuyuki Horita
Introduction: Familial Mediterranean Fever (FMF) is an auto-inflammatory disorder
that causes recurrent fevers and painful serosal inflammation in the abdomen and pleura
as well as synovial inflammation in the joints. Missense M694V, V726A, M694I, M680I
and other mutations in exon 10 of the MEFV gene are well known to cause FMF, usually
with a recessive mode of inheritance. The MEFV gene encodes pyrin, a key component
of the pyrin inflammasome. FMF-associated mutations in pyrin cause dysregulated activation
of the inflammasome, leading to activation of caspase, which converts pro-interleukin-1
(IL-1) beta to its active cleaved form.
Objectives: We obtained a Turkish kindred with multiple cases with Familial Mediterranean
Fever (FMF) and Behçet's disease (BD)-like manifestations. The index case and her
two daughters, all with Behçet-like disease, were previously found to have a TNFAIP3
frameshift mutation. The high frequency of affecteds could be consistent with a dominantly
inherited inflammatory disease in this family, although other individuals had clinical
features consistent with recessively inherited FMF. We sequenced DNA from members
of this family to determine whether the TNFAIP3 frameshift mutation and MEFV variants
could explain this autoinflammatory disease pedigree.
Methods: Patients were clinically diagnosed to have FMF or BD. Sanger sequence targeting
TNFAIP3 exon 5 and MEFV exon 10 was carried out.
Results: A maternal uncle of the index case and the mother of the index case had compound
heterozygous FMF-associated MEFV exon 10 mutations, M680I and R761H. Two daughters
of the maternal uncle also had compound heterozygous FMF-associated MEFV mutations,
M680I and V726A. The index case and her two daughters had a TNFAIP3 exon 5 frameshift
mutation (TNFAIP3 c.799delG, p.Pro268Leufs*19), which is consistent with their HA-20
diagnosis, and also carried a single allele (heterozygous) of the MEFV R761H mutation.
Conclusion: Segregation of BD-like manifestations in a single Turkish family with
multiple FMF patients could be explained by co-inheritance of a heterozygous exon
10 MEFV variant and one TNFAIP3 mutation, and contribution of MEFV variants on the
BD-like manifestations of HA20 requires further studies.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1034 Systematic review of biological treatment of deficiency of interleukin-36 receptor
antagonist (DITRA) in children and adolescents
Toni Hospach1, Fabian Glowatzki1, Friederike Blankenburg1, Dennis Conzelmann1, Christian
Stirnkorb1, Sandra Müllerschön2, Peter von den Driesch2, Lisa Koehler3, Meino Rohlfs3,
Christoph Klein3, Fabian Hauck3
1Olgahospital Stuttgart; 2Klinikum Stuttgart, Stuttgart; 3Dr. von Haunersches Kinderspital,
Universität München, München, Germany
Correspondence: Toni Hospach
Introduction: Deficiency of interleukin-36 receptor antagonist (DITRA) is a life threatening
autoinflammatory disease caused by autosomal recessive mutations of the IL36RN gene
leading to recurrent episodes of generalized pustular psoriasis with systemic inflammation
and fever. For this disease no standardized treatment guidelines do exist.
Objectives: To systematically review and analyze the data of biologically treated
pediatric DITRA patients.
Methods: For systematic research we made a “pubmed” research using the term “Deficiency
of interleukin-36 receptor antagonist”, “Deficiency of interleukin-36 antagonist”,
“IL36RN mutation” and “DITRA” with age restriction to 18 years.
Results: Our literature research revealed 13 pediatric patients with DITRA and biolocial
treatment. Ten patients were homozygous including six with the p.Leu27Pro, three with
the p.Arg10 Argfs* and one with the p.Thr123Met mutation and four were compound heterozygous.
We add an unreported DITRA patient with a compound heterozygous IL36RN p.Pro76Leu/pSer113Leu
mutation. In total 29 flares in 14 patients were treated with biological agents- targeting
IL-1/R, IL-17, IL-12/23 and TNF-α. Complete response was achieved in 15 (52%), partial
in 4 (14 %), and no response in 10 (34 %) of the flares. Response rates were heterogeneous
among the different agents. While complete/partial/no response with inhibition of
TNF-alpha could be achieved in 6 (46%)/3 (23%)/4 (31%), the inhibition of IL-17 and
of IL-12/23 led in each 4 flares to a 100 % complete response. IL-1/R inhibition led
to complete/partial response in each 1 (13 %) and was not effective in 6 (75%) flares.
Of note, the unreported patient was successfully treated with weekly dosed adalimumab.
Conclusion: DITRA is a rare disease that has to be considered in patients with generalized
pustular psoriasiswith systemic inflammation and fever. It can be effectively treated
with specific biological inhibition of TNF-alpha, IL-12/23 and IL- 17, while anti-IL-1/R
treatment seems less effective. Weekly dosed adalimumab appears to be a novel treatment
option for pediatric patients. Further reports and studies of biological treated pediatric
DITRA patients are warranted for evaluation of optimal treatment.
Disclosure of Interest
None Declared
P1035 Familial Mediterranean fever in Slovakia – clinical and genetic characteristics
of Slovak cohort
Milos Jesenak1,2,3, Lenka Kapustova1, Katarina Hrubiskova4, Tomas Dallos5, Peter Banovcin1
1Centre for Periodic Fever Syndromes, Department of Pediatrics; 2Centre for Periodic
Fever Syndromes, Department of Pulmonology and Phthisiology, Jessenius Faculty of
Medicine, Comenius University in Bratislava; 3Department of Clinical Immunology and
Allergology, University Teaching Hospital in Martin, Martin; 4Centre for Periodic
Fever Syndrome, 5th Department of Internal Medicine, Comenius University in Bratislava,
Faculty of Medicine, University Teaching Hospital; 5Department of Pediatrics, National
Institute of Children’s Diseases, Comenius University in Bratislava, Faculty of Medicine,
Bratislava, Slovakia
Correspondence: Milos Jesenak
Introduction: Familial Mediterranean fever (FMF) is considered to be a rare disease
in the region of Central Europe (CE). True prevalence is still not known and awareness
of FMF is very low.
Objectives: Since the data about FMF prevalence are missing, we aimed to find all
the FMF cases from the whole area of Slovakia. Then we aimed to analyse the clinical
and genetic characteristics of Slovakian FMF patients’ cohort.
Methods: We performed the questionnaire based survey in outpatient clinics for clinical
immunology and rheumatology and hospital departments in Slovakia. We collected all
the genetically-confirmed FMF patients and invite them for clinical examination in
the National Centre for Periodic Fever Syndromes in Martin. They underwent complex
clinical and laboratory examination and detailed history analysis.
Results: All together, we detected 53 FMF patients (males 23, 42%), aged 33.64±17.33
years (males 28.93±17.42 years, females 35.39±17.34 years). The age of first symptoms
was 12.90±13.37 years and the age of FMF confirmation was 31.30±18.18 years, so the
average diagnostic delay was almost 19 years. All the patients had recurrent abdominal
pain (100%) which was accompanied by recurrent fever in 50 pts (94.3%). Other reported
symptoms associated with FMF were: fatigue (77.4%), arthralgia/arthritis (66.0%),
chest pain (56.6%), cervical lymphadenopathy (32.1%), tonsillitis (28.3%), headache
(26.4%) and skin rash during flares (15.1%). Pleuritis was confirmed in 18.9%, pericarditis
in 11.3% and ascited in 22.6%. 3 patients suffered from renal amyloidosis. 3 pts (5.7%)
were homozygotes for pathogenic mutation, 10 (18.9%) compound heterozygotes, 28 (52.8%)
with pseudo-AD inheritance and 12 (22.6%) patients carried mutations of unknown or
possible benign origin. 79% pts were treated by colchicine (mean dose was 1.03±0.51
mg/day), 10 with anakinra (3 regular, 7 on demand) and 9 by canakinumab. 4 patients
were intolerant to colchicine. Isolated elevation of serum amyloid A without concomitant
elevation of C-reactive protein between the flares before the initiation of the treatment
was observed in 34% pts. In 5 of them (9.4%), the IgD elevation was found. In 7 patients,
the origin from FMF endemic regions was confirmed.
Conclusion: This the first complex report about the epidemiology of FMF in Central
European Country with presumed low incidence. We confirmed much higher prevalence
as was expected. The majority of our patients have pseudo-AD form of FMF. All the
available therapeutic options were applied. It is necessary to raise the awareness
of FMF and to shorten the diagnostic delay.
Disclosure of Interest
None Declared
P1036 Diagnostic criteria for proteasome-associated autoinflammatory syndromes (PRAASS)
including Nakajo-Nishimura syndrome, JMP syndrome and CANDLE syndrome
Nobuo Kanazawa1, Hiroaki Ida2, Noriko Kinjo3, Tomoaki Ishikawa4, Ryuta Nishikomori5
1Department of Dermatology, Wakayama Medical University, Wakayama; 2Department of
Medicine, Division of Respirology, Neurology, and Rheumatology, Kurume University
School of Medicine, Kurume; 3Department of Pediatrics, University of the Ryukyus Graduate
School of Medicine, Nishihara; 4Department of Pediatrics, Nara Medical University,
Kashihara; 5Department of Pediatrics, Kyoto University Graduate School of Medicine,
Kyoto, Japan
Correspondence: Nobuo Kanazawa
Introduction: Nakajo-Nishimura syndrome (NNS) was described originally as “secondary
osteoperiostosis with pernio” in Japanese by Nakajo in 1939 and by Nishimura in 1950,
and then reported in English as “a syndrome with nodular erythema, elongated and thickened
fingers, and emaciation” in 1985 and as “hereditary lipo-muscular atrophy with joint
contracture, skin eruptions and hyper-gamma-globulinemia” in 1993. It was in 2011
that similar syndromes have first been reported from outside Japan, which included
“joint contractures, muscular atrophy, microcytic anemia and panniculitis-induced
lipodystrophy (JMP)” syndrome and “chronic atypical neutrophilic dermatitis with lipodystrophy
and elevated temperature (CANDLE)” syndrome. As PSMB8 mutations have commonly been
identified in NNS and these two syndromes, they are now collectively called as “proteasome-associated
autoinflammatory syndromes (PRAASs)”. Recently, their responsible genes are expanding
to other proteasomal genes and, on the other hand, a similar but distinct proteasome-associated
entity “proteasome-associated autoinflammation and immunodeficiency disease (PRAID)”
has been proposed. In Japan, NNS is now registered as an officially-recognized intractable
disease diagnosed by officially-approved criteria.
Objectives: To define the diagnostic criteria of PRAASs.
Methods: So far reported 30 NNS, 3 JMP and 21 CANDLE/PRAAS cases are reviewed and
the temporal diagnostic criteria of NNS are verified for these cases.
Results: Among 8 points of 1) autosomal recessive inheritance (parental consanguinity
or familial occurrence), 2) pernio-like purplish rash in hands and feet (appearing
in winter since infancy), 3) haunting nodular erythema with infiltration and induration
(sometimes circumscribed), 4) repetitive spiking fever (periodic, not necessarily),
5) Long clubbed fingers and toes with joint contractures, 6) progressive partial lipomuscular
atrophy and emaciation (marked in the upper part of body), 7) hepatosplenomegaly,
and 8) basal ganglia calcification, more than 5 are required for temporal clinical
diagnosis of NNS. 80% of NNS, 100% of JMP and 67% of CANDLE/PRAAS cases meet these
criteria, while most of NNS cases reported before 1990 and CANDLE/PRAAS cases without
any description on pernio-like rash do not meet the criteria. If the point 7) is changed
to hepatomegaly and 2 points of 9) microcytic anemia and 10) hyper-gamma-globulinemia
are added and more than 6 of the final 10 points are required for the diagnosis, positivity
of the new criteria reaches 93% of NNS, 100% of JMP and 76% of CANDLE/PRAAS cases.
PRAID cases do not meet these criteria. Genetically, 11 cases of NNS, 3 cases of JMP
and 11 cases of CANDLE/PRAAS cases have homozygous or compound heterozygous PSMB8
mutations, while other digenic (PSMB8 + PSMA3, PSMB8 + PSMB4, PSMB9 + PSMB4), compound
heterozygous PSMB4 or heterozygous POMP mutations are observed in 8 CANDLE/PRAAS patients.
PRAID cases have distinct heterozygous POMP or PSMB9 mutations.
Conclusion: We propose a new diagnostic criteria for PRAASs: clinically, at least
6 points are required among above-mentioned 10 points, and genetically, “definite”
when disease-associated proteasomal gene mutation(s) are identified and “probable”
even if such mutation(s) are not identified, but when other diseases are differentiated.
Disclosure of Interest
None Declared
P1037 Short term follow-up results of children with familial Mediterranean fever after
cessation of colchicine: is it possible to quit?
Ayşe Tanatar, Hafize Emine Sönmez, Şerife Gül Karadağ, Mustafa Çakan, Nuray Aktay
Ayaz
Pediatric Rheumatology, Health Sciences University Kanuni Sultan Süleyman Training
and Research Hospital, Istanbul, Turkey
Correspondence: Şerife Gül Karadağ
Introduction: To define the characteristics of children with familial Mediterranean
fever (FMF) whose colchicine treatment was discontinued and then to compare these
features of the patients whose colchicine was restarted with the ones not restarted.
Methods: Sixty-four out of 1786 children with FMF whom colchicine was stopped by the
physician or patients/parents own decision were enrolled. These patients were grouped
into two as: group 1; children whose colchicine was re-started and group 2; children
whose colchicine was not re-started. The demographic, clinical and genetic data were
collected and compared between group1 and group 2.
Results: Colchicine was stopped in 59.4% (38/64) by the physician and 40.6% (26/64)
of them had stopped colchicine by patients/parents will. Colchicine was ceased at
a median of 10.6 (2.120.5) years of age, and attack- and inflammation-free periods
of 18.2 (6-148) months. The median follow-up of 64 patients after colchicine cessation
was 37.4 (6.4-154.7) months. It was re-started in seventeen patients due to attacks
(n=11) or elevated acute phase reactants (n=6), while remaining 47 patients did not
require colchicine. The age at cessation of the colchicine was lower (p= 0.04) and
duration of colchicine treatment until its cessation was shorter (p= 0.007) in group
1 than group 2.
Conclusion: Even though the results of our study are not satisfactory enough to endorse
the hypothesis that colchicine may be discontinued by close follow-up; older age and
long duration of colchicine treatment before cessation may be two important features
that should be considered in the future studies
Disclosure of Interest
None Declared
P1038 Periodic fever syndromes: a year follow-up of a tertiary pediatric rheumatology
outpatient clinic in Turkey
Nuray Aktay Ayaz, Şerife G. Karadağ, Hafize Emine Sönmez, Ayşe Tanatar
Pediatric Rheumatology, Health Sciences University Kanuni Sultan Süleyman Training
and Research Hospital, Istanbul, Turkey
Correspondence: Şerife G. Karadağ
Introduction: To define the frequency of patients who were suspected to have periodic
fever syndromes (PFS) and their final diagnosis.
Methods: We prospectively evaluated the patients who were initially referred to our
department with suspicion of PFS in a year period. These findings cover only ten months
results as a preliminary study.
Results: A total of 2317 new patients (1142 male/1175 female) were seen. Among them,
724 patients were referred to evaluate for the presence of PFS. Finally, 553 patients
were classified as having PFS. Of those, 444 patients were diagnosed with familial
Mediterranean fever, 43 with periodic fever with aphthous stomatitis, pharyngitis,
and adenitis, 2 with cryopyrin-associated periodic fever syndromes, and 1 with hyper-immunoglobulin
D syndrome. Genetic analyses are still in progress in the remaining 63 patients. Most
common MEFV variant was M694V in our patients. The rest of the patients who were suspected
to have PFS were diagnosed as follows: gastrointestinal disorders (n= 161), infections
(n=6), dysmenorrhea (n=2), immunodeficiency (n=1).
Conclusion: Diagnosing PFS requires a careful evaluation. As our study shows nearly
one third of patients referred to our center were not accepted as PFS.A detailed evaluation
of the patient’s signs and symptoms and also taking the recurrency of these features
into account will help to exclude unnecessary referrals to pediatric rheumatology
units. Although recommendations are present for rheumatologists, generating some clear-cut
algorithms about PFS may provide a practical approach for general pediatricians while
they are evaluating and referring these patients.
Disclosure of Interest
None Declared
P1039 Assessing French liberal pediatricians awareness and referral for reccurent
fever syndromes: the fireville survey
Valerian Koskas1, Remy Assathiany2, Sylvie Hubinois3, Corinne Levy4, Marc Koskas5,
Isabelle Koné-Paut6
1Pediatric Rheumatology, APHP, University of Paris Sud, Le Kremlin Bicêtre; 2Pediatrics,
Liberal Exercise, Issy les Moulineaux; 3AFPA (Association Française de Pédiatrie Ambulatoire),
Saint Germain en Laye; 4Association Clinique et Thérapeutique Infantile du Val de
Marne; 5Liberal Pediatrician, Saint Maur; 6Pediatric rheumatology, APHP, Bicetre Hospital,
Le Kremlin Bicêtre, France
Correspondence: Valerian Koskas
Introduction: Patients with recurrent fevers almost always refer initially to their
family (liberal) paediatrician, their general physician and/or the emergency hospital
departments. If in most cases, benign recurrent viral infections are in causes, it
may underlie rare well–defined disorders such as systemic auto inflammatory diseases
(SAID). At present few is known on the degree of awareness of liberal paediatricians
on SAID and nothing on how they deal with these patients in terms of further investigations,
treatment and referral. FIREVILLE study tries to better understand why patients with
SAID undergo complex medical journey before appropriate referral in our country.
Objectives: To survey, liberal paediatricians on theirs knowledge and practices regarding
children with recurrent fevers
Methods: We took the facilities of the AFPA (French Association of Ambulatory Paediatrics)
to email 1248 active liberal paediatricians between June and September 2018, to answer
a Survey-Monkey type questionnaire. The survey, included 36 questions divided into
3 parts; i.e.Socio-demographic characteristics of paediatricians and their knowledge
on recurrent fever syndromes (RFS), clinical case analysis, then more general evaluation
of knowledge on and analysis of city-hospital networks.
Results:
360 paediatricians (28.8%) answered the survey after 4 email reminders. 77% were women
aged 44 to 60 years with a completion rate of 79%. 22% had part time of hospital practice.
The top 3 regions were: Paris ile de France: 24.9%, Auvergne-Rhône-Alpes: 18.3% and
Provence-Alpes-Côte d'Azur f 9,9%. 69% of paediatricians considered their knowledge
on HRF, and 83% on SAID. PFAPA was the best known (46%), on the basis of the frequency
(92%) and the regularity (89%) of fever. Only 66% considered the duration of fever
as an added diagnostic value. The clinical case was a PFAPA chart. 92% of paediatricians
required whole blood cell count and 91.8% a CRP. 70% of paediatricians ruled out radiologic
evaluations. They were 80.6% to suspect PFAPA and 14% to suspect FMF. 57% asked second
opinion, in a paediatric rheumatology unit (46%) and in general paediatrics (35%).
Youngest paediatricians chose more significantly a paediatric rheumatology unit (p
= 0.009).Only 44% of responders knew a SAID referral centre in their area. Finally,
90% were interested in joined city-hospital care.
Conclusion: This is the first study surveying liberal paediatricians on their knowledge
and practices with a child with supposed HRF. In spite of their thought insufficient
knowledge, their answers were accurate in most cases, however the questionnaire revealed
insufficient knowledge of the dedicated resources and network for SAID.
Disclosure of Interest
None Declared
P1040 Crimean Tatars is new target nationality for the familial Mediterranean fever
Olga Zhogova1, Natalya Lagunova1, Sergey Ivanovskiy1, Evgeny Suspitsin2,3, Mikhail
Kostik2
1V.I. Vernadskiy, Crimean Federal University, Simferopol; 2Saint-Petersburg State
Pediatric Medical University; 3N.N. Petrov Institute of Oncology, Saint-Petersburg,
Russian Federation
Correspondence: Mikhail Kostik
Introduction: Familial Mediterranean Fever (FMF) is a monogenic autoinflammatory disease
with high prevalence in some nationalities, such as Jew, Armenians, Turkish, Arabians
and other nationalities with Mediterranean origin. Before 2016 there were no data
about FMF distribution in the Crimea region, but the first 15 new cases of FMF were
diagnosed in the last 2 years.
Objectives: The aim of our study is the evaluation of the distribution of FMF in the
Crimea region.
Methods: Our cohort consists of 13 children and 2 adults, among them were 2 parents
and 6 kids from 1 family. All belong to Crimea Tatar nationality. This nationality
is close to Turkish. The diagnosis of FMF was based on the Tel-Hashomer criteria and
later was confirmed by MEFV gene sequence.
Results: 10 children with FMF have M694V heterozygous mutation, 3 have M694V homozygous
mutations, and 2 adults (parents) have M694V homo (father) and heterozygous (mother)
mutations. Ten children and 2 adults are treated with colchicin. 2 kids and 1 adult
(all M694V/M694V) received canakinumab due to inefficacy and 1 child (M694V/N) due
to intolerance of increased doses. Clinical characteristic of the studied population
are in the table.
Conclusion: Crimean Tatars is a new nationality with an increased prevalence of FMF
with typical high penetrance mutations. Further epidemiological studies required about
MEFV alleles distribution in the healthy population and in the FMF patients.
Disclosure of Interest
None Declared
Table 1 (abstract P1040).
See text for description
The # of patients
Big criteria
1. Typical recurrent seizures fever with serositis
15
2. Peritonitis
13
3. Pleurisy
1
4. Monoarthritis (hip, knee, ankle joints)
12
Small criteria
1. Stomach
13
2. Thorax
1
3. Joint
10
4. Load pain in legs
9
5. A good response to colchicine therapy.
9
Supporting criteria
1. The presence of FMF cases in the family history
11
2. Belonging to the relevant ethnic group
15
3. Age of onset of the disease d 20 years
15
4. heavy bedridden
14
5. spontaneous resolution attack
15
6. the presence of bright gaps
15
7. increase in laboratory markers of inflammation
14
8. episodes of proteinuria/hematuria
9. unproductive laparotomy or removal of “white”appendix
10. parental blood marriage
3
P1041 New variant in the IL1RN-gene associated with late onset and atypical presentation
of DIRA – follow-up
Jasmin B. Kuemmerle-Deschner1, Kerstin Reicherter2, Susanne Schlipf3, Sandra Hansmann1,
Anton Hospach4, Ilias Tsiflikas5, Xiao Liu6, Susanne Benseler7, Alexander Weber6
1Department of Pediatrics, Division of Pediatric Rheumatology, University Hospital
Tuebingen; 2CEGAT, Tuebingen; 3Kinderarztpraxis Dr. Lakner, Schwäbisch Gmünd; 4Zentrum
für Pädiatrische Rheumatologie, Klinikum Stuttgart, Olgahospital, Stuttgart; 5Pediatric
Radiology, Department of Radiology, University Hospital Tuebingen; 6Department of
Immunology, University of Tuebingen, Tuebingen, Germany; 7Rheumatology, Department
of Pediatrics, University of Calgary, Calgary, Canada
Correspondence: Jasmin B. Kuemmerle-Deschner
Introduction: Deficiency of the Interleukin-1 receptor antagonist (DIRA) is an autoinflammatory
disease characterized by severe systemic inflammation with bone and skin involvement
present in the first days of life. Here we report on diagnosis, treatment and follow
up of a novel variant in the IL1RN-gene associated with late onset and atypical phenotype
of DIRA.
Objectives: Here we report on diagnosis, treatment and follow up of a novel variant
in the IL1RN-gene associated with late onset and atypical phenotype of DIRA.
Methods: A 3 year-old boy presented with recurrent monthly episodes of fever and fatigue,
associated with lymphadenopathy, pericarditis, pleuritis, pancreatitis, and arthritis
involving sacroiliac, hip, knee and ankle joints in the absence of any skin involvement.
Symptoms had started at age one and had progressed over time to life-threatening episodes
requiring intensive care therapy. Throughout, inflammatory parameters including ESR,
CRP, SAA, S100A8/9, leukocytes and platelet counts were highly elevated. Treatment
with colchicine and steroids improved symptoms but did not prevent flares. Typical
immune deficiencies were ruled out; genetic testing for FMF, CAPS, TRAPS, HIDS and
DITRA did not reveal variants in the associated genes.
Results: Whole exome sequencing detected a novel homozygous stop variant c.62C>G;
p.Ser21* in the ILRNgene (NM_173842.2). Mother, father and brother were heterozygous
for the same variant. In addition, three variants of unknown significance were identified
in the patient's PCGF5, CPA1and SPTA1genes. Functional studies revealed only marginal
secretion of IL-1RA in the patient’s unstimulated leukocytes and after stimulation
with IL-1βand LPS, confirming the disease-causing nature of the variant.
IL-1 inhibition with anakinra at 2 mg/kg/d was started and resulted in complete resolution
of clinical symptoms and signs of inflammation on MRI, in normal inflammatory markers,
and dramatically improved energy levels. Intolerance to daily subcutaneous injections
prompted a switch to canakinumab at 4 mg/kg/4 weeks. However, as per the patient’s
and mother’s assessment of disease activity, canakinumab was inferior to anakinra.
After four months a flare occurred, prompting re-start of anakinra and resulting in
sustained and complete resolution of symptoms in an observation period of 14 months.
Conclusion: This is the first report of the novel c.62C>G; p.Ser21* variant in the IL1RN-gene
primarily causing severe serositis in a homozygous carrier, while heterozygous family
members were completely symptom-free. Skin disease, one of the most prominent features
in other patients with DIRA was not observed in this patient, while IL-1 inhibition
was likewise effective.
The different phenotype in the patient reported here, may be due to the selective
loss of secreted IL1RN. Unlike one report of successful canakinumab treatment of one
patient with late onset of DIRA [1], our patient did not respond favourably to canakinumab,
but treatment with anakinra lead to sustained remission.
1 Ulusoy et al. J Med Case Reports 2015; 9:145
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
J. Kuemmerle-Deschner Grant / Research Support from: Novartis, SOBI,Consultant for:
Novartis, SOBI, K. Reicherter Employee of: CEGAT, S. Schlipf: None Declared, S. Hansmann:
None Declared, A. Hospach Consultant for: Novartis, Chugai-Roche, SOBI, I. Tsiflikas:
None Declared, X. Liu: None Declared, S. Benseler Consultant for: Novartis, SOBI,
abbvie, A. Weber: None Declared
P1042 Efficacy of anti-IL-1 treatment in familial Mediterranean fever: a single-center
experience
Tuba Kurt, Halide O. Basaran, Fatma Aydın, Nermin Uncu, Banu Celikel Acar
Pediatric Rheumatology, Ankara, Child Health Hematology and Oncology Education and
Research Hospital, Ankara, Turkey
Correspondence: Tuba Kurt
Introduction: In 5%–10% of patients with familial Mediterranean fever (FMF), colchicine
is not effective in preventing inflammatory attacks. Furthermore, another 5%–10% of
patients are intolerant to effective doses of colchicine and experience serious side
effects. In recent years, it has been shown that interleukin-1 (IL-1) plays a central
role in the pathogenesis of FMF.Several reports have pointed out the efficacy of IL-1
blockade in colchicine resistant FMF.
Objectives: To review the patients followed with FMF who received anti-IL-1 treatment,
in terms of outcome and side effects
Methods: 18 FMF patients who were treated with anti-IL-1 treatment were retrospectively
reviewed with regard to indication, effect on disease activity and acute phase response,
adverse events and AIDAI score and patient global assessment. Colchicine resistance
was defined as at least one attack per month for three consecutive months and elevated
erythrocyte sedimentation rate or C-reactive protein in-between attacks despite taking
adequate dose of colchicine.
Results: There were 18 patients with FMF (9 M/ 9 F) who were treated with Anakinra
and Canakinumab for various indications (colchicine resistant recurrent febrile attacks
in 16, colchicine related side effects in 1, subclinic inflamation in 1). 11 patients
were treated with Anakinra while were 15 patients with Canakinumab. All patients except
5 had homozygous or compound heterozygous exon ten mutations. The mean age of onset
of anti-IL-1 treatment was 15± 2 (11-18 years) years. The mean duration of the disease
was 11.1 ± 4.34 years. All patients were taking adequate dose of colchicine for their
age before treatment with a median dosage of 0,03 ±0,012 mg/kg/day before anti-IL-1
treatment (0.03–0.06 mg/kg/day). 11 patients were treated with anakinra with a median
duration of 29,7 months (8- 60 months), but 6 of them switched to canakinumab because
of noncompliance and side affects (2 headache, 1 urticerial rash), all responded.After
the initiation of Anakinra treatment 6 patients became attack-free, 2 patients reported
more than 50% decrease, and 3 patients no change in the frequency of the attacks.
15 patients were treated with Canakinumab but 2 (%13,3) of them swiched to anakinra
because had increase in frequency of the attacks. All of patients complete respondend
and any of them were no side effects.
A significant decrease was observed in the mean CRP (from 8.5± 8.7 mg/dLto 0.68 ±
0.75 mg/dL), WBC (from 10335 ± 3206 mm³ to 7047 mm³± 2108mm³) and ESR levels (from
44.35 ± 18.7 mm/h to 9.5 ± 7.6 mm/h), respectively (referance range for CRP: 0–0.3mg/dL).
AIDAI score decreased from 25±17,5 to 0,33±1 and mean pyscian’s global assessment
7,4±1,5to 1,25±1,1 respectively, under anti-IL-1 treatment treatment.
As for the adverse events, 1 patients (%9) had allergic reactions under Anakinra treatment
(severe disseminated rash in 1 patient ) and 2 patients (%18,1) had headache which
necessitated termination of treatment in 3 patients. There were no adverse events
in the remaining all patients during the course of treatment.
Conclusion: Based on the results of our study, anti-IL-1 therapy seems to be a safe
and effective alternative for patients with FMF who do not respond to or cannot tolerate
colchicine, however approximately one fourth of the patients stop anakinra for insufficient
response and injection site reaction. The treatment should be modified and decided
for each patient on an individual basis.
Disclosure of Interest
None Declared
P1043 Erysipelas-like erythema as the primary gripe of FMF
Omer Kuru1, Ahmet Ki̇vanc Cengi̇z2
1Physical Medicine and Rehabilitation, Division of Rheumatology, University of Heath
Sciences, Istanbul Okmeydani Research and Training Hospital, Istanbul; 2Physical Medicine
and Rehabilitation-Rheumatology, 19 Mayis University Faculty of Medicine, Samsun,
Turkey
Correspondence: Omer Kuru
Introduction: Familial Mediterranean Fever (FMF) is a monogenic autoinflammatory disease
characterized by recurrent polyserositis attacks, mainly involving peritoneum, pleura
and synovium. Erysipelas-like erythema (ELE) is an aseptic neutrophilic dermatose
defined as well-demarcated, warm, tender, erythematous and infiltrated plaques which
resolves spontaneously in 2-3 days. ELE is a pathognomic cutaneous manifestation of
FMF. The reported frequency of ELE is 5-30 % in different populations. It typically
developes on the extensor surface of lower extremities especially on dorsum of ankles
and feet. It is usually unilateral and associated with more severe FMF clinical phenotype
and M694V homozygosity.
Objectives: Here we would like to present a 12 year old girl admitted to the emergency
service with an erythematous, painful rash at the dorsum of her foot. This was her
fourth admission in approximately 9 monthstime with a similar skin lesion at dorsum
of the same foot. In her medical records previous diagnosis for the described lesion
were insect bite, contact dermatitis and cellulitis. Oral and topical antibiotics,
topical steroids were prescribed in her previous visits. She told that regardless
of the medication used the lesions resolved spontaneously in 3-4 days time. She had
also noticed that the lesions usully occured after her volleyball matches. Exercise
and long time standing usually has caused pain in her legs and if she insists on the
activity despite this pain, the lesions occured. She had no prominant abdominal or
pleural pain. She didn’t have arthritis but had episodes of fever lasting 36-48 hours
accompanying the skin lesions. Her family history was unremarkable except FMF in one
of her cousins. Her laboratory tests revealed leukocytosis, elevated crp and fibrinogen
levels. She did not have proteinuria.
Methods: Case report
Results: The recurrence of the typical lesion, spontaneous recovery in 3-4 days time,
accompanying fever and positive family history reminds the diagnosis of FMF. Genetic
analysis was performed and compound heterozygous genotype (M694V/V726A) was detected.
Colchicine was prescribed. She is 14 years old now and did not have any typical serositis
attack yet. Under colchicine treatment the ELE attacks did not disappear completely
but their frequency and severity decreased prominently and fever did not accompany
her ELE attacks any more.
Conclusion: Spontaneous recovery, recurrence of the attacks, accompanying fever and
elevated acute phase reactants during the attacks points out FMF especially in inhabitants
of the Mediterranean basin. Occurence of ELE as the first manifestation of FMF is
rare but this possibility must also be kept in mind.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1044 Analysis of new referrals to a specialist UK adult autoinflammatory disease
service
Serdal Ugurlu1, Philip N. Hawkins2, Charalampia Papadopoulou2, Tamer Rezk2, Dorota
Rowczenio2, Helen J. Lachmann2
1Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty,
University of Istanbul - Cerrahpasa, Istanbul, Turkey; 2National Amyloidosis Centre,
Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free
Campus, UCL, London, United Kingdom
Correspondence: Helen J. Lachmann
Introduction: Diagnosis of the SAIDs requires a high index of suspicion and previous
series has suggested that there are often long diagnostic delays, particularly in
TRAPS and MKD.
Objectives: To look at the case mixed referred to a single adult clinic in London
specialising in assessment of potential SAIDS over the course of the year of 2017.
Methods: All new referrals were accepted for clinical assessment. At the first visit
patients had a full history and examination, genetic testing – varying from single
gene to a 20 gene panel depending on clinical features, and laboratory testing including
fortnightly blood draws for serial analysis of the hepatic acute phase response proteins,
CRP and SAA over a 3 month period.
Patients with a non suggestive history, non contributory genetic testing and no evidence
of inflammation accompanying symptoms were felt not to have SAIDS and referred back
to their local hospitals for further management. Other cases were diagnosed based
on full clinical assessment, other investigations – for example ferritin in AOSD,
genetic testing results, serial monitoring of CRP and SAA and therapeutic trials,
for example colchicine in presume FMF and anti IL-1 therapies in CAPS and Schnitzler’s
syndrome.
Results: 273 new patients were referred. Median age at referral was 37.4 years, the
oldest patient was 84.3 years old and 59% were female. 174 (64%) were of northern
European ancestry, 68 (25%) were eastern Mediterranean, west Asian or southern European
ancestry, 19 (7%) were of south or east Asian ethnicity and 4% were of African or
Afro-Caribbean ancestry. 76% of referrals were from hospital specialities. The referral
source was: rheumatology 38%, general practitioner 24%, dermatology 8%, immunology
8%, gastroenterology 6%, infectious diseases 3%, clinical genetics 3%, nephrology
2%, haematology 2%, gynaecology 2%, emergency department 1%, respiratory 1%, other
2%.
After work up 135 (49.5%) were felt not to have a SAID as the cause of their symptoms.
Of the remaining 138 patients who did have evidence of a SAID the diagnoses made were:
FMF 33%, uncharacterised SAID 26%, CAPS 9%, AOSD 8%, recurrent idiopathic pericarditis
6%, Schnitzler’s Syndrome 5%, TRAPS 4%, variant PFAPA 4%, DADA2 1%, MKD 1%, CRMO 1%,
Behcets 1%, Cattleman’s disease 1%.
The median interval between reported symptom onset and diagnosis were as follows:
16 yrs for FMF, 28.1 yrs for CAPS, 5.0 years for recurrent idiopathic pericarditis,
4.5 yrs for Schnitzler’s Syndrome, 5.7 yrs for TRAPS, 20.5 yrs for variant PFAPA,12.5
yrs for DADA2, 17 yrs for MKD and 2 years for CRMO.
Conclusion: This series suggests that recognition and diagnosis of the SAIDS remains
a challenge. More than 1/3 of referrals were from rheumatology, referrals from primary
care were almost exclusively from patients with a known family history of one the
inherited syndromes. The wide variety of referring specialities reflects the diverse
nature of SAIDS and the importance of almost all specialities considering the possibility
of SAIDS. Only just over 50% referrals had evidence of diseases falling within the
recognised SAID spectrum and 26% of these have currently uncharacterised disease with
non diagnostic genetic testing. Of those in whom a diagnosis could be made there are
significant diagnostic delays fortunately despite late initiation of treatment no
patients had evidence of systemic AA amyloidosis.
Disclosure of Interest
None Declared
P1045 Application of autoinflammatory disease damage index (ADDI) to other autoinflammatory
diseases in a tertiary referral hospital
Mireia Lopez, Estefania Moreno
Pediatric Rheumatology, Hospital Vall d’Hebron, Barcelona, Spain
Correspondence: Mireia Lopez
Introduction: Autoinflammatory diseases (AIDs) cause systemic inflammation that can
be chronic and result in damage to multiple organs. Recently, the autoinflammatory
disease damage index (ADDI) has been developed and validated to the four most common
monogenic AIDS, cryopyrin-associated periodic syndrome (CAPS), familial Mediterranean
Fever (FMF), mevalonate kinase deficiency (MKD) and tumor necrosis factor receptor-associated
periodic fever syndrome (TRAPS). ADDI could be useful in other AIDs different than
the four reported.
Objectives: The aim of the study is to asses the application of ADDI to patients with
AIDs followed in our hospital with the four most common monogenic diseases and other
AIDs, determine the reliability and point out encountered comments about the scoring.
Methods: All patients with AIDs followed in Transitional Care unit or Pediatric Rheumatology
specialized in AIDs consult from Hospital Universitari Vall d’Hebron were identified.
A cross- sectional, descriptive study was performed applying ADDI by two pediatric
rheumatologists (EM, ML). Laboratory test including C-reactive protein (CRP) mg/dl,
amyloid protein (AP) mg/L, erythrocyte sedimentation rate (ESR) mm/h and protein/creatinine
rate (mg/g Cr) were performed at the moment ADDI was applied. Variables related with
disease duration, current treatment and accumulated corticosteroids treatment was
assessed. The continuous data are presented as mean and standard deviation (SD). Categorical
variables are presented by percentages.
Results: A total of 41 patients with AIDs were included, of whom 61% were female,
with a median age of 20 years (SD 11.9) at inclusion. Disease duration has a mean
of 11 years (SD 8.2). AIDs included were 11 patients with FMF (26.8%), TRAPS n=4 (9.8%),
MKDn=3 (7.3%), CAPS n= 2 (4,9%), Blau syndrome n= 7 (17.1%), SAVI syndrome n=3 (7.3%),
CRMO n=4 (9.8%), PFAPA n=2 (4.9%), APLAID n=1 (2.4%), Stickler syndrome n=1 (2.4%),
and 3 unknown AIDs with genetic test negative n=3 (7.3%). Current treatment is variable
among patients, 6 (15.8%) are taking disease-modifying antirheumatic drugs (DMARDs),
9 (23.7%) Colchicine, 8 (21.1%) Anakinra, 13 anti-TNF therapy (34.2%), 1 (2.6%) Ruxolitinib
and 1 (2.6%) Abatacept.Just 6 patients were receiving corticoids with mean prednisone
dose of 7.5 mg/day.
ADDI mean score was 2.3 (SD 2.2) for all patients. Regarding the eight different items
evaluated, musculoskeletal domain was the highest punctuated with a mean of 1.02 points,
followed by ocular domain with 0.42 points. Laboratory test results were mean ESR
27.2 mm/h (SD 26.7), CRP 0.7 mg/dl (SD 1.3), AP 13.9 mg/L (SD 18.6). Proteinuria was
present in 2 patients with mean 286.5 mg/g (SD 246.1). EM and ML applied ADDI in 5-10
minutes average.
Conclusion: ADDI is a feasible index suitable to measure damage in a single patient.
Despite it was performed to the four most common AIDs it could be applied to other
diseases. In our cohort mean ADDI was low with musculoskeletal item as the highest
punctuated. This result could be explained by the correct control of the disease with
the current treatment.Laboratory tests also support this finding. Despite good response
to medication, it is difficult to reverse bone deformities or joint restriction. Nevertheless,
some organ systems are not represented like respiratory, cardiovascular or cutaneous
damage, important in some syndromes included in our cohort. Knowing the difficulties
of conducting an unified index for all diseases, ADDI must be applied in longitudinal
cohorts.
Disclosure of Interest
None Declared
P1046 Vasculitis in autoinflammatory diseases in a tertiary hospital
Rosa M. Alcobendas, Sara M. Loza, Pablo F. Fraga, Clara U. Gascon, Catarina Fervenza,
Agustin Remesal
Pediatric Rheumatology, University Hospital La Paz, Madrid, Spain
Correspondence: Sara M. Loza
Introduction: Autoinflammatory diseases with vasculitis and interpheronopaties have
been recently described and may present with variable clinical signs. Such entities
are considered rare diseases and potentially life-threatening. Clinicians should be
aware of the existence of autoinflammatory vasculitis to diagnose and treat them correctly.
Objectives: To describe the initial manifestations, laboratory findings and therapeutic
approaches of patients diagnosed with autoinflammatory vasculitis during the last
5 years in a pediatric rheumatology unit of a tertiary hospital.
Methods: Retrospective chart review. Inclusion criteria were: children under 18 years
diagnosedwith monogenic autoinflammatory vasculitis in a tertiary hospital.
Results: During the study period, 5 patients were identified (2 boys and 3 girls).
The main clinical manifestations were severe cutaneous lesions (5/5), intermittent
fever (4/5) and neurological involvement (4/5) (see table 1).The only patient without
neurologic manifestations had relatives with psychomotor retardation and sensorineural
symptoms of unknown etiology. All patients were diagnosed of with another rheumatology
condition,with no response to conventional treatment.
Conclusion: Autoinflammatory vasculitis are extremely rare entities but potentially
fatal. The early age of onset, the intense skin involvement as well as the presence
of affected relatives may be suggestive data. Clinical suspicion is important in order
to establish an early and adequate treatment.
Disclosure of Interest
None Declared
Table 1 (abstract P1046).
Clinical characteristics of the patients
Diagnosis and gene
Age of onset and clinical manifestations
Laboratory & inmunology
Previous diagnosis
Treatment & response
Patient 1
CANDLE
(PSMB8)
Neonatal period:
Fever, chondritis, aseptic meningitis, joint limitations, erythematous plaques,lipodystrophy,
lymphadenopathy, splenomegaly and hepatomegaly
Anemia, ESR 122 mm/h, CRP 100 mg/L, AST 55 U/L, ALT 51 U/L,
CINCA
Anakinra (no)
Tocilizumab (no)
Baricitinib (yes)
Patient 2
ISG15 defficiency (ISG15)
6 months:
Intermittent fever, severe cutaneous ulcerations skin, chorioretinitis, brain calcifications
CRP 75 mg/L, HLA B51 (+), ANA (-), ANCA (-), AST 80 U/L, ALT 65 U/L
Early onset Behçet disease
Corticosteroids (yes)
Etanercept (partial)
Anakinra (no)
Adalimumab (no: ADA)
Tocilizumab (partial)
Patient 3
FCL (TREX1)
6 years: Raynaud, amputation of phalanx, inflammatory arthritis and chilblains
Normal blood counts,
Inmunology (-)
JIA
Etanercept (no)
Tofacitinb (yes)
Patient 4
DADA2
(CECR1)
7 months:
intermittent fever,
livedo reticularis,
paralysis of VI craneal nerve,
Raynaud
CRP 16 mg/L, IgG 567 mg/dl, IgA 22 mg/dlIgM 32 mg/dl, Total lymphocytes 950/μL
ANA and ANCA (-)
PAN
ASA
Etanercept (yes)
Patient 5
DADA2
(CECR1)
5 years:
Intermittent fever,
livedo resticularis,
paralysis of VI craneal nerve,
painful nodular lesions, arthromyalgia, abdominalgia, Raynaud, peripheral neuropathy
ESR 27 mm/h; RCP 87.6 mg/L ANA and ANCA (-)
PAN
ASA
Corticosteroids (yes)
Cyclophosphamide (no)
Etanercept (unknown)
---
CRP: C-reactive protein, ESR: erytrosedimentation rate, ADA: antidrug antibodies,
FCL: familiar chilblain lupus, JIA: Juvenile Idiopathic Arthritis, PAN: polyarteritis
nodosa, ANA: antinuclear antibodies, ANCA: antineutrophilic antibodies, ASA: acetylsalicylic
acid
P1047 Diagnosis and treatment of periodic fevers: a single centre experience
Peter McNaughton1,2, Jane Peake1,3, Ben Whitehead1,3, Su Han Lum2, Kahn Preece4
1Queensland Children's Hospital, Brisbane, Australia; 2Great North Children’s Hospital,
Newcastle upon Tyne, United Kingdom; 3University of Queensland, Brisbane; 4John Hunter
Hospital, Newcastle, Australia
Correspondence: Peter McNaughton
Introduction: Diagnosis of periodic fever syndromes is difficult due to atypical presentations
and overlap in inflammatory symptoms. Treatment of suspected periodic fevers varies
widely due to the lack of established clinical guidelines.The utility of genetic testing
in identifying monogenic periodic fever syndromes is also unclear due to high frequency
of variants of uncertain significance, somatic mutations and heterozygous mutations
in genes associated with autosomal recessive conditions.
Objectives: This study aims to evaluate the diagnosis, treatment and use of genetic
testing of patients diagnosed with periodic fever syndromes at a single tertiary paediatric
hospital.
Methods: We retrospectively reviewed the clinical history of patients diagnosed with
periodic fever syndromes at Queensland Children’s Hospital, Brisbane, Australia between
November 2014 and June 2018.
Results: 43 patients were diagnosed based on their clinical presentation with periodic
fever syndromes.10 patients were diagnosed with PFAPA, 9 with TRAPS, 6 with CAPS,
4 with MKD and 14 unspecified.Median age of onset of symptoms was 24m (range: birth-96m)
and median age of diagnosis was 60m (9m-180m).Median time to diagnosis from onset
of symptoms was 24m (0-149m).
Multiple medications were used in 15 patients.The medications used varied widely (prednisolone
(22), anakinra (9), etanercept (5), tofacitinib (2), tocilizumab (2), cimetidine (2)).
Genetic testing of between 1-26 genes was performed in 26 patients (60%).1-3 genes
were tested in 13 patients, targeted panels in 10 patients, SNP only in 1 patient.Genetic
variants were identified in 9 patients (34% of those tested) however only 2 of these
variants were clearly pathogenic (7.7% of those tested).
Clinical diagnosis and the Eurofever classification criteria were in agreement for
patients diagnosed with CAPS (p=0.046) and TRAPS (p=0.025) but not for patients diagnosed
with MKD (p=0.47).10 of the patients where clinical diagnosis and Eurofever classification
criteria were in agreement had 2 diagnoses positive on the classification score.Two
patients diagnosed with CAPS were exclusively positive for CAPS on the classification
score and none of the patients diagnosed with TRAPS were exclusively positive for
TRAPS.6 of the 7 TRAPS patients had a positive eurofever score for at least one PFS
diagnosis.
Conclusion: As reported in previous studies there was a significant delay between
onset of symptoms and diagnosis.This reflects an ongoing need to raise awareness of
these conditions with primary care providers. The large number of patients treated
with multiple medications and the broad range of medications used reflects the lack
of established treatment protocols and varied response to treatments in this group
of patients.
The clinical diagnosis and diagnostic score showed agreement for CAPS and TRAPs however
many patients had a diagnostic score positive for more than one diagnosis meaning
that a combination of clinical score and clinical judgement is required to make a
diagnosis.
Consistent with previous studies many patients with heterozygous mutations in genes
associated with periodic fevers were identified.The significance of these variants
is not clear and the diagnostic yield from genetic testing in this cohort was low.
Further improvements in availability of next generation sequencing and molecular understanding
of autoinflammatory conditions will hopefully improve this yield and allow more confident
diagnoses and targeted therapies.
Disclosure of Interest
None Declared
P1048 Multifocal osteomyelitis revealing a PSTPIP1- associated myeloid-related proteinemia
inflammatory (PAMI) syndrome: case report and review of the literature
Manel Mejbri, Katerina Theodoropoulou, Michael Hofer
Femme-Mère-Enfant, Centre Hospitalier Universitaire Vaudois CHUV, Lausanne, Switzerland
Correspondence: Manel Mejbri
Introduction: PAMI syndrome is a recently described condition, previously known as
Hyperzincemia/Hypercalprotectinemia(Hz/Hc) syndrome. It is a very rare auto-inflammatory
disorder characterized by a chronic systemic inflammation, cutaneousand osteo-articular
manifestations, hepatosplenomegaly, anemia and neutropenia. Increased blood levels
of MRP 8/14(S100A8/A9 or calprotectin) and zinc distinguish this condition. Specific
pathogenic mutations in PSTPIP1 gene (p.E250K andp.E257K) were identified as the genetic
cause of this condition.
Objectives: Case report and review of the literature of PAMI syndrome
Methods: We report a case of 13 months age female referred to our unity for recurrent
episodes of osteoarthritis.Physical examination showed hepatosplenomegaly. Blood work
revealed a systemic inflammation, a microcytic anemia and neutropenia. A complete
workup for metabolic disorders, oncologic processes and uncommon infections was negative.Because
of history of recurrent osteoarthritis, a whole-body MRI was performed and confirmed
a multifocal osteomyelitis.
Whole exome sequencing identified the missense p.E250K in the PSTPIP1 gene.
A literature search on PAMI syndrome was performed until the15 October 2018. Pubmed
was screened using a combination of the following terms: Hyperzincemia, Hypercalprotectinemia,
E250K mutation, PSTPIP1 mutation, PAPA with E250K mutation.
Results: We identified 20 cases of PAMI syndrome in the literature. PAMI syndrome
is an early onset inflammatory diseasewith a median age of 2.4 years. Clinical manifestations
include Osteo-articular manifestations (80%), skin lesions (71%), splenomegaly (89%),
hepatomegaly (68%), lymphadenopathy (42%), growth failure (58%) and hemorragic diasthesis
withrecurrent epistaxis and/or haematoma tendency in 5 patients. All cases had relevant
abnormalities in hematologic parameters:mild to severe neutropenia and anemia (100%).
Thrombocytopenia (42%). Systemic inflammation was confirmed in 94% using the monitoring
of CRP, ESR or SAA. Zinc and MRP 8/14 blood concentrations were markedly elevated
in all tested patients. Genetic analyses of PSTPIP1 gene revealed the two specific
identified mutations (p.E250K and p.E257K) in all patients. Response to the treatment
was variable with no consistently effective therapy. Most common therapeutic optionswere
AINS, Corticosteroids (n=9), Anakinra (n=9), Anti-TNF (n=6) and Cyclosporine A (n=4).
Conclusion: PAMI syndrome is a rare auto inflammatory condition which should be considered
in patients with undefined systemic inflammation and neutropenia, even without skin
or osteo-articular manifestations. Zinc and serum MRP 14/8measurement may be helpful
tools for the diagnostic orientation in these cases.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Monogenic autoinflammatory diseases (basic science)
P1049 Investigation of inflammasome components in the process of cell migration in
FMF patients
Tayfun H. Akbaba1, Z. Yeliz Akkaya-Ulum1, Selcan Demir2, Zeynep Tavukcuoglu1, Seza
Ozen2, Banu Balci-Peynircioglu1
1Medical Biology; 2Pediatric Nephrology and Rheumatology, Hacettepe University, Ankara,
Turkey
Correspondence: Tayfun H. Akbaba
Introduction: Autoinflammatory diseases, periodic fever syndromes, are a group of
diseases that develop recurrent inflammatory response in the absence of infection.
Familial Mediterranean fever, which is the most common disease among autoinflammatory
diseases, is caused by mutant pyrin production due to mutations in MEFV gene. Pyrin
protein is thought to be involved in inflammatory pathways by means of protein-protein
interactions. There are studies supporting the role of pyrin as a proinflammatory
regulator in the literature and involved in pathways associated with cell migration.
Objectives: The aim of this study was to investigate the effect of pyrin inflammasome
on cell migration in FMF patients, in CAPS patient as disease control and healthy
controls.
Methods: Within the scope of the thesis; pyrin inflammasome was examined in mononuclear
cells isolated from the blood samples of 11 FMF patients homozygous for M694V mutation,
1 CAPS patient with somatic mosaicism and 7 healthy individuals in the process of
inflammatory cell migration. Lipopolysaccharide was used to induce the activation
of inflammasome in the cells, while arachidonic acid was used for the inhibition of
inflammasome. IL-1 beta secretion was analyzed by western blot as an indicator of
inflammasome activation, and transwell filter assay was performed in order to examine
the differences in cell migration.
Results: We demonstrated that the inhibition of inflammasome in the cells of FMF patients
compared to the controls was less under the same application conditions. Following
inflammasome activation and inhibition, filter experiments were performed and fetal
bovine serum was used to induce inflammatory cell migration. In both inflammasome
activation and suppression conditions; we observed a statistically significant increase
in the ratio of cell migration of the mononuclear cells of the FMF patients compared
to CAPS patient and control indivuals.
Conclusion: These findings support the idea of increased cell migration ratio in patients
with FMF due to the more active pyrin inflammasome seen in patients. Although the
involvement of other inflammasome components remains to be defined, this study has
made significant contributions to illuminate the role of pyrin protein in inflammatory
cell migration through the structure of inflammasome.
Keywords: FMF, pyrin inflammasome, cell migration.
This thesis was supported by Hacettepe University Scientific Research CoordinationUnit
(Project Number: TYL-2018-17354)
Disclosure of Interest
None Declared
P1050 Cell migration defect in hyperimmunoglobulin D syndrome
Tayfun H. Akbaba1, Selcan Demir2, Z. Yeliz Akkaya-Ulum1, Seza Ozen2, Banu Balci-Peynircioglu1
1Medical Biology; 2Pediatric Nephrology and Rheumatology, Hacettepe University, Ankara,
Turkey
Correspondence: Tayfun H. Akbaba
Introduction: Hyper-IgD syndrome or Mevalonate Kinase Deficiency(HIDS/MKD, MIM #260920)
is a ultra rare, autosomal recessive hereditary autoinflammatory syndrome caused by
compound heterozygous or homozygous mutations in the mevalonate kinase(MVK) gene.
It is characterized by recurrent febrile episodes with abdominal pain, lymphadenopathy
and an increased serum immunoglobulin D (IgD) level.Anti-IL-1 and anti-TNF treatment
are applied to alleviate the symptoms of the disease and to reduce the number of attacks.
Objectives: In this study, we aimed to analyze cell migration, an important process
of inflammation,in HIDS patients and compare with FMF patients and controls in inflamasome
activated and inhibited conditions.
Methods: Peripheral blood mononuclear cell isolation from HIDS patients, FMF patients
and controls was performed. LPS was used to induce inflammasome in isolated cells
while arachidonic acid was used for inhibition of inflammasome.After activation and
inhibition of inflammasome, transwell filter experiments were performed with isolated
cells from patients. As a result of the experiment, the migrating cells were stained
with calcein-AM and analyzed by Image J programme.
Results: We did not observe cell migration in HIDS patients’ mononucleer cells under
normal conditions, after LPS stimulation. We observed increased cell migration in
FMF patients and normal rate in controls as a positive control of these experiments.Considering
that 2 HIDS and 1 FMF patients involved in these experiments were receiving anti-IL-1
treatment, it was thought that the drug used by the patients had no effect in cell
migration pattern that we observed.
Conclusion: Our preliminary data is the first study identified cell migration defect
seen in HIDS. Due to the mutant protein produced as a result of MVK gene mutations,
the deficiency in the function of the mevolanate kinase enzyme observed in HIDS leads
to the depletion of geranylgeranyl pyrophosphate, a key substrate for protein prenylation.Considering
the close relationship between protein prenylation and cytoskeleton elements related
with cell migration, a possible decrease in prenylation may be a potential explanation
of cell migration defect seen in HIDS patients.
Keywords: HIDS, cell migration defect, prenylation
This project was supported by Hacettepe University Scientific Research Coordination
Unit (Project Number: TYL-2018-17354)
Disclosure of Interest
None Declared
P1051 Possible regulatory effects of miRNAs in the pathogenesis of systemic auto inflammatory
diseases, from the perspective of familial Mediterranean fever
Z. Yeliz Akkaya-Ulum1, Zeynep Tavukcuoglu1, Ezgi Deniz Batu-Akal2, Tayfun Hilmi Akbaba1,
Hafize Emine Sonmez2, Banu Balci-Peynircioglu1, Seza Ozen2
1Medical Biology; 2Pediatric Nephrology and Rheumatology, Hacettepe University, Ankara,
Turkey
Correspondence: Tayfun Hilmi Akbaba
Introduction: Systemic Auto Inflammatory Diseases (SAID) is a group of rare and hereditary
periodic fever syndromes with recurrent inflammatory involvement developing in the
absence of infection. Among same SAID patients, phenotypic heterogeneity is common,
and modifier mechanisms such as epigenetic factors may be considered as one of the
reason of these variations. MicroRNAs (miRNAs), a type of epigenetic mechanisms, are
regulated in most of the biological processes like inflammation.
Objectives: This study aimed to explore the potential effect of miRNAs in the auto
inflammation mechanism seen in SAID from the perspective of Familial Mediterranean
fever (FMF) which is the most common auto inflammatory disorder.
Methods: The expression levels of miRNAs were analyzed by miRNA array, performed on
whole blood RNA samples from healthy controls, homozygous FMF patients with severe
phenotype, homozygous FMF patients with mild phenotype, carriers who displayed the
disease phenotype, healthy carriers and other rare SAIDs, in pediatric term. The raw
data was analyzed by Multi Experiment Viewer (MeV) and TAC programs. Then we performed
pathway analyses using DAVID v6.8. and Panther analysistools. Candidate miRNAs shown
to be related with inflammatory pathways by bioinformatics analysis, are further studied
functionally for their possible effect on expression levels of inflammatory genes,
caspase I activation and cell migration (transwell and wound healing experiments)
in SW982 (synovial fibroblast) cell lines.
Results: The four patient groups were compared in between and miR-30e-3p, miR-374b-5p,
miR-329-3p, miR-29c-3p, miR-25-5p were found to be significantly down regulated in
the patient groups. The expression levels of these miRNAs were validated with qRT-PCR.
All these miRNAs were found to be known regulators in TGF-beta and Toll-like receptor
signaling pathway, apoptosis and actin cytoskeleton regulation by bioinformatics.
After pre-miR transfection of miR-30e-3p, miR-374b-5p, miR-29c-3p; expression levels
of inflammatory genes (IL-1β, IL-18, TNF-α, TGF-β) were decreased, caspase I activation
and cell migration ratio were significantly decreased (p<0.05).
Conclusion: Functional results of this study showed that these miRNAs may possibly
have an anti-inflammatory effect and can regulate the expression of genes found in
inflammatory pathways. The investigation of potential target genes of these miRNAs
by bioinformatics tools and 3’ UTR luciferase assay is underway. The results of this
study will be informative for understanding and investigating the possible effect
of miRNAs in other auto inflammatory diseases.
This project has been funded by E-RARE-3 project (INSAID, grant 003037603) and The
Technical and Scientific Research Council of Turkey (TUBITAK), Grant number: TUBITAK
1001-SBAG 315S096.
Keywords: SAID, FMF, epigenetics, miRNA, inflammation.
Disclosure of Interest
None Declared
P1052 MIR-197 regulates inflammation in monocytes and synovial fibroblasts by targeting
IL1R1
Yeliz Z. Akkaya Ulum1, Zeynep Tavukcuoglu1, Tayfun Hilmi Akbaba1, Engin Yilmaz2, Banu
Balci-Peynircioglu1
1Medical Biology, Hacettepe University, Ankara; 2Medical Biology, Acibadem Mehmet
Ali Aydinlar University, Istanbul, Turkey
Correspondence: Yeliz Z. Akkaya Ulum
Introduction: Familial Mediterranean Fever (FMF); is an autosomal recessively inherited
autoinflammatory disease. FMF is caused by the mutations in the Mediterranean Fever
(MEFV) gene which encodes the pyrin protein. In many studies, pyrin has been implicated
in important cellular processes like apoptosis, cytoskeleton dynamics, signal transduction,
and inflammation. Recent studies have shown that epigenetic control mechanisms, particularly
non-coding RNAs, may play a role in the pathogenesis of autoinflammation. microRNAs
(miRNAs) are small non-coding RNAs that play critical roles in regulating host genome
expression at the post-transcriptional level. Dysregulated miRNA expression patterns
have been documented in a broad range of diseases including cancer, inflammatory,
and autoimmune diseases.
Objectives: Phenotypic heterogeneity seen in FMF disease indicated that FMF is not
a simple monogenic disease. Therefore it has been suggested that epigenetic factors
can be one of the reason for the variations.
Methods: Previously we identified miR-20a-5p and miR-197-3p as significantly differentially
expressed among healthy controls (-/-) and patients (M694V/M694V). The validation
of differentially expressed miRNAs was done by quantitative reverse transcription
polymerase chain reaction (qRT-PCR). miRNA target genes were determined in miRWalk,
the database on predicted and validated miRNA targets. Then pathway analysis was performed
in DAVID. For functional assays, SW982 (synovial fibroblast) and THP-1 (monocyte)
cell lines were cultured and transfected with miR-197 mimic and scramble control.
After transfection, cytokines expression levels (MEFV, IL-1b, IL-18, TNF-α, TGF-β),
caspase I activity, apoptosis and cell migration rate were determined. Migration was
analyzed in two ways by Transwell migration chamber and wound healing assays. For
target gene studies, 3’UTR lusiferase activity assay was done.
Results: qRT-PCR analysis confirmed the results of the miRNA profiling for 2 miRNAs.
From two of them; miR-20a showed induction and the other one; miR-197 showed reduction
in the homozygote group compared to controls (Akkaya-Ulum et al., 2017).
For functional studies, after pre-miR-197 transfection, the expression levels of cytokines
were decreased, cells showed less migration and caspase 1 activity. There was no effect
in apoptosis. These results showed that miR-197 could have an anti-inflammatory effect
by causing less migration and cytokine secretion. miR-197 was found to bind to the
interleukin-1beta (IL-1β) receptor, type I (IL1R1), which is one of the key molecules
of the inflammatory pathways.
Conclusion: These findings provide evidence that miR-197 may play role in FMF pathogenesis.
Therefore, this study may contribute to understand the inflammatory process seen in
FMF disease, as well as to development of the new drug targets and biomarkers in addition
to the existing colchicine and similar treatments.
As miRNA-based therapeutics are promising approaches for treating autoinflammatory
diseases, we are planning to continue to study on potential therapeutic usage of miR-197
in mouse model of FMF disease.
This study was supported by The Scientific and Technological Research Council of Turkey
TUBITAK 1001-SBAG Project Number: 214S106 and Hacettepe University Scientific Research
Projects Coordination Unit, Thesis Support, PhD Project Number: TDK-2017-16253 and
BAP Comprehensive Project Number: 013D05101005 and Turkey Rheumatology Association.
Keywords: Familial Mediterranean Fever, inflammation, microRNA, miR-197, IL1R1.
Reference
Akkaya-Ulum YZ, Balci-Peynircioglu B, Karadag O, Eroglu FK, Kalyoncu U, Kiraz S, et
al. Alteration of the microRNA expression profile in familial Mediterranean fever
patients. Clin Exp Rheumatol. 2017 Nov-Dec;35 Suppl 108(6):90-94.
Disclosure of Interest
None Declared
P1053 Comparison of FMF patients with age of onset before 20 versus 40 years and over
Okan Aydin, Serdal Ugurlu, Huri Ozdogan
Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty,
University of Istanbul - Cerrahpasa, Istanbul, Turkey
Correspondence: Okan Aydin
Introduction: Familial Mediterranean fever (FMF) isa disease withan onset before 20
years of age in 90% of the patients.However late onset FMF defined as age of onset
over 40 years is being recognised more frequently.
Objectives: To better define patients with FMF who had their first attack before age
40 and compare them with early onset patient group in Turkish population
Methods: The files of 2180 FMF patients followed in a single center between 2008-2017
who have fulfilled Tel-Hashomer criteria, were reviewed with regard to age of onset
40 years and over (index patients, Group 1).For control purposesfiles before and after
the index patients were browsed and
first patients with an onset before age 20 years (Group 2) were included. The demographic,
clinical and geneticcharacteristics are compared between these 2 subgroups.
Results: Patients with an onset after 40 years consisted 2.7% of our FMF population.
50 of the 59 patients with an onset 40 yearsor over were re-evaluated and compared
with early onset group consisting of 100 patients (Table 1).The delay in diagnosis,
and disease durationwere significantly longer and number of patients with M694V homozygosity
and M694V allele frequencywere significantly more frequent among group 2. In general,
phenotypes of both onset groups were similar, the only significant differences being
the frequency of fever and myositis which were less common amonggroup 1. Also response
to colchicine was more pronouncedingroup 1. One other interesting observation was
the low incidence ofamyloidosis in a group with such a significant delay in diagnosis
and thus treatment.
Conclusion: FMF should be included among the differential diagnosis of patients over
40 years of age with recurrent autoinflammatory manifestations. Less than 3% of FMF
patients experience their first attacks after 40 years of age. The frequency of M694V
is significantly less in the late onset group, pointing out a milder disease.
Disclosure of Interest
None Declared
Table 1 (abstract P1053).
Demographic, clinical and genetic features of the study groups
≥40 yearsn=50
≤20 yearsn= 100
p
Sex (F:M); present age (mean±SD) (yr)
32:18; 57.2±7.9
62:38; 31.8±9.1
NS; <0.001
Mean age at onset,(mean±sd) (yr)
45.6±5.2
8.7±4.8
<0.001
Mean age at diagnosis (mean ±sd) (yr)
50.4±7.3
19.1±11.2
<0.001
Delay in diagnosis (mean ±sd) (yr)
4.8±5.5
10.4±11.8
<0.001
Mean disease duration (mean ±sd) (yr)
11.5±6.4
23.1±10.8
<0.001
Abdominal pain, n (%)
44(88)
89(89.0)
NS
Chest pain, n (%)
7(14.0)
27 (27.0)
NS
Fever, n (%)
30(60.0)
81(81.0)
0.005
Arthritis, n (%)
12(24.0)
33(33.0)
0.25
Myalgia, n (%)
1(2.0)
12(12.0)
0.04
Amyloidosis, n (%)
1(2.0)
3(3.0)
NS
Positive family history, n (%)
33(68.7)
62 (65.2)
NS
Response to colchicine, n (%)
37(82.2)
93 (94.8)
0.014
M694VHomozygous, n (%)
2(4.5)
23(25.8)
0.003
N of M694Vallelles
24( 48 )
82 (82)
0.014
No mutation, n (%)
3(6.8)
2(2.2)
NS
P1054 What history of appendectomy will tell us about the course of familial Mediterranean
fever in adulthood?
Erdal Bodakçi1, Nazife S. A. Bilge1, Nuh Ataş2, Berkan Armağan3, Hasan Satış2, Alper
Sarı3, Hakan Babaoğlu2, Gözde K. Yardımcı3, Reyhan B. Salman2, Levent Kılıç3, Mehmet
A. Öztürk2, Berna Göker2, Seminur Haznedaroğlu2, Umut Kalyoncu3, Abdurrahman Tufan2,
Timuçin Kaşifoğlu1
1Deparment of Internal Medicine, Division of Rheumatology, Eskişehir Osmangazi University
Faculty of Medicine, Eskişehir; 2Deparment of Internal Medicine, Division of Rheumatology,
Gazi University Faculty of Medicine; 3Deparment of Internal Medicine, Division of
Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
Correspondence: Erdal Bodakçi
Introduction: Peritonitis attacks of FMF usually requires emergency medical admissions
and it’s hard to distinguish a typical attack from surgical causes of acute abdomen.
Therefore, unrevealing abdominal surgery history, particularly appendectomy, is very
common in patients with FMF. However, history of appendectomy might also give some
clues about the disease course of FMF.
Objectives: to determine whether history of appendectomy is associated with disease
course of FMF in adulthood.
Methods: All patients recruited from FMF in Central Anatolia (FiCA) cohort, comprising
970 (mean age 35.3±12 years, 61.5%female) adult subjects. All patients fulfilled Tel
Hashomer criteria. Demographic data, FMF disease characteristics, co-morbid conditions,
past medical history including surgeries, disease complications were meticulously
questioned and laboratory features and genotype data (if available) were recruited
from patient files. Disease severity and FMF associated damage were assessed with
International Severity Scoring System (ISSF) for FMF and Autoinflammatory Disease
Damage Index (ADDI), respectively.
Results: Appendectomy history was evident in 240 (24.7%) subjects.Peritonitis (4.4±6.7
vs 2.9±4.3 attacks/per year, p<0.001) and pleuritis (3.9±5.2 vs 2.8±4.4 attacks/per
year, p=0.03) attacks were more frequent in appendectomy performed (AP) group than
appendix intact (AI) group. However, there were no difference between AP and AI groups
for the attack frequencies of musculoskeletal and skin components. Considering all
types of attacks, AP group had more attacks (6.4±8.2 vs 4.3±6.6 attacks, p<0.001),
despite they had used more higher doses of colchicine (1.43±0.6 mg/day vs 1.27±0.5
mg/day, p=0.002). ISSF scores were also higher in AP group 3.13±1.68 vs 2.73±1.48,
p=0.001). Colchicine nonresponse were more prevalent in AP group as well (15.1% vs
6.7%, pearson X2=20.2, p<0.001). However, ADDI damage scores were similar between
AP and AI groups.
Conclusion: Appendectomy history is common in FMF patients and associated with frequent
serositis attacks in adulthood. These patients require more colchicine doses with
a lower response rate. Hence, history of appendectomy would be a worthy clue for the
management of FMF patients.
Disclosure of Interest
None Declared
P1055 Complement endorse the pathogenesis in autoinflammation
Juergen Brunner1, Wilfried Posch2, Doris Wilflingseder2
1Pediatrics; 2Division of Hygiene and Medical Microbiology, Medical University Innsbruck,
Innsbruck, Austria
Correspondence: Juergen Brunner
Introduction: The complement system represents a major part of the innate immune system,
consisting of more than 30 different proteins in plasma and on cell surfaces and can
be activated through three different pathways.Inflammasomes are also part of the innate
immune system.A group of disorders in inflammasomes have been associated with autoinflammatory
diseases (AIDs). Familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome
(MWS) and chronic infantile neurological, cutaneous and articular syndrome/neonatal
onset multisystem inflammatory disease (CINCA/NOMID) were originally described as
three distinct diseases. After the identification of their common genetic origin,
i.e. mutations in the NLRP3 gene on chromosome 1q44, they are perceived as a continuum
of one disease entity and labelled cryopyrin-associated periodic syndromes (CAPS).
Objectives: Aim of this preliminary study in a patient with MWS was to find a correlation
between the complement system and a disorder of autoinflammation.
Methods: PBMCs (peripheral blood mononuclear cells) were isolated from blood of a
healthy donor and of an individual suffering from MWS by density gradient centrifugation
using a Ficoll Paque Premium (GE Healthcare). After washing, PBMCs were incubated
with anti-human CD14 Magnetic Beads (BD) to obtain CD14+ monocytes. These were stimulated
by addition of cytokines (IL-4 and GM-CSF) for five days to generate immature moDCs
(iDCs), which were used for cytokine ELISAs and flow cytometric analyses. IL-6 and
IL-1β cytokine ELISAs were performed according to the manufacturer (Biolegend) following
stimulation of cells using either LPS or differentially complement opsonized HIV-1.
Phenotypical characterization of pathogen-exposed DCs was performed by analyzing characteristic
surface markers (CD11c, DC-SIGN, CD86) by multi-color flow cytometry.
Results: IL-1β production of iDCs is higher in the patients cells than in the cells
of the healthy donor. However, the most significant difference was shown in complement
opsonized iDCs. DC-SIGN is higher expressed in complement opsonized iDCs in patient
cells compared to cells of a healthy donor (37,12% v28,64%). DC-SIGN is also higher
expressed in the iDCs of the MWS patient after stimulation with LPS.
Conclusion: The complement system may play an important role in the development of
an proinflammatory milieu in patients with disorders of autoinflammation. The phenomenon
shown in a patient with MWS has to be reproduced in more MWS patients a well as in
patients with other disorder of autoinflammation.
Disclosure of Interest
None Declared
P1056 Generation of ADA2 genetic knockout in a myeloid cell line using CRISPR/CAS9
genome editing: an in vitro cell line model to study DADA2
Marina S. Casimir, Ying Hong, Paul Brogan, Despina Eleftheriou
Infection, Inflammation and Rheumatology, UCL Great Ormond Street Institute of Child
Health, London, United Kingdom
Correspondence: Marina S. Casimir
Introduction: Deficiency of adenosine deaminase type 2 (DADA2) is an autosomal recessive
genetic disease causing systemic inflammation and vasculitis resembling polyarteritis
nodosa, caused by loss of function mutations in the ADA2 gene. We are curently exploring
an alternative treatment strategy of curing DADA2 using gene therapy. An important
first step for this line of work was to develop a cell line model, with abrogation
of ADA2 protein and enzyme expression and to determine whether the immunophenotype
and characteristics of this cell line mimic the phenotype of primary cells derived
from DADA2 patients.
Objectives: To develop an ADA2 knockout (KO) monocyte cell line (THP-1) derived using
Clustered Regularly-Interspersed Small Palindromic Repeats (CRISPR)/CAS9 and to confirm
that this KO has comparable immunophenotype to monocytes from DADA2 patients (reduced
ADA2 expression; M1/M2 skewing and pro-inflammatory cytokine production).
Methods: A plasmid delivered CRISPR/CAS9 system was used to generate the ADA2 KO THP-1
cell line. ADA2 enzyme activity was assessed using a modified commercially available
assay and ADA2 protein expression using immunoblotting. Cells were treated with PMA
to induce differentiation into macrophages before polarisation into M1 through LPS/
INF-γ stimulation; and M2 polarisation through IL-4, IL-10 and IL-13 stimulation.
Immunophenotyping was assessed using gene expression analysis by qPCR. We performed
similar experiments in monocyte-derived macrophages (MDM) from 4 DADA2 patients using
the same protocol as for the cell line. Cytokine production was evaluated using MSD
electrochemiluminescence.
Results: We first confirmed effective knockout of ADA2 at the genetic and protein
level and a complete loss of ADA2 enzyme activity in culture supernatants when compared
to scramble control THP-1 cells (p<0.01).M1 polarised ADA2 KO THP1 cells exhibited
increased activation of pro inflammatory markers such as TNF-α (p<0.001), CXCL-10
(p<0.001), STAT-1 (p<0.01) and IL-1β (p<0.001) when compared to control THP-1 cells.
The M1/M2 ratio was reversed in the ADA2 KO THP-1 cell line compared to the wild type
THP-1 cells. In MDM cells from DADA2 patients, we observed similar induction of the
pro-inflammatory pathway as indicated by increased TNF-α and IL-1β gene expression.
Release of TNF-α in culture supernatants from M1 polarised cells was also enhanced
for both the ADA2 KO THP-1 cell line and in cells derived from DADA2 patients.
Conclusion: We have generated an effective ADA2 genetic KO myeloid cell line using
a CRISPR/Cas9 system and confirmed that these cells have a complete loss of ADA2 enzyme
activity and a comparable immunophenotype to monocytes from DADA2 patients. This in
vitro system can now be used to examine the possibility to reverse the defects associated
with DADA2 using gene therapy strategies.
Disclosure of Interest
None Declared
P1057 Promising blood test for diagnosis and treatment options in patients with suspected
chronic auto-inflammatory syndromes
Anne-Laure N. Chetaille1, Nathalie Pagé2, Marie-Pier Longchamps2, Louis Bessette2,
Laetitia Michou2, Paul Fortin2, Philippe Tessier2, Martin Pelletier2
1Rhumatologie Adulte et Pédiatrique; 2CHU de Québec-Université Laval, Québec, Canada
Correspondence: Anne-Laure N. Chetaille
Introduction: Diagnosis and treatments of Auto-Inflammatory Syndromes (AIS) patients
are challenging as clinical symptoms are non-specific especially compared with Systemic
Autoimmune Rheumatic Diseases (SARD) and detection rate of genetic mutations in patients
with high suspicion for AIS is low. Even if a mutation is found, genotypes don’t correlate
with phenotypes neither with the response to treatments. As a consequence, patients
can be misdiagnosed, receive inappropriate treatment, leading to severe complications
and substantial socio-economic costs.
Objectives: The cytokines abnormally secreted by each individual are unknown. We hypothesized
that the secretion of cytokines by peripheral blood mononuclear cells (PBMC) could
be an indicator of the disease and could guide the treatment to the most suitable
anti-cytokine. Quantification of the secretome of leukocytes may guide diagnosis and
treatment of AIS patients.
Methods: Plasma and peripheral blood mononuclear cells (PBMCs) were isolated from
healthy controls, suspected AIS patients, and rheumatoid arthritis (RA) and systemic
lupus erythematosus (SLE) patients from the CHU de Québec SARD Biobank Repository
Database (SBRD). PBMCs were stimulated with well-known immune activators to trigger
inflammasome activation, and cytokine levels were analyzed in the plasma and the supernatants
by multiplex assays.
Results: Plasma cytokine levels were similar and did not allow to discriminate between
suspected AIS patients, SARD patients or healthy volunteers. PBMCs, on the contrary,
had a distinct profile of cytokine secretion between groups. PBMCs from AIS patients
spontaneously secreted more IL-1a, IL‑12 and IL-18 than cells from SARD patients or
healthy control subjects, as well as IFNg in response to NLRP3, AIM2 and pyrin inflammasome
activation. PBMCs from some suspected AIS patients secreted excessive IL-1a or IL-1b
in the absence of the antagonist IL‑1RA, suggesting blockers of IL-1 could be used
as biotherapeutic approach. PBMCs from other suspected AIS patients secreted high
levels of IFNg, IL-12 and IL‑18, pointing to the usefulness of treatments such as
Janus kinase small molecule inhibitors, and may be the anti-IL‑12/IL-23 p40 antagonist
and/or the novel anti-IL-18 in clinical development.
Conclusion: This study demonstrates that analysis of leukocytes’ secretome is reliably
more sensitive than serum to reveal cytokine signatures and to predict biologic treatment
options in patients with suspected chronic AIS. Quantification of leukocytes’ secretome
allows personalized medicine by guiding diagnosis and treatment options of AIS patients.
Disclosure of Interest
None Declared
P1058 Specific dysbiosis associated with familial Mediterranean fever complicated
or not with AA amyloidosis
Samuel Deshayes1, Soraya Fellahi2, Jean-Philippe Bastard2, Jean-Marie Launay3, Jacques
Callebert3, Thibault Fraisse4, David Buob5, Jean-Jacques Boffa6, Irina Giurgea7, Charlotte
Dupont8, Sarah Jegou9, Marjolène Straube9, Alexandre Karras10, Achille Aouba1, Gilles
Grateau4, Harry Sokol11, Sophie Georgin-Lavialle4 and AA Amyloidosis Study Group
1Internal Medicine, CHU Côte de Nacre, Caen; 2Biochemistry, Hôpital Tenon; 3Biochemistry,
Hôpital Lariboisière; 4Internal Medicine; 5Anatomopathology; 6Nephrology, Hôpital
Tenon; 7Medical Genetics, Hôpital Trousseau; 8Reproduction Biology, Hôpital Tenon;
9AP-HP Laboratoire des Biomolécules (LBM), UPMC Université Paris 06; 10Nephrology,
Hôpital Européen Georges Pompidou; 11Gastroenterology, Hôpital Saint-Antoine, Paris,
France
Correspondence: Samuel Deshayes
Introduction: Familial Mediterranean fever (FMF) can be complicated by inflammatory
(AA) amyloidosis, but the reason why only some patients will develop amyloidosis is
not completely understood.
Objectives: To assess gut microbiota composition and inflammatory markers in FMF patients
complicated or not by AA amyloidosis.
Methods: We included 34 FMF patients without AA amyloidosis, 7 FMF patients with AA
amyloidosis, 19 patients with AA amyloidosis from another origin, and 26 controls.
The gut microbiota was studied by 16S ribosomal ribonucleic acid gene sequencing on
an Illumina MiSeq platform. Associations between bacterial taxa and clinical phenotype
were evaluated using the multivariate association with linear models (MaAsLin) statistical
method. Blood dosages of interleukin (IL)-1β, IL-6 and tumor necrosis factor-α were
carried out by enzyme-linked immunosorbent assay.
Results: Compared to healthy subjects, significant decreases in α-diversity were noted
in FMF patients without amyloidosis and in patients with non-FMF-related AA amyloidosis.
β-diversity analysis also showed significant differences between healthy controls
and two same groups. After multivariate association testing with the MaAsLin statistical
method to control for the effects of potential confounding factors (such as age, gender,
body mass index and treatments), several operational taxonomic units belonging to
the Clostridiales order were associated with FMF. Moreover, 2 operational taxonomic
units belonging to the Clostridiales order were overrepresented in FMF-related AA
amyloidosis compared to FMF patients without AA amyloidosis.
All studied groups had higher blood levels of IL-1β, IL-6 and tumor necrosis factor-α
than controls.
Conclusion: FMF was associated with a gut microbiota dysbiosis characterized by a
decreased α-diversity and a significant alteration in composition. Although these
results are descriptive, they suggest that the gut microbiota might be involved in
the clinical expression of FMF. In FMF patients, amyloidosis was independently associated
with a specific alteration in the microbiota composition, suggesting that the gut
microbiota may play a role in AA amyloidosis pathogenesis. These data need to be further
consolidated in mechanistic and interventional studies.
Disclosure of Interest
None Declared
P1059 Proinflammatory cytokines induced by PBMCS from a patient with a NLRP1 variant
showing severe corneal intraepithelial dyskeratosis
Troels Herlin1, Sofie E. Jørgensen2, Christian Høst1, Mette Christiansen3, Dorte A.
Larsen4, Trine H. Mogensen5
1Pediatrics, Aarhus University Hospital; 2Biomedicine, Aarhus University; 3Clinical
Immunology; 4Ophthalmology; 5Infectious diseases, Aarhus University Hospital, Aarhus,
Denmark
Correspondence: Troels Herlin
Introduction: Corneal intraepithelial dyskeratosis is an extremely rare autosomal
dominant inherited disorder with the classical form known as hereditary benign intraepithelial
dyskeratosis (HBID). Variants of the nucleotide-binding leucine-rich repeat containing
purine domain 1, NLRP1gene, have recently been associated with autoinflammatory disorders
with arthritis, vitiligo and dyskeratosis, including HBID.
Objectives: In a boy with severe HBID, with a variant p.A59P in the autoinhibitory
PYD domain of NLRP1, to examine the level of NF-kB activation and proinflammatory
cytokines in stimulated PBMCs.
Methods: \5-year-old boy with severe inflammation of the gingival mucosa with premature
loss of several teeth, painful corneal and conjunctival inflammation of both eyes
leading to marked photophobia, corneal opacification and loss of vision. He had mild
eczema, but no dyskeratosis of the skin. He is the only child of non-consanguineous
Danish parents. Grandfather’s brother and father’s grandfather both had hyperkeratotic
dermatosis and swollen gingival mucosa but no eye inflammation.
NLRP1Sanger sequencing was performed. Peripheral blood mononuclear cells (PBMCs) from
patient and 3 healthy controls were stimulated with NF-kB inducers (TNFa and LPS or
left untreated. Phosphorylated IkBa, as a measure of NF-kB activation, was measured
by Luminex technology. PBMCs were stimulated with different ligands (TNFa and LPS
and muramyl dipeptide (MDP) or left untreated for 16 hrs. Proinflammatory cytokines
(IL-1b, IL-6, IL-18, and TNFa) were measured in the supernatants using Mesoscale U-plex
multiplex assays.
Results: Sanger sequencing identified a heterozygous variant (c.175G>C, p.A59P) in
the autoinhibitory PYD domain of NLRP1. The variant has a high CADD score of 24.1
predicting a high likelihood of deleteriousness and is not present in the gnomAD database.
The sequencing revealed other variants (p.L155H, p.V1063M and p.M1188V) with high
minor allele frequencies, most likely benign. Family analysis showed that A59P and
L155H were carried by the father and the grandfather’s brother but none by the mother.
Patient PBMCs demonstrated significantly increased levels of Ser32/36 phosphorylated
IkBa in response to TNFa and LPS stimulation compared to controls, indicating increased
NF-kB activation. In response to especially MDP, but also TNFa stimulation, patient
PBMCs expressed extremely high levels of IL-1b and IL-6 and increased IL-18 levels
in unstimulated PBMCs compared to controls. Clinically and biochemically the patient
responded well to monthly treatment with subcutaneous canakinumab (5 mg/kg) with rapid
improvement of the gingivitis, and ophthalmologically administration of diluted anakinra
(2.5% solution) as 1 eye-droplet three times per day had a dramatic effect on ocular
pain and inflammation.
Conclusion: We here report A59P NLRP1 as a novel defect causing inflammasome hyperactivation/autoinflammatory
disease and a clinical picture including severe inflammation of the gingival mucosa
and keratitis in a 5-year-old boy with a family history suggesting HBID. Patient PBMCs
exhibited increased NF-kB activation and elevated levels of IL-1 and IL-6 in response
to proinflammatory stimuli. Thus, our results enabled us to select relevant targeted
therapy deploying IL-1binhibition with systemic canakinumab and topical anakinra.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1060 Gain-of-function mutation of NOD2 impairs its ligand specific immune responses
in BLAU syndrome patient-derived IPS cells
Naotomo Kambe1, Nhung T. M. Ly1, Megumu K. Saito2, Hiroyuki Okamoto1
1Dermatology, Kansai Medical University, Hirakata, Osaka; 2Clinical Application, CiRA,
Kyoto University, Kyoto, Japan
Correspondence: Naotomo Kambe
Introduction: NOD2 is crucial for innate immune response and mainly expressed in hematopoietic
lineage cells, especially in monocytic cells. On the recognition of its ligand, muramyl
dipeptide (MDP), NOD2 leads to activation of NF-κB pathway, causing upregulation of
pro-inflammatory cytokines.
Objectives: Mutations of NOD2 have been associated with Blau syndrome, but the details
regarding mechanisms associated mutant NOD2 leads to granuloma formation are still
unclear. By using iPS cells derived from the patients, we tried to reveal the molecular
mechanism of Blau syndrome.
Methods: The iPS cells with R334W mutation in NOD2 have been established from a Blau
patient and we corrected the mutation of the iPS cells into wild type (WT) by using
a CRISPR-Cas9 system. These isogenic iPS cells were differentiated into monocytic
cell lineages, then transfected with the lentiviral vectors and maintained in the
StemPro-34 medium with M-CSF and GM-CSF.
Results: IFNγ induced the same upregulation of NOD2 in iPS-derived monocytes with
WT and those with R334W. Without MDP stimulation, pro-inflammatory cytokine production
was only found in those with mutant NOD2, suggesting that Blau-associated NOD2 is
gain-of-function mutation. However, after stimulating with MDP, the R334W mutant cells
showed NF-κB pathway activation and cytokine secretions less than WT cells even with
or without IFNγ treatment. On the other hand, both the cell groups showed the comparative
immune response to TNFα and LPS treatment, unrelated to NOD2 mutation.
Conclusion: The response to MDP by mutant NOD2 was selectively impaired in Blau syndrome,
that may incompletely lead to neutrophilic inflammation but compensatively induce
granuloma formation in host defense.
Disclosure of Interest
None Declared
P1061 The role of DNA methylation for disease severity in patients with heterozygous
mutations in the Mediterranean fever gene MEFV
Julie Krainer1, Walter Pulverer1, Dirk Foell2, Seza Özen3, Andreas Weinhäusel1
1AIT - Austrian Institute Of Technology, Vienna, Austria; 2Pediatric Rheumatology
& Immunology, University Children's Hospital, Muenster, Germany; 3Department of Pediatric
Rheumatology, Hacettepe University, Ankara, Turkey
Correspondence: Julie Krainer
Introduction: Familial Mediterranean Fever (FMF) is the most common hereditary SAID,
with a high prevalence in patients of eastern Mediterranean decent. It is known as
an autosomal dominant disease with mutations in the MEFV gene that encodes for Pyrin,
an important innate immunity regulator. However, some heterozygous individuals also
show an FMF phenotype, which leads to the assumption that other modifying factors
lead to a manifestation of the phenotype1. In recent years, DNA methylation has demonstrated
suitable as biomarker and its potential for disease diagnosis by several studies.
DNA methylation plays an important epigenetic regulatory effect on gene expression,
and aberrances can result in pathological disease states.
Objectives: The main goal of this study was to evaluate the DNA methylation in patients
carrying heterozygous mutations in the MEFV gene but show different phenotypes. We
hypothesis that alterations in DNA methylation can add important and valuable information
about the disease etiopathogenesis.
Methods: The study included 32 patients, 12 of the patients show a typical FMF phenotype
and SNP analysis showed a heterozygous mutation, 9 patients showed similar heterozygous
mutations but lack FMF characteristics and are healthy. We also included 12 control
samples without any mutation in the MEFV gene.
We performed a genome wide DNA methylation analysis using Illumina’s EPIC BeadArray,
interrogating over 850.000 CpG sites at single C resolution covering the first exon
of >84% of all Genes2. The results were processed and normalized using the R package
Champ3 and group comparisons were performed with limma4.
Results: In total four different group comparisons were calculated including Heterozygous
Healthy vs. Heterozygous Disease, Heterozygous Healthy vs. Control, Heterozygous Disease
vs. Control and Heterozygous (Disease + Healthy) vs. Control. Each comparison revealed
over 30000 significant cpgs (p<0.05) where between 28 and 75 cpgs showed at least
15% differences in mean methylation between the groups. Eighty of the significant
cpgs were present in every group comparison covering 62 unique genes. During hierarchical
clustering the three clusters separated visibly, where two Heterozygous Healthy patients
cluster within the control samples. A group comparison between the two Heterozygous
groups revealed 71 differentially methylated sites (p<0.05, difference ≥ 15%), able
to separate the two groups.
Conclusion: During our experiments we were able to detect differentially methylated
sites separating Heterozygous Healthy and Heterozygous Disease patients. We hypothesize
that the identified CpG sites can contribute to provide information to the etiopathogenesis
of FMF in general.
REFERENCES
[1] Sönmez et al.. Familial Mediterranean fever. Current perspectives. In: Journal
of Inflammation Research 9; 2016. S. 13–20. DOI: 10.2147/JIR.S91352.
[2] Pidsley et al. “Critical evaluation of the Illumina MethylationEPIC BeadChip microarray
for whole-genome DNA methylation profiling.” Genome Biology 17 (1), S. 208; 2016.
DOI: 10.1186/s13059-016-1066-1.
[3] Morris et al. “Champ: 450k chip analysis methylation pipeline.” Bioinformatics,
30(3), 428-30; 2014. DOI: 10.1093/bioinformatics/btt684.
[4] Ritchie ME et al. “limma powers differential expression analyses for RNA-sequencing
and microarray studies.” Nucleic Acids Research, 43(7), e47; 2015. DOI: 10.1093/nar/gkv007
Disclosure of Interest
None Declared
P1062 Differential kinetic of actin polymerization in neutrophil from patients with
familial Mediterranean fever
David Poghosyan1, Anush Martirosyan1, Nune Mkrtchyan2,3, Sona Margaryan1, Susanna
Ghonyan1, Gayane Amaryan2,3, Gayane Manukyan1
1Laboratory of Molecular and Cellular Immunology, Institute of Molecular Biology;
2Arabkir Medical Centre, Institute of Child and Adolescent Health, National Pediatric
Centre for Familial Mediterranean Fever; 3Yerevan State Medical University, Yerevan,
Armenia
Correspondence: Gayane Manukyan
Introduction: Seemingly unprovoked trafficking of neutrophils to the serosal/synovial
membranes is a key event in acute inflammatory attacks of familial Mediterranean fever
(FMF). Migratory events behind abnormal trafficking of the cells remain largely unknown.
Objectives: The aim of the present study is to analyze kinetic of actin polymerization
and migration rate of neutrophils from colchicine naïve and colchicine receiving FMF
patients.
Methods: FMF patients in acute attack (colchicine naïve A-FMF), FMF patients in remission
period (receiving colchicine, R-FMF), and healthy controls (HD) were enrolled in the
study. We have measured the amounts of F-actin in untreated and pre-treated with colchicine
neutrophils induced by fMLP at 5s, 15s, 30s, 60s, 120s, and 180s time points in vitro.
Actin polymerization was investigated by flow cytometry using FITC-Phalloidin. Neutrophils
migration to fMLP was assessed using Transwell cell migration assay.
Results: Neutrophils from A-FMF displayed higher migration rate compared to R-FMF
and HD (P< 0.05). R-FMF patients, who were receiving colchicine, displayed the lowest
actin polymerization activity in neutrophils at all-time points. The cells from FMF
patients in A-FMF stimulated with fMLP displayed a maximal F-actin polymerization
earlier (at 5s) than in R-FMF (at 30s) and HD (at 15s) (P< 0.05). In opposite, plateau
levels of F-actin content were reached earlier in HD neutrophils (after 1 min), while
plateau levels in A-FMF and R-FMF cells were reached later (after 2 min). Colchicine-pretreated
cells in all studied groups reached maximal F-actin polymerization later than in untreated
with colchicine cells, namely at 15s in A-FMF and 30s in R-FMF and HD groups.
Conclusion: We have demonstrated actin dysfunctions in neutrophils from FMF patients
which might cause defects in neutrophil functioning. The results suggest that colchicine
may affect actin polymerization in the cells due to unknown mechanism.
Disclosure of Interest
None Declared
P1063 CARD15 mutations in an Indian cohort of Blau syndrome
Amit Rawat1, Deepti Suri1, Rajni Kumrah1, Sagar Bhattad2, Sandesh Guleria1, Vignesh
Pandiarajan1, Ankur Jindal1, Anju Gupta1, Isabelle Ceccherini3, Marco Gattarno4, Surjit
Singh1
1Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh;
2Pediatric Immunology and Rheumatology, Aster CMI Hospital, Bengaluru, India; 3Genetica
Medica; 4U.O.C. Pediatria II - Reumatologia, Istituto Giannina Gaslini, Genoa, Italy,
Genoa, Italy
Correspondence: Amit Rawat
Introduction: Blau syndrome is an autosomal dominant disorder resulting from genetic
variants in the CARD15 gene previously known as NOD2. It is characterized by a clinical
triad of arthritis, uveitis and skin rash. Classic features also include skin lesion
with non-caseating granulomas, boggy synovitis or tenosynovitis and camptodactyly.
CARD15 gene comprises eleven exons encoding for a 1044 amino acid protein. The protein
has N-terminal caspase recruitment domains (CARDs) linked to a nucleotide binding
domain (NBD) and C- terminal leucine-rich repeats (LRRs).
Objectives: The objective of the study was to determine the underlying genetic variants
in our cohort of patients with Blau syndrome and to establish a genotype-phenotype
correlation if any.
Methods: Genetic variants in CARD15 were determined in 11 of our patients with Blau
syndrome. Targeted next- generation sequencing was employed to detect these variants
in six patients at the Istituto Giannina Gaslini, Genoa, Italy. In rest of the 5 patients,
conventional Sanger sequencing was used. Since most of the variants have been detected
in Exon 4, the exon4 was amplified by polymerase chain reaction. Four pairs of specific
primers described in Resource of Asian Primary Immunodeficiency Diseases Database
were used for amplification of the Exon 4 and the PCR amplifications generated were
sequenced using conventional Sanger sequencing.
Results: Single nucleotide substitutions resulting in missense variants were detected
in all of the eleven patients. Nine of the eleven patients had a recurrent, previously
reported missense variant in Exon 4 which encodes for the nucleotide binding domain
(NBD). This variant resulting from the substitution of Thymine for cytosine at c.1000;
c.1000C>T causes the replacement of Arginine with Tryptophan at codon 344; p.R344W.
This variant has been reported in the Infevers database. Three of the nine patients
with this variant were related, an affected mother with her son and daughter. Rest
of the six were from unrelated families. However, six of the nine patients were from
the north Indian state of Haryana, and one was from the adjoining northern state of
Punjab. The remaining two patients were from the eastern part of India. Two patients
had another missense variant in the Exon 4; p.G299D with replacement of Glycine with
Aspartic acid at codon 299. This variant has not been reported in the Infevers database
or the Human Gene Mutation Database (HGMD), but it has been reported in the Exome
Aggregation Consortium (ExAC).
Conclusion: The detection of a similar previously reported missense variant in 9 of
the 11 patients might denote a founder mutation especially given the fact that seven
of the nine patients with the p.R344W variant were from the same geographical locale
in North India. This recurrent variant also provides an opportunity for development
of an amplification-refractory mutation system for its detection without resorting
to sequencing.
Disclosure of Interest
None Declared
P1064 Differential activation of the Pyrin inflammasome in monocytes and macrophages
predicts the pathological significance of MEFV variants in familial Mediterranean
fever (FMF) patients
Takeshi Shiba1, Takayuki Tanaka1, Hiroaki Ida2, Misa Watanabe3, Haruna Nakaseko4,
Mitsujiro Osawa5, Hirofumi Shibata1, Kazushi Izawa1, Takahiro Yasumi1, Yuri Kawasaki5,
Megumu K. Saito5, Junko Takita1, Toshio Heike6, Ryuta Nishikomori1
1Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto; 2Department
of Respiratory, Neurology, and Rheumatology, Kurume University School of Medicine,
Fukuoka; 3Department of Pediatrics, Toho University School of Medicine, Tokyo; 4Department
of Infection and Immunology, Aichi Children’s Health and Medical Center, Aichi; 5Department
for Clinical Application, Center for iPS cell Research and Application, Kyoto University,
Kyoto; 6Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center,
Hyogo, Japan
Correspondence: Takeshi Shiba
Introduction: While numerous MEFV sequence variants have been reported, the impact
of these variants on pyrin inflammasome functions remains unknown.
Objectives: To determine the effect of MEFV variants on IL-1β production by monocytes
and monocyte-derived macrophages from Familial Mediterranean Fever (FMF) patients
and to extend this approach to the functional evaluation of rare MEFV variants.
Methods: Freshly isolated monocytes and monocyte-derived macrophages from patients
with typical FMF and healthy donors were analyzed for IL-1β secretion in response
to the pyrin inflammasome activator Clostridium difficile toxin A (TcdA). Induced
pluripotent stem cell (iPSC) clones derived from FMF patients and healthy donors were
differentiated into macrophages and analyzed for pyrin inflammasome activation. Rare
MEFV variants were expressed in iPSC-derived macrophages.
Results: IL-1β secretion by FMF monocytes in response to TcdA was comparable to that
of healthy donors, and colchicine inhibited IL-1β secretion from healthy donors, but
not from FMF monocytes. FMF macrophages secreted significantly higher levels of IL-1β
than healthy donor macrophages, and their IL-1β secretion could be inhibited with
colchicine. The characteristics observed in monocyte-derived macrophages were recapitulated
in iPSC-derived macrophages. Finally, iPSC-derived macrophages transgenically expressing
the N679H variant were functionally similar to those expressing the pathogenic MEFV
variant M694I, while cells expressing the T577N variant had a similar phenotype as
control cells.
Conclusion: While FMF monocytes carrying the typical MEFV mutations were distinct
from healthy monocytes in their unresponsiveness to colchicine, FMF macrophages showed
hyperactivation of the pyrin inflammasome and were sensitive to colchicine inhibition.
Our novel approach may be useful for identifying MEFV variants that cause the typical
FMF phenotype according to their capacity to induce pyrin inflammasome activation.
Disclosure of Interest
None Declared
P1065 Cross-talk between type I IFN pathway and TLR sensing in DNase2 mutated fibroblasts
Alessandra Tesser1, Elisa Piscianz2, Valentina Boz2, Giulia Piperno3, Federica Benvenuti3,
Alberto Tommasini1
1IRCCS Burlo Garofolo, Trieste, Italy; 2University of Trieste, Italy; 3ICGEB, Trieste,
Italy
Correspondence: Alessandra Tesser
Introduction: Cytoplasmic sensing of nucleic acids via cGAS-TBK1 pathway leads to
type I interferon (IFN) production. DNase2 deficiency impairs DNA digestion in phagosomes
resulting in cGAS-dependent IFN hyper-production (1). However, other sensors like
TLRs can stimulate this pathway, as recently shown in animal models (2).
Objectives: To investigate the interaction between cGAS and TLRs stimulation in DNAse2-deficient
fibroblasts.
Methods: Fibroblasts from a subject with DNase2 deficiency and from healthy controls
were treated with different Multiplicity Of Infection (MOI) of E. coli and concentration
of bacterial LPS, 2’3’-cGAMP and Poly(I:C) for 1 hour. After stimulation, phosphorilated-TBK1
was measured by flow-cytometry with intracellular staining.
Results: Fibroblasts with DNase2 deficiency responded to an overload of bacteria with
a greater activation of the IFN pathway compared to healthy controls. DNase2-mutated
cells showed an enhanced IFN response even after stimulation with pure E. coli derived-LPS
(Tab. 1). Moreover, the combined stimulation of the cGAS-STING pathway and on TLRs
(cGAMP + LPS, cGAMP + Poly(I:C)) resulted in a synergic increase of TBK1 phosphorylation
compared with any stimulus alone (Tab. 1).
Conclusion: The possibility that the dysregulated IFN pathway in DNase2-deficient
fibroblasts may sensitise cells to an increased response to LPS is supported by others
preliminary data (not shown) proving that intact STING is necessary for LPS-induced
IFN production. Indeed, there are evidences that STING can be activated not only by
2’3’-cGAMP, but also by other molecules collecting the signals from distinct TLRs.
Considering these results, we can assume that a dysfunctional IFN pathway could display
a “permissive” role towards other stimuli acting on STING-TBK1 signaling. Ongoing
experiments are being carried out to clarify the convergence of different TLRs stimuli
on the cGAS-TBK1 axis.
1. Rodero MP, et al. Type I interferon-mediated autoinflammation due to DNase II deficiency.
Nat Commun. 2017 Dec 19;8(1):2176.
2. Manfredo VS, et al. Translocation of a gut pathobiont drives autoimmunity in mice
and humans. Science. 2018 Mar 09:Vol. 359, Issue 6380, pp. 1156-1161.
Disclosure of Interest
None Declared
Table 1 (abstract P1065).
TBK1 phosphorylation assessed by flow-cytometry after infection with different MOI
(20, 120, 400) of E. coli, single stimulation with LPS (0.5 ug/ml), cGAMP (20 ug/ml)
and Poly(I:C) (20 ug/ml), and combined stimulation of cGAS/TBK1 and TLRs pathways
(cGAMP + LPS; cGAMP + Poly(I:C); Poly(I:C) + LPS)
pTBK1 (MFI)Healthy control fibros
pTBK1 (MFI)DNase2 mut fibros
NS
2.9
3
E.coli MOI 120
3.1
7
E.coli MOI 400
3.7
8
LPS
2.3
6.1
cGAMP
3.3
4.3
Poly(I:C)
3.4
5.6
cGAMP + LPS
4.5
7.5
cGAMP + Poly(I:C)
4.5
7.6
Poly(I:C) + LPS
2.8
4.4
NS: not stimulated; MFI: mean fluorescence intensity
P1066 Auto-inflammatory diseases (SAIDS) in Western Switzerland: a descriptive study
through the JIRcohorte platform
Lorenzo Tosetti, Manel Mejbri, Aikaterini Theodoropoulou, Michael Hofer
Pediatric Immunology Allergology Rheumatology Unit, University Hospital Lausanne and
University Hospital Geneva, Lausanne and Geneva, Switzerland
Correspondence: Lorenzo Tosetti
Introduction: SAIDs are a large and heterogeneous group of inflammatory conditions,
including monogenetic and multifactorial diseases, associated with a dysregulation
of innate immune system. Early diagnosis and treatment of these conditions are essential
to prevent serious complications, in particular the development of amyloidosis. Biological
treatments blocking the Interleukins (IL-) 1 and 6 can lead to rapid remission and
are expected to improve long-term outcome in these patients. Five of them received
an indication to be treated by these medications in Switzerland; therefore, we are
interested to evaluate the number of patients who may receive these treatments.
Objectives: To describe and estimate the prevalence of FMF, MKD, TRAPS, CAPS and SoJIA
in Switzerland.
Methods: This is a monocentric, prospective and descriptive cohort study, through
the JIRcohorte platform. Patients with juvenile-onset sAIDs attending the pediatric
rheumatology unit of Western Switzerland in the University Hospitals of Lausanne and
Geneva were enrolled at the study until August 2018. AIDs included diagnosis of Systemic
onset juvenile idiopathic arthritis (SoJIA), Familial Mediterranean fever (FMF), Cryopyrin-associated
periodic syndromes (CAPS), Mevalonate kinase deficiency (MKD) and Tumor necrosis factor
receptor-associated periodic syndrome (TRAPS). A projection for Switzerland was made
using the population data extracted from the Swiss Federal Statistical Office in 2016.
Results: A total of 123 patients were enrolled, including 67 % females. The median
age at last visit was 12.3 years[TA1] . Patients were distributed as follows: 61 patients
with SoJIA, 35 with FMF, 15 with CAPS, 8 with MKD and 4 patients with TRAPS. Biologic
agents (anti IL-1 or anti IL-6) were used for treatment in 55 % of our patients. The
prevalence in our population is 1.4 per 100.000 for sAIDS and 1.5 per 100.000 for
SoJIA. The total number of patients with sAIDs is estimated at 139 for monogenic fevers
and 131 for SoJIA in Switzerland.
Conclusion: AIDs are rare but not negligible conditions in Switzerland. A national
study through the JIRcohorte database is ongoing aiming to evaluate the number of
pediatric and adult patients with sAIDs in Switzerland, in order to study clinical
presentation, treatments and long term complications.
Disclosure of Interest
None Declared
P1067 Familial Mediterranean fever associated infertility and underlying factors
Nuh Atas1, Berkan Armagan2, Erdal Bodakci3, Timucin Kasifoglu3, Hasan Satis1, Alper
Sari2, Nazife S. Y. Bilge3, Hakan Babaoglu1, Gozde K. Yardimci2, Reyhan B. Salman1,
Levent Kilic2, Mehmet A. Ozturk1, Berna Goker1, Seminur Haznedaroglu1, Umut Kalyoncu2,
Abdurrahman Tufan1
1Department of Internal Medicine, Division of Rheumatology, Gazi University Faculty
of Medicine; 2Department of Internal Medicine, Division of Rheumatology, Hacettepe
University Faculty of Medicine, Ankara; 3Department of Internal Medicine, Division
of Rheumatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
Correspondence: Abdurrahman Tufan
Introduction: Familial Mediterranean Fever (FMF) is characterized by recurrent attacks
of fever, serositis and arthritis, but some patients may experience long-term complications
of disease such as infertility/subfertility.The published data about FMF associated
infertility is still limited.
Objectives: The aim of this study is to investigate the frequency and to determine
potential factors for FMF associated infertility /subfertility.
Methods: All patients recruited from FMF in Central Anatolia (FiCA) cohort, currently
comprising 970 adult subjects. All patients fulfilled Tel Hashomer criteria and all
were using colchicine for at least 1 year. Demographic data, FMF disease characteristics
and genotype data (if available), disease complications, autoinflammatory damage index
(ADDI), laboratory parameters and treatment features were recorded. For this study
data on 582 patients (mean age 41±10.6, 65.8% female) who had been willing to have
children were used.
Results: Proportions of FMF manifestations were fever 82.3%, peritonitis 90.5%, pleuritis
48.1%, arthritis 41.1% and skin rash 24.7%. MEFV mutations were available in 454 subjects
and 79.5% of subjects were harboring M694V mutation (44.5% homozygous for M694V).
Among all, 53 (9.1%) patients were colchicine resistant (crFMF). Infertility was present
in 64 patients (14.6 % of females and 4 % of males). Multivariate analysis showed female
sex (odds ratio, 8.19; 95% confidence interval [CI95%] 2.69-24.97; p<0.05), FMF disease
onset <20 years (odds ratio, 9.9; [CI95% 2.06-47.82]; p<0.05), damage accrual (ADDI
score) (odds ratio, 2.02; [CI95% 1.65-2.50]; p<0.05) and colchicine nonresponse (odds
ratio, 2.07; 95% confidence interval, [CI95% 1.47-2.93]; P<0.05) are the independent
predictors of infertility.
Conclusion: Damage accrual (ADDI), FMF disease onset <20 years, colchicine nonresponse
and female sex were found to be the independent predictors of infertility. The value
of effective therapeutic interventions must be determined to treat infertility in
these patients.
Disclosure of Interest
None Declared
P1068 MEFV-mutant induced pluripotent stem-cells have reduced anti-inflammatory properties
Katharina Kessel1,2, Christoph Kessel1, Nadine Ludwig3, Toni Weinhage1, Dirk Foell1,
Helmut Wittkowski1
1Pediatric Rheumatology and Immunology, University Children’s Hospital; 2Department
of Nuclear Medicine; 3Department of Anesthesiology, Intensive Care and Pain Medicine,
University Hospital Münster, Muenster, Germany
Correspondence: Helmut Wittkowski
Introduction: Familial Mediterranean Fever (FMF) is a prototypic autoinflammatory
disorder associated with MEFV pyrin-encoding gene mutations, characterized by unprovoked
episodes of inflammation. On a molecular level, pyrin inflammasome activation with
consecutive increased IL-1beta maturation is an important mechanism of inflammation
in FMF.
Objectives: Experiments with human MEFV-mutated cells rely on FMF patient material,
but patients are often already treated with an anti-inflammatory therapy, i. e. Colchicine.
In order to systematically study functional consequences of MEFV pyrin-encoding gene
mutations on a therapy-naïve background we aimed to generate human induced pluripotent
stem cells (hiPSCs) from M694V homo- and heterozygous FMF-patients as well as healthy
controls and differentiated those to functional human monocytes.
Methods: HiPSCs were generated from MEFV-mutant patients with clinical FMF and from
healthy controls by reprogramming of peripheral blood-derived (PB) CD34+ HSCs. After
confirmation of MEFV genotypes, HiPSCs were differentiated to monocytes using an embryoid
body (EB)-based differentiation protocol. Terminally differentiated cells were phenotyped
regarding extra- and intracellular marker expression as well as cell morphology and
were subjected to different functional assays. Cells were stimulated with LPS, ATP
and S100A12 and cytokine secretion into culture supernatants was quantified by multiplexed
bead array assay. For confirmation of observed phenotypes, ex vivo purified primary
monocytes from FMF-patients were likewise stimulated and analysed.
Results: Terminally differentiated hiPSC-derived monocytes from both FMF patients
and HCs were larger in cell area (mm2) compared to primary human monocytes. On the
level of 25F9, CD16a and CD68 expression hiPSC derived monocytes ranged between that
detected on primary cells and in vitro differentiated primary monocyte derived macrophages.
All cells expressed identical levels of CD14. Similar to our observations on primary
monocytes from FMF patients and controls both CD14 and CD16 expression was lowest
on p.M694V homozygous hiPSC derived monocytes. On the contrary intracellular S100A9
and A12 expression in both primary as well as hiPSC derived monocytes increased with
p.M694V gene dose. Correspondingly, p.M694V homozygous hiPSC-derived monocytes revealed
increased S100A8 expression at base line and already spontaneous protein release in
stimulation experiments. In contrast, Il1rn expression in p.M694V mutant hiPSC-derived
monocytes was low compared to HCs. When induced by IFNa, Il1rn expression was reciprocal
according to p.M694V gene dose. In similar lines, p.M694V mutant hiPSC-derived monocytes
revealed strongly decreased IL-10 expression on both gene and protein level compared
to healthy control cells.
Conclusion: We successfully generated mature monocytes from hiPSC derived from p.M694V
hetero- and homozygous FMF-patients as well as healthy individuals. Apart from S100
proteins p.M694V mutant cells did not reveal a pronounced overexpression of inflammatory
cytokines but rather demonstrated an intrinsic lack of anti-inflammatory counter-regulation
on the level of IL-1Ra and IL-10 expression.
Disclosure of Interest
None Declared
Monogenic autoinflammatory diseases (genetics)
P1069 Three novel cases of late-onset cryopyrin-associated periodic syndromes due
to somatic NLRP3 mosaicism
Anna Mensa-Vilaró1, María Teresa Bosque2, Enrique Gómez de la Fuente3, Natalia Palmou4,
Luis Martín-Penagos5, Concha Delgado2, Susana Plaza1, Rocío Lara1, María Carmen Antón1,
Helios Martinez-Banaclocha6, Juan J. Martinez-García6, Jordi Yagüe1,7,8, Miguel Ángel
González-Gay4, Pablo Pelegrin6, Juan I. Arostegui1,7,8
1Immunology, Hospital Clinic, Barcelona; 2Rheumatology, Hospital Universitario Lozano
Blesa, Zaragoza; 3Dermatology, Hospital Universitario Fundación Alcorcón, Alcorcón;
4Rheumatology; 5Nephrology, Hospital Universitario Marqués de Valdecilla, Santander;
6Instituto Murciano de Investigación Biosanitaria IMIB-Arrixaca, Murcia; 7Institut
d’investigacions Biomèdiques August Pi i Sunyer; 8Universitat de Barcelona, Barcelona,
Spain
Correspondence: Juan I. Arostegui
Introduction: Monoallelic gain-of-function NLRP3 mutations are the genetic cause of
the dominantly-inherited cryopyrin-associated periodic syndromes (CAPS), which represent
the prototypical early-onset, interleukin-1b-mediated disease (1). Post-zygotic NLRP3
mutations leading to somatic mosaicism have been shown as the disease-causing mechanism
in a moderate, but increasing number of patients (2-3). Recent reports have also shown
that somatic NLRP3 mosaicism may appear later in life, leading to forms of the disease
that started during adulthood (4-7).
Objectives: To describe the clinical, analytical and genetic features as well as the
outcome of administered treatments in three unrelated Spanish patients with late-onset
CAPS carrying somatic NLRP3 mosaicism.
Methods: Clinical and analytical data, and outcome of treatments were collected from
patients’ medical charts. Genetic studies were performed using both Sanger and amplicon-based
deep sequencing.
Results: The following table summarizes the clinical data of the three enrolled patients.
All patients displayed increased counts of white blood cells, neutrophils and platelets,
as well as increased plasma levels of acute-phase reactants.
Genetic studies revealed in each patient a post-zygotic NLRP3 variant: p.Gln306His
variant in patient 1 (minor allele frequency [MAF]: 5.1%), p.Ala352Thr variant in
patient 2 (MAF: 18.7%) and p.Gln636Glu in patient 3 (MAF: 18.4%). All these NLRP3
variants were classified as pathogenic and gain-of-function variants on the basis
of their absence among healthy controls and in public databases, the damaging predictions
by using different bioinformatics analyses and additional ex vivo evidences of inflammasome
hyperactivation.
All three patients are being treated with anti-IL-1 drugs since several years, resulting
in a successful clinical control of the disease, normalization of acute phase reactants
and hematological parameters, and improvement of renal function in patient 1 who suffered
from AA amyloidosis.
Conclusion: The results here shown add additional evidences of the relevant role of
somatic NLRP3 mosaicism as the disease-causing mechanism in patients with late onset,
but otherwise typical CAPS. Due to the serious consequences that these data could
have with regard to their treatments, this genetic mechanism should be seriously considered
in the design of genetic analyses to be done in candidate patients.
References
1Nat Immunol 2017; 18: 832-842
2Arthritis Rheum 2011; 63: 3625-3632
3Ann Rheum Dis 2015; 74: 603-610
4J Allergy Clin Immunol 2015; 135: 561-564
5Arthritis Rheumatol 2015; 67: 2428-2436
6Arthritis Rheumatol 2016; 68: 3035-3041
7Front Immunol 2017; 8: 1410.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P1069).
See text for description
Patient 1
Patient 2
Patient 3
Sex / Current Age (years)
Female / 63
Female / 66
Male / 67
Age at disease Onset (years)
47
55
56
Fever
Yes
No
Yes
Urticaria-like Rash
Yes
Yes
Yes
Eye Inflammation
Bilateral Uveitis
No
Conjunctivitis
Joint Inflammation
Arthralgias
Arthralgias / Arthritis
Arthralgias / Arthritis
Headache
Yes
Yes
No
Hearing Loss
Yes
No
Yes
AA-type Amyloidosis
Yes
No
No
P1070 The NLRP3 p.A441V mutation in cryopyrin-associated periodic syndrome pathogenesis:
functional consequences, phenotype-genotype correlations and evidence for a founder
effect
Eman Assrawi1, Fawwaz Awad2, Claire Jumeau1, Sylvie Odent3, Veronique Despert4, G.
Cam5, Aleth Perdriger6, Camille Louvrier1, Laetitia Cobret1, Bruno Copin1, Phillipe
Duquesnoy1, William Piterboth1, Claire Le Jeunne7, Sophie Georgin-Lavialle8, Gilles
Grateau8, Marie Legendre1, Irina Giurgea1, Sonia Athina Karabina1, Serge Amselem1
1Sorbonne Université, Inserm UMR_S933; 2Sorbonne Université,Inserm UMR_S933, Paris;
3Centre Hospitalier Universitaire de Rennes, Service de Génétique; 4Centre Hospitalier
Universitaire de Rennes, Département de Médecine de L’enfant et de L’adolescent, Rennes;
5Centre Hospitalier de Saint-Malo, Service de Néphrologie, Saint-Malo; 6Centre Hospitalier
Universitaire de Rennes, Service de Rhumatologie, Rennes; 7Hôpital Cochin; 8Hôpital
Tenon , Service de Médecine Interne, Paris, France
Correspondence: Eman Assrawi
Introduction: Cryopyrin‑associated periodic syndromes (CAPS) are a group of rare monogenic
autoinflammatory diseases caused by heterozygous missense gain-of-function mutations
in NLRP3 gene, coding for the NLRP3.Upon activation, NLRP3 initiates the formation
of a multiprotein complex called inflammasome, which regulates proinflammatory cytokine
secretion.
Objectives: To determine the molecular and cellular basis of autoinflammatory syndromes
in two unrelated families with two clinically overlapping CAPS phenotypes; a multigenerational
French family with Muckle-Wells syndrome and in a patient originating from Portugal
with familial cold autoinflammatory syndrome.
Methods: Sanger sequencing of NLRP3 exon 3 was performed in all accessible patients.
Microsatellites analysis was used to test the intra-familial segregation of the identified
variant and to look for a founder effect. Functional analyses included the study of
(i) ASC speck formation in HEK293T cells (stably expressing ASC-GFP and pro-caspase1-FLAG)
transiently expressing the wild-type or mutated NLRP3 protein, (ii) IL1β secretion
from transfected THP1 cells, and (iii) inflammasome-related gene expression and cytokine
secretion from monocytes isolated from patients in crisis (probands from the two families),
related patients out of crisis, and from controls.
Results: The same heterozygous mutation (c.1322C>T, p.A441V) in NLRP3 exon 3, segregating
with the disease within the first family, was identified in the two families which
were shown to share the same mutation-associated NLRP3 haplotype. HEK293T cells transfected
with the pNLRP3-A441V construct showed a significantly higher percentage of ASC specks,
a common readout of inflammasome activation, as compared to cells transfected with
pNLRP3-WT. Transfection of THP1 cells with pNLRP3-A441V led to significantly higher
levels of secreted IL1β, a hallmark of inflammasome activation, as compared to cells
transfected with pNLRP3-WT. Monocyte inflammasome-related gene expression and cytokine
secretion profile was similar in patients out of crisis and in the healthy controls.
However, the expression of the inflammasome-related genes in the two probands was
different from that of patients without crisis and healthy controls. In addition,
this expression pattern was found to be differentially regulated between the two probands,
correlating with their phenotypic status.
Conclusion: These molecular and cellular findings, which indicate a founder effect
in these two families, clearly demonstrate the pathogenicity of the p.A441V missense
mutation in CAPS and point to the interest of studying patients’ primary cells to
assess disease activity.
Disclosure of Interest
None Declared
P1071 The analysis of IL-36RA structural dynamics improves pathogenicity predictions
for IL36RN variants observed in generalised pustular psoriasis
Camilla Davan-Wetton, Niina Karoliina Hassi, Joseph Chifung Ng, Franca Fraternali,
Francesca Capon
King's College London, London, United Kingdom
Correspondence: Francesca Capon
Introduction: Generalised pustular psoriasis (GPP) is a potentially life-threatening
autoinflammatory condition. While GPP is associated with mutations of the interleukin-36
receptor antagonist (IL-36Ra encoded by IL36RN), commonly used pathogenicity predictors
cannot fully differentiate IL36RN disease alleles from polymorphisms.
Objectives: The aim of this study was to systematically assess the impact of IL-36Ra
mutations on the protein three-dimensional structure, in order to identify the computational
approaches that best predict in-vitro stability and variant pathogenicity.
Methods: The IL-36Ra 3D structure was derived by homology modelling. The effects of
mutations were assessed using the mCSM and RAPSODY programs. Experimental validation
was undertaken by western blot analysis of mutagenized constructs.
Results: The results of the mCSM analysis partially correlated with those obtained
by western blot, particularly for well-characterised mutations like p.Leu27Pro and
p.Ser113Leu. An improved correlation with the western blot data was achieved using
RAPSODY, which incorporates information on protein structural dynamics. Of note, this
programme also out-performed sequence- based predictors such as CADD.
Conclusion: Computational methods that take into account the dynamic features of the
IL-36Ra protein structure show the strongest correlation with experimental data. Extending
their implementation to other IL36RN variants (e.g. those that affect the interaction
between IL-36Ra and its receptor) will improve our understanding of GPP mutations
and enable the development of more accurate pathogenicity predictors to help disease
diagnosis.
Disclosure of Interest
C. Davan-Wetton: None Declared, N. K. Hassi: None Declared, J. C. Ng: None Declared,
F. Fraternali: None Declared, F. Capon Grant / Research Support from: Boheringer Ingelheim,
Consultant for: AnaptysBio
P1072 Spondyloenchondrodysplasia and systemic lupus erythematosus: case report of
two sibling
Bulent Kara1, Ayse Cefle2, Ozgur Kasapcopur3, Ayfer Sakarya Gunes1
1Department of Pediatrics Division of Child Neurology; 2Department of Internal Medicine
Division of Rheumatology, Kocaeli University Faculty of Medicine, Kocaeli; 3Department
of Pediatric Rheumatology, Istanbul University Cerrahpasa Medical School, Istanbul,
Turkey
Correspondence: Ayse Cefle
Introduction: Interferons (IFNs) are signalling proteins that are synthesised and
released by immune host cells in response to the presence of the several pathogens.
Interferonopathies comprise an expanding group of monogenic diseases characterised
by disturbance of the homeostatic control of IFN-mediated immun responses. Although
differing in the degree of phenotypic expression and severity, the clinical presentation
of the diseases shows a considerable degree of overlap, reflecting their common pathogenetic
mechanisms.
Objectives: Spondyloenchondrodysplasia with immune dysregulation (SPENCDI) is an immuno-osseous
dysplasia combining the typical metaphyseal and vertebral bone lesions of SPENCDI
and neurologic involvement.
Methods: 19 years old a male patient presented with arthralgia and rash in 2014. On
physical examination short stature and erythematous skin rash were noted. Laboratory
studies revealedproteinuria (740 mg/d), lymphopenia (1150/mm3), elevated ESR (51 mm/h),
CRP (15 mg/l, N<5) and low C3 level. The C4 level was normal. ANA was homogenously
positive, while the anti ds-DNA antibody was also positive. Anticardiolipin IgG and
IgM and the lupus anticoagulant were negative. HBsAg, HCV and HIV were negative. IgG,
IgA and IgM levels were normal. Skin bipsy revealed perivascular dematitis, while
a kidney biopsy showed class II lupus nephritis. The patient was given methyl prednisolone,
hydroxycholoroquine and azathioprine. On follow up, the proteinuriadecreased. However,
he developed attacks of seizuresand ataxia. The neurologic examination, EEG and EMG,
were normal. Cranial tomography revealed calcification of lentiform nucleus, corona
radiata, frontal lobe white matter and dentate nuclei. In 2015, he presented with
abdominal paine, vomiting and nausea. Abdominal CT revealed edema and inflammation
of jejenum and dudenum.The steroid dose was increased. After a few months, the symptoms
recurred. The patient was thought to have gastrointestinalinvolvement due to systemic
lupus erythematosus (SLE) and rituximab was added to the treatment. Thereafter the
patient did not have anysymptoms related toacute abdomen.
Results: A direct raiographic examination of the spine revealed platyspondyly. The
parents were consanguineous. His sister was under follow up due to a diagnosis of
juvenil onset SLE.Intracranial calcifications, spastic paraparesis, short stature,
systemic lupus erythematosus and platyspondyly suggested a diagnosis of SPENCD. Next
generation sequencing of the ACP5 gene showed that the patient and his sisters were
homozygous for the c.155A C/p.K52T variant. Both parents were heterozygous forthis
variant.
Conclusion: SPENCDI is a recessive genetic disease caused by homozygous or compound
heterozygous mutation in the ACP5 gene on chromosome 19p13. Immune dysregulation ranges
from autoimmunity to immunodeficiency. Neurologic and autoimmune manifestations have
been observed in different combinations. Skeletal, nneurologic and immune phenotypes
were observed between members of the same family.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1073 ADA2 deficiency without ADA2 mutations explained by a structural homozygous
variation in 22Q11.1
Alice Grossi1, Francesca Garbarino2, Roberta Caorsi3, Roberto Cusano4, Marta Rusmini1,
Federica Penco3, Francesca Schena3, Rosa Anna Podda5, Paolo Uva4, Isabella Ceccherini1,
Marco Gattorno3
1UOC Genetica Medica, IRCCS Istituto Giannina Gaslini; 2Università degli Studi di
Genova; 3Clinica Pediatrica Reumatologia e UOSD Centro Malattie Autoinfiammatorie-Immunodeficienze,
IRCCS Istituto Giannina Gaslini, Genova; 4Centre for Advanced Studies Research and
Development in Sardinia (CRS4), Science and Technology Park Polaris, Pula; 5Clinica
Pediatrica,Talassemie e Malattie Rare, Ospedale Brotzu e Università degli studi di
Cagliari, Cagliari, Cagliari, Italy
Correspondence: Alice Grossi
Introduction: Adenosine Deaminase 2 deficiency (DADA2) is an autosomal recessive autoinflammatory
disease caused by loss of function mutations in the ADA2 gene, located on chromosome
22q11.1. The clinical spectrum of the disease is heterogeneous, ranging from multisystemic
inflammation with vascular and multiorgan involvement to immunodeficiency and immunedysregulation.1
A small proportion of patients, despite consistent phenotype and lack of ADA2 enzymatic
activity, has an incomplete or negative genotype.
Objectives: To define the genetics underlying DADA2 in a 9 years old girl with a complete
clinical phenotype and deficient enzymatic activity but without any mutation in the
coding region of the ADA2 gene.
Methods: Whole Genome Sequencing (WGS) was performed in the proband by TruSeq Nano
DNA Library Prep kit (Illumina) and HiSeq 3000 Instrument (Illumina) with 150bp paired-end
reads. Structural variants were identified with Manta.
Results: At the age of 3 months, the patient began to suffer from intermittent episodes
of fever and livedo reticularis. At 1-year old inflammatory symptoms became persistent
and the patient developed hypertension and a severe dilatative myocarditis, responsive
to high doses of steroids. Anakinra was not effective, hence steroid therapy could
not be suspended for years. Hypogammaglobulinemia was also present, together with
recurrent upper airways infections. At the age of 6 years, following the withdrawal
of steroids, the patient presented two episodes of ischemic and hemorrhagic stroke.
Anti-TNF treatment (etanercept) was then started, allowing a complete control of clinical
manifestations, as well as the normalization of Ig levels, without the need of any
steroid treatment. The patient has been on anti-TNF as monotherapy for 4 years and
is still in complete clinical remission. Whole Genome Sequencing (WGS) has revealed
a homozygous tandem duplication of the genomic region encompassing exons 3 and 4 (involving
12895 bases), generated by two breakpoints in intron 2 and intron 4 respectively.
This has led to a gene transcript postulated to contain 1967 instead of 1536 nucleotides,
leading to a frameshift starting from codon V252 followed by a premature stop codon
after 11 aminoacid residues (p.V252Gfs11*). PCR reactions properly designed to amplify
the junction fragments from both the genomic DNA and the cDNA confirmed such findings.
Conclusion: Chromosome 22q11, where the ADA2 gene lies, is regarded as an unstable
region subjected to copy number variations and other structural genomic alterations,
whose occurrence is mediated by low copy repeat sequences or segmental duplications,
found in association with several different Syndromes.2 The structural variation identified
in the present patient represents the first demonstration of non-allelic homologous
recombination (NAHR) occurred in DADA2, different from causative bi-allelic loss-of-function
point mutations, typically found in the coding portion of the ADA2 gene. The identification
of ADA2 enzymatic impairment in patients with clinical phenotypes consistent with
DADA2 should lead to extensive molecular approaches, especially in the absence of
any mutation at standard DNA sequencing.
References
1. Moens L., Hershfield M., Arts K., Aksentijevich I., Meyts I. “Human adenosine deaminase
2 deficiency: a multi-faceted inborn error of immunity” Immune Rev 2019; 287(1):62-72
2. Vergés L, Vidal F, Geán E, Alemany-Schmidt A, Oliver-Bonet M, Blanco J. “An exploratory
study of predisposing genetic factors for DiGeorge/velocardiofacial syndrome” Sci
Rep 2017;7:40031
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1074 Evaluation of the role of SAA1, SAA2 and SAA4 genes in AA amyloidosis
Claire Jumeau1, Camille Louvrier1, Eman Assrawi1, Fawaz Awad1, Laetitia Cobret1, Sophie
Georgin-Lavialle1,2, Cécile Cazorla3, Philippe Duquesnoy1, Jean-Simon Rech3, William
Piterboth1, Florence Dastot-Le Moal1, Bruno Copin1, David Buob4, Gilles Grateau1,5,
Jean-François Bernaudin1,6, Marie Legendre1, Sonia-Athina Karabina1, Irina Giurgea1,
Serge Amselem1
1Sorbonne Universite, INSERM UMR_S933, Hôpital Trousseau; 2Hôpital Tenon, Service
de Médecine Interne, Paris; 3Service de Médecine Interne et Infectiologie, Nouméa;
4Hôpital Tenon, Service d'Anatomie et Cytologie Pathologiques; 5Hôpital Tenon, Service
de Médecine Interne, Paris; 6Hôpital Avicenne, Service de Pneumologie, Bobigny, France
Correspondence: Claire Jumeau
Introduction: AA amyloidosis is a rare inflammatory disease, mostly seen as a long
term complication of chronic inflammation (ie obesity, gout). It is characterized
by amyloid A (AA) deposits inside or outside the cells, affecting organ function.
AA proteins originate from the cleavage of serum amyloid A proteins (SAA1, SAA2, SAA4)
encoded by the corresponding genes. No molecular etiology for AA amyloidosis has been
identified so far; however, a specific genotype (SAA1.1/SAA1.1) at the SAA1 locus
has been associated with AA amyloidosis in familial Mediterranean fever (FMF) patients
of Armenian origin (OR=7). Another genotype at the SAA1 locus (SAA1.3/SAA1.3) was
associated with AA amyloidosis in Japanese patients with rheumatoid arthritis.
Objectives: gout.
This work aimed at identifying candidate genes in primary AA amyloidosis or secondary
to obesity or gout.
Methods:
SAA1, SAA2 and SAA4 genes were screened by Sanger sequencing in all patients and the
genotype at the SAA1 locus was determined in 35 independent patients: 18 presented
with primary AA amyloidosis, 10 with AA amyloidosis in the context of obesity and
7 with AA amyloidosis in the context of gout.
Results: We initially searched for rare variants in the 3 SAA genes in the different
groups of patients. Only one rare heterozygous variant in SAA2 resulting in a missense
variation p.(Ala79Val) was identified in one patient with primary AA amyloidosis.
The characterization of the genotypes at the SAA1 locus showed a higher frequency
(89 and 80%) of the SAA1.1/SAA1.1 genotype in the groups of patients with primary
amyloidosis and amyloidosis secondary in the context of obesity, significantly different
from its theoretical frequency in healthy controls based on gnomAD database (22%)
(Fisher test: p=1,3 .10-4 and p=0.023 respectively). However in the group of patients
with AA amyloidosis in the context of gout, 71% presented the SAA1.3/SAA1.3 genotype.
Conclusion: The variation in SAA2 affects evolutionarily conserved amino-acid. This
result paves the way for functional studies on AA fibril formation in order to assess
its pathogenicity. The predominance of the SAA1.1/SAA1.1 genotype among patients with
primary AA amyloidosis and with amyloidosis in the context of obesity suggests that
this genotype could be a risk factor for AA amyloidosis.
Disclosure of Interest
None Declared
P1075 An integrated data sharing and analysis application for systemic autoinflammatory
diseases
Barend P. Kant1, K J. van der Velde2, Mariska K. Slofstra2, Joost Frenkel3, Andreas
Weinhäusel4, Isabelle Touitou5, Dirk Föll6, JuanI. Aróstegui7, Seza Ozen8, Marco Gattorno9,
Mariëlle E. van Gijn1, Morris A. Swertz2 and the INSAID Consortium
1Department of Genetics, University Medical Center Utrecht, Utrecht; 2Genomics Coordination
Center and Department of Genetics, University of Groningen and University Medical
Center Groningen, Groningen; 3Department of Pediatrics, University Medical Center
Utrecht, Utrecht, Netherlands; 4Department of Health and Environment, Austrian Institute
of Technology, Vienna, Austria; 5Department of Medical Genetics, Rare Diseases and
Personalised Medicine, Inserm, Montpellier, France; 6Department of Pediatric Rheumatology
and Immunology, University of Münster, Münster, Germany; 7Department of Immunology,
Hospital Clínic of Barcelona, Barcelona, Spain; 8Department of Pediatrics, Hacettepe
University, Ankara, Turkey; 9Department of Pediatric Rheumatology, IRCCS G. Gaslini
Institute, Genoa, Italy
Correspondence: Barend P. Kant
Introduction: Systemic autoinflammatory diseases (SAID) are a group of monogenic and
multifactorial conditions caused by deregulation of mechanisms controlling the innate
immune response. The diagnosis of patients with SAID is difficult, which can result
in delayed treatment and irreversible organ damage. Patients benefit from fast molecular
diagnosis, but for most patients with a clinical picture strongly resembling autoinflammatory
disease, molecular analysis will not provide diagnostic confirmation. These patients
are classified as undefined SAID (uSAID).
Objectives: The INSAID consortium aims to improve the performance of genetic diagnosis
by speeding up identification of new conditions, biomarkers and causal DNA variants
(in new genes). For this purpose, a central and easy to use bioinformatics platform
has been set up, facilitating sharing of clinical, genetics, epigenetics, immunomics
and proteomics data among the consortium partners and community-driven data analysis
and interpretation.
Methods: Clinical data were retrieved from the Eurofever registry. Other data were
produced by the consortium partners. A MOLGENIS database was set up for data sharing
and analysis. MOLGENIS is a user friendly open-source web-application created to collect,
manage, analyze, visualize and share large and complex biomedical datasets.
Results: The INSAID database is being used by the INSAID consortium. All data types
are being captured using patient identifier codes as keys for data integration and
analysis. New patients can be included and future data and data types can be uploaded
and integrated. Consortium progress can be monitored and discussed using the database.
The database’s interface is easy to operate and cluster analyses and statistical tests
can be written and shared within the database. This enables all consortium partners
with or without data analysis skills to query, sort, filter, analyze and visualize
the available multi-omics data.
Conclusion: The INSAID database is set up to facilitate data sharing and to perform
multi-omics analysis. This will enable diagnosing patients with currently undefined
SAID, discovery of pathways involved and further elucidating disease pathogenesis,
ultimately contributing to development of new or improved treatment.
Disclosure of Interest
None Declared
P1076 Comparative analysis ofreported 54 HA20 cases and 520 Japanese Behcet’s disease
patients
Yohei Kirino, Naomi Tsuchida, Yutaro Soejima, Hideaki Nakajima
Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School
of Medicine, Yokohama, Japan
Correspondence: Yohei Kirino
Introduction: Phenotype of haploinsufficiency A20 (HA 20) and Behcet’s disease (BD)
are reported to be similar. However, the distinction between HA 20 and BD is unknown.
Objectives: To clarify specific features of HA20 compared to BD.
Methods: The clinical features of 54 cases of HA 20 cases were examined from the literature
including our 4 cases and compared with 520 Japanese BD patients followed at our facility.
All BD patients met the 1987 revised diagnostic criteria of the Japanese Bebcet's
Disease Eesearch Committee. The research protocol was approved by the facility review
committee of Yokohama City University School of Medicine. Statistical analysis was
performed using SPSS version 22 (IBM Japan, Tokyo, Japan). Category variables were
analyzed using Chi-square test or Cochran-Armitage test. Continuous variables were
examined using Student's t test. A p value less than 0.05 was considered to be statistically
significant.
Results: significantly high recurrent fever (74.0%) and gastrointestinal involvement,
and less eye involvement than BD. Among gastrointestinal involvement and HA20 patients,
22 (81.8 percent) 18 showed gastrointestinal ulcers including 2 cases with typical
deep iliocecal ulcer seen in BD. The positive rate of HLA-B51 was lower (27.3 %) than
that of BD (47.8 %), but since the majority of HA 20 has been reported by European
populations whose HLA-B51 positive rate is lower than Japanese, it is uncertain whether
HLA-B51 affects on HA20 phenotype or not.
Conclusion: Comparison of HA 20 and BD cohort revealed several important features
of HA 20: early onset, familial onset, recurrent fever, gastrointestinal involvement,
and less eye involvement. Patients with familial recurrent fever with early onset
with BD symptoms, especially gastrointestinal disorders, should consider TNFAIP3 gene
screening.
Disclosure of Interest
None Declared
Table 1 (abstract P1076).
See text for description
Characteristics
HA20
BD
p
Odds ratio
95%CI
(n=54)
(%)
(n=520)
(%)
Age at onset (years) (mean ± SD)
6.1 ± 6.5
36.4 ± 12.3
< 0.001
533.71
171.84
1657.65
Familial history
15 /25
60
19 /332
5.7
< 0.001
24.71
9.8
62.29
Recurrent fever
37 /50
74
39 /364
10.7
< 0.001
23.72
11.62
48.43
Oral ulcer
46 /52
88.5
518 /520
99.6
< 0.001
0.03
0.01
0.15
Genital ulcer
34 /52
65.4
372 /520
71.5
0.35
0.75
0.41
1.37
Eye involvement
5 /51
9.8
330 /520
63.5
< 0.001
0.06
0.02
0.16
Skin involvement
27 /51
52.9
461 /520
88.7
< 0.001
0.14
0.08
0.27
Gastrointestinal involvement
22 /52
40.7
78 /520
15
< 0.001
4.16
2.28
7.58
P1077 Novel missense mutation of TNFAIP3 gene in a family with A20 haploinsufficiency
Charlotte Borocco1,2, Guillaume Sarrabay3,4, Guilaine Boursier3,4, Solene Artru5,
Helene Palluy1, Isabelle Touitou3,4, Isabelle Kone-Paut1,2
1Pediatric Rheumatology, Bicetre University Hospital; 2CeReMAIA, Le Kremlin-Bicêtre;
3Laboratory of Rare and Autoinflammatory Genetic Diseases, Montpellier University
Hospital; 4CeReMAIA, Montpellier; 5Department of Pediatric Gastroenterology, Hepatology
and Nutrition, Necker Enfants Malades University Hospital, Paris, France
Correspondence: Isabelle Kone-Paut
Introduction: A20 haploinsufficiency syndrome is a newly described autoinflammatory
disease which involves TNFAIP3 gene. The heterozygous mutations of this gene lead
to an impaired negative regulation of the NF-κB pathway. The phenotype is broad and
still in process of characterization but encompasses mainly a Behçet phenotype with
an unusual gastro intestinal involvement. Patients can encompass an autoinflammatory
and an autoimmunity phenotype.
Objectives: We report a French family with 4 affected members and a new mutation.
Methods: Four patients over 3 generations were assessed. All the clinical and laboratory
data were collected retrospectively. The genetical data were performed by new generation
sequencing and Sanger sequencing.
Results: We identified in all the 4 patients a novel heterozygous missense mutation
c.[464C>T] p. Thr155Met in the ovarian tumor domain of the TNFAIP3 gene. This is the
second missense mutation described. This mutation seems to have a variable penetration
with a carrier patient presenting only psoriasis. The symptoms presented in this Caucasian
family were: oral ulcers (n=3), recurrent fever (n=2), arthralgia (n=2), rectorrhagia
(n=2), genital ulcers (n=1), abdominal pain (n=2), Gougerot-Sjögren syndrome (n=1),
primary biliary cholangitis (n=1), purpuric rash (n=1), Asperger syndrome (n=1) and
psoriasis (n=1). For the laboratory abnormalities, one patient presented a transient
rheumatoid factor, one had permanent anti-nuclear antibodies associated to anti-SSA
and anti-centromere antibodies and one had double negative T lymphocytes increased.
One patient was treated by colchicine with a partial effect on oral ulcers.
Conclusion: A20 haploinsufficiency syndrome is a new cause of autoinflammatory and
autoimmunity disease. As an autosomal dominant heritance disease, the penetration
can be variable. We confirm the possibility of a second missense mutation in TNFAIP3.
Futher funtional studies will be required to confirm the mecanism of pathogenecity
in this family.
Disclosure of Interest
None Declared
P1078 Development and clinical application of a targeted next generation sequencing
gene panel for monogenic autoinflammatory diseases of the CNS
Dara McCreary1, Ebun O. Omoyinmi1, Ying Hong1, Ciara Mulhern1, Charalampia Papadopoulou2,
Muthana Al Obaidi2, Kshitij Mankad3, Kimberly Gilmour4, Cheryl Hemingway5, Paul Brogan6,
Despina Eleftheriou1,7
1Infection, Immunity and Inflammation, University College London; 2Paediatric Rheumatology
Department, GOSH; 3Paediatric Neuroradiology, UCL Great Ormond Street Institute of
Child Health; 4Paediatric Immunology Department; 5Paediatric Neurology Department,
GOSH; 6Infection, Immunity and Inflammation, UCL GOSH; 7ARUK centre for adolescent
rheumatology, University College London, London, United Kingdom
Correspondence: Dara McCreary
Introduction: Monogenic autoinflammatory diseases (AID) are severe lifelong systemic
inflammatory disorders with dysregulated innate immunity, causing significant morbidity,
mortality, and economic burden. Often these diseases present with isolated central
nervous system (CNS) involvement and mimic other non-inflammatory CNS disorders. This
significantly hampers the clinical management of these patients, who are subjected
to expensive and often invasive diagnostic patient pathways. Securing a molecular
diagnosis is of major importance in these cases for treatment, prognosis, and genetic
counselling. Routine genetic screening is time-consuming, costly, and lacks sensitivity
since only common disease harbouring exons of a minority of the known genes causing
autoinflammation of the CNS are currently tested using Sanger sequencing. Next-generation
sequencing (NGS) offers the ability to rapidly and cost-effectively screen all exons
of a gene panel containing hundreds of genes. This approach has not yet been routinely
introduced in the UK for these conditions.
Objectives: To develop and evaluate the performance of a NGS gene panel for AID with
predominant CNS involvement.
Methods: The Agilent SureDesign tool was used to design an NGS panel targeting 256
genes, grouped into the following broad clinical phenotypes: AID; monogenic vasculitis/vasculopathy;
interferonopathies; haemophagocytic lymphohistiocytosis (HLH); immunodeficiencies;
metabolic diseases and other inherited white matter diseases. The targeted region
includes coding exons, conserved non-coding exons, upstream promoter regions, and
splice sites. Captured and indexed libraries (QXT Target Enrichment System) were sequenced
as a multiplex of 16 samples on an Illumina MiSeq sequencer in paired-end mode. Positive
controls for panel validation comprised 16 DNA samples from patients with confirmed
mutations. We then applied the panel to test 60 prospective samples with suspected
but unconfirmed monogenic autoinflammation of the CNS. Read alignment, variant calling,
and annotation were performed using Agilent SureCall v3.0 software.
Results: In the validation stage, our targeted panel detected all known mutations
in the 16 positive control samples. The panel was effective at detecting different
types of variants, including rare and common single nucleotide variants (SNVs), insertion/deletions,
splice-junction variants, upstream promoter region variants, and somatic mosaicism.
Prospective testing of the panel in 60 patients revealed pathogenic variants (class
4 or 5) in 23 of 60 patients giving a detection rate of 38%.A definitive molecular
diagnosis was established in 11/60 patients (18%). These included patients with isolated
CNS involvement in the context of primary HLH (5/11), monogenic interferonopathies
(2/11), AID (2/11), metabolic conditions (1/11) and immunodeficiencies (1/11).
Conclusion: This study demonstrates the clinical utility of a comprehensive NGS-based
targeted gene panel which was both highly sensitive and specific in detecting different
sequence variants of clinical significance. We are currently integrating this panel
into a routine diagnostic laboratory testing strategy for monogenic autoinflammatory
diseases of the CNS.
Disclosure of Interest
None Declared
P1079 Next generation sequencing analysis of an NLRP3 mutation negative CAPS cohort
Sonia Melo Gomes1, Ebun Omoyinmi1, Juan Arostegui2, Ying Hong1, Nigel Klein1, Paul
Brogan1
1Infection, Inflammation and Rheumatology, UCL GOS Institute of Child Health, London,
United Kingdom; 2Immunology -CBD, Hospital Clínic, Barcelona, Spain
Correspondence: Sonia Melo Gomes
Introduction:
Cryopyrin Associated Periodic Syndromes (CAPS) are caused by autosomal dominant gain
of function mutations in the NLRP3 gene. However, a subset of these patients with
typical clinical features and good response to anti-IL-1 treatment, have no mutation
in NLRP3 detected by conventional Sanger DNA sequencing. Somatic mosaicism may account
for between 19 to 69% of these, from previous reports. Genetic heterogeneity has also
been implicated in patients with CAPS-like phenotypes, with the identification of
pathogenic mutations in the NLRP12, PLCG2 and NLRC4 genes (Familial Cold Autoinflammatory
Syndrome subsets 2, 3 and 4, respectively).
Objectives:
To explore the genetic cause(s) in a paediatric cohort of mutation negative CAPS patients using
Next Generation Sequencing (NGS) techniques, by assessing:
the rate of somatic NLRP3 mosaicism, and
possible contribution of other/novel genes
Methods:
Patients from a single paediatric centre who met the CAPS diagnostic criteria and
had no NLRP3 mutations identified by partial (exons 3, 4 and 6) or total Sanger sequencing,
were identified.
The NGS approach used in this study was Amplicon-based Deep Sequencing (ADS) for identification
of NLRP3 mosaicism; and Whole Exome Sequencing (WES) for exploration genetic heterogeneity
(i.e. other causative mutations). ADS was performed on an Ion Torrent platform using
the Ion Torrent PGM HiQ sequencing kit. Resulting sequences were analysed using the
Amplicon Variant Analyzer software. WES was performed using the Nextera Exome Capture
sequencing kit and Hiseq sequencing platforms. Exome data was analysed in the Galaxy
web-based suit. The wANNOVER web-based software was used for variant annotation.
Results: A total of 8 patients who met the CAPS clinical diagnostic criteria and had
no mutation identified by conventional Sanger sequencing were included in this study.
ASD identified the presence of a somatic mutation in 3 of these patients (37.5%),
with an allelic frequency varying from 3.1 to 14.5%.
The remaining patients were studied by WES. In Patient 4 a novel NLRP3 mutation was
identified in exon 5, which had been previously missed due to a restricted Sanger
approach.Patient 5 had a novel NOD2 mutation, thus redefining the diagnosis as Blau
syndrome. WES findings in the other patients are summarized in the Table.
Conclusion:
In this study, somatic NLRP3 mutations were identified in 3/8 (37.5%) of our cohort,
and 3/8 had variants in 3 other genes, potentially of relevance to the phenotype.
In particular, the identification of a NOD2 mutation and subsequent reclassification
of that patient as Blau syndrome, illustrates the limitations of current CAPS diagnostic
criteria as well as potential clinicaloverlap between different autoinflammatory syndromes,
reiterating the use of a wider NGS approach.At present it is unclear how the variants
found in patients 6 and 7 could modulate the phenotype, therefore in 3 patients a
clear genetic cause is yet to be found.
In conclusion, this study suggests that NGS approaches are superior to conventional
sequencing for the molecular diagnosis of CAPS and CAPS like phenotypes since they
can detect somatic mosaicism or alternative molecular diagnoses mimicking CAPS.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P1079).
See text for description
Patient(gender, age at testing)
CAPS phenotype
NGS
Gene
aa change
Type
1- M, 8y
CINCA
ADS
NLRP3
p.F566L
Mosaic 14.5%
2-M, 8y
MWS
ADS
NLRP3
p.E567K
Mosaic3.1%
3-M, 1y
MWS
ADS
NLRP3
p.G564D
Mosaic 12.5%
4 -M, 2y
CINCA
WES
NLRP3
p.G779V
Heterozygous
5-F, 16y
CINCA-like
WES
NOD2
p.D512Y
Heterozygous
6- M, 14y
MWS-like
WES
IL36RN
p.S113L
Heterozygous(AR)
7- M, 8y
MWS
WES
AP1S3
p.F4C
Heterozygous
8- F, 2y
MWS
WES
-
-
-
P1080 A recessive mutation in NLRC4 (A160T) causes autoinflammation and immunedysregulation,
and predisposes to ulcerative colitis in heterozygous carriers
Leonardo O. Mendonca1,2, Annemarie Steiner3, Alessandra Pontillo4, Isabella Ceccherini5,
Francesco Caroli5, Alice Grossi5, Jonas Moecking6, Fiona Moghaddas6,7,8, Marco Gattorno9,
Seth Masters3
1International Center for Autoinflammatory Diseases and Primary Immunodeficienceis,
Istituto Giannina Gaslini; 2Immunogenetics Laboratory, Biomedical Science Institute,
University of São Paulo, Sao Paulo, Brazil; 3Inflammation Division, The Walter and
Eliza Hall Institute of Medical Research, Parkville, Australia; 4Immunogenetics Laboratory,
Biomedical Science Institute, University of São Paulo, São Paulo, Brazil; 5UOC Medical
Genetics, Istituto Giannina Gaslini, Genoa, Italy; 6Inflammation Division, The Walter
and Eliza Hall Institute for Medical Research; 7Department of Medical Biology, The
University of Melbourne; 8Department of Clinical Immunology and Allergy, The Royal
Melbourne Hospital, Parkville, Australia; 9International Center for Autoinflammatory
Diseases and Primary Immunodeficienceis, Istituto Giannina Gaslini, São Paulo, Brazil
Correspondence: Leonardo O. Mendonca
Introduction: NLRC4 associated autoinflammatory disease (NLRC4-AID) was recently described
due to autosomal dominant mutations. The clinical spectrum ranges from macrophage
activation syndrome with severe enterocolitis to CAPS-like disease. As opposed to
mutations that trigger other inflammasomes, which result in IL-1b driven disease,
IL-18 seems to be the cytokine responsible for the clinical manifestations of NLRC4-AID.
Objectives: Report the phenotype of a patient carrying a novel, homozygous mutation
in NLRC4 (A160T). Describe in vitro evaluation that supports the pathogenicity of
NLRC4 A160T in terms of inflammasome activation and IL-18 production. Provide evidence
for a genetic association between heterozygous A160T and ulcerative colitis.
Methods: Clinical data were acquired from patients records. DNA was extracted and
sequenced using standard procedures. Monocytes were isolated by adherence from peripheral
blood using Ficoll-Paque gradient for IL-1, IL-6 and IL-18 measured by ELISA. Flow
cytometry for quantification of ASC speck formation by TOFIE was examined with overexpressed
WT or A160T NLRC4 in HEK 293T cells. THP-1 monocytes were reconstituted with WT and
A160T NLRC4, then priming was performed with Pam3CSK4 at a final concentration of
100 ng/ml for 3 hours to evaluate cell death and Il-18 secretion. Genome wide assocaition
of NLRC4(A160T) with ulcerative colitis was interrogated using data from the IBD exomes
portal.
Results:Case Report- The adult patient complained since 6 months of life of recurrent
episodes of systemic inflammation characterized by recurrent low grade fever, chills,
oral ulcer, uveitis, arthralgia and abdominal pain followed by diarrhea with mucus
and variable skin rash Low levels of IgG and CD19 were a persistent finding. High
doses of corticosteroids were effective in controlling disease and anti-IL1 partially
controlled symptoms. Serum cytokine levels during the use of anti-IL1 evidenced increased
levels of IL-18 (285 pg/mL) compared to healthy control (median - 100 pg/mL) and undetectable
level of IL-1. Genetic analysis- Target gene panel found an homozygous mutation in
NLRC4 gene (NM_021209), exon 4, c.478G>A (p.Ala160Thr). Familial genetic segregation
was done using standard Sanger Sequencing and the father, mother and a healthy brother
are heterozygous for the mutation. The estimated allele frequency is of 0,09% and
the frequency for the homozygous status is 0%.In vitro studies- Increased ASC speck
formation, and IL-1b/IL-18 secretion was observed when NLRC4 (A160T) was overexpressed
in human cell lines. Dominant mutations in NLRC4 (eg S171F) result in stronger inflammasome
activation than A160T, which is recessively inherited in these two cases. Patient
monocytes evidenced high levels of IL-1b and IL-18 secretion in response to ATP, LPS
and Flagellin.GWAS association- The NLRC4(A160T) allele is significantly enriched
in ulcerative colitis compared to healthy controls, OR 2.546 (95% 1.778-3.644), p=0.01305.
Conclusion: Homozygous NLRC4(A160T) causes a monogenic disease characterised by autoinflammation
and immunedysregulation. This allele is pathogenic in vitro, however with reduced
strength compared to dominant mutations in NLRC4. Carriers with NLRC4(A160T) are at
increased risk of developing ulcerative colitis.
Disclosure of Interest
None Declared
P1081 The Australian Autoinflammatory Diseases Registry (AADRY): a streamlined approach
to the genetic and immunological evaluation of monogenic autoinflammatory diseases
Fiona Moghaddas1,2,3, Jenni Harris2, Dunja Vekic4, Harapas Cassandra2, Dale J. Calleja2,
Navid Adib5, Jonathan Akikusa6, Roger Allen6, Dan Andrews7, Vanessa Bryant3,8, Geoffrey
Cains4, Jeffrey Chaitow9, Britt Christensen10, David Coman11, Matthew Cook12, Angela
Cox6,13, Jo A. Douglass1, Peter Gowdie6,13, Laine Hosking14, Matthew F. Hunter15,
Paul Kubler16, Senq J. Lee17, Jane Munro6, Samar Ojaimi18, William Renton6, Davinder
Singh-Grewal9,19, Charlotte Slade1,3,8, Joanne Smart14, Georgina Tiller6, Ben Whitehead20,
Jane Woods4, Philip Wu21, Sam Mehr14, Ian P. Wicks2,3,22, Seth L. Masters2,3 and AADRY
1Clinical Immunology and Allergy, The Royal Melbourne Hospital; 2Inflammation Division,
WEHI; 3Department of Medical Biology, The University of Melbourne; 4Dermatology Department,
Liverpool Hospital; 5Queensland Rheumatology Services, Arthur House, Red Hill; 6Rheumatology
Department, The Royal Children's Hospital; 7The John Curtin School of Medical Research,
Australian National University, Canberra; 8Immunology Division, WEHI; 9Rheumatology
Department, The Children’s Hospital at Westmead; 10Gastroenterology Department, The
Royal Melbourne Hospital; 11Metabolic Medicine, Queensland Children’s Hospital, Brisbane;
12Centre for Personalised Immunology; 13Paediatric Rheumatology Department, Monash
Children’s Hospital; 14Paediatric Immunology Department, The Royal Children’s Hospital;
15Monash Genetics, Monash Health; 16Department of Rheumatology, Royal Brisbane and
Women's Hospital; 17Department of Rheumatology, Perth Children's Hospital; 18Department
of Infection and Immunity, Monash Children’s Hospital; 19Rheumatology Department,
The Sydney Children’s Hospital; 20Rheumatology Department, Queensland Children’s Hospital,
Brisbane; 21Australian Phenomics Facility, Australian National University, Canberra;
22Rheumatology Department, The Royal Melbourne Hospital, Australia
Correspondence: Fiona Moghaddas
Introduction: Since the original publication in 1971 outlining two cases of FMF complicated
by pulmonary amyloidosis, there have been only two studies looking at the status of
monogenic autoinflammatory disorders (AIDs) in Australia. Clinicians caring for patients
with an AID without a pathogenic mutation in known disease-causing genes do not have
a streamlined approach to further genetic evaluation.
Objectives: The Australian Autoinflammatory Diseases Registry (AADRY) aims to provide
clinicians with access to a research team to further evaluate patients without an
established genetic diagnosis as well as to address limitations in the current knowledge
of AIDs in Australia.
Methods: Patients with suspected AIDs were recruited as trios. Whole exome sequencing
(WES) was performed on whole blood or saliva using the Hiseq 4000 platform and Illumina
Sureselect XT V5 library. A variant list was generated using a pipeline, variant caller
and filtering strategy previously described. Initial filtering of the variants proceeded
by excluding synonymous and common variants, and intronic variants more than 50 base
pairs from an intron-exon junction. Sequence data quality was assessed by viewing
the BAM file on the Integrated genomics viewer. Variant classification was based on
ACMG consensus guidelines.
Results: From September 2015 to June 2018, 34 index cases underwent WES. Initial curation
analysis looked at autoinflammatory genes as per IUIS and ISSAID. A total of 77 variants
in 34 patients were filtered with no pathogenic or likely pathogenic variants detected.
The majority (82%) of variants were VUS. Nineteen trios underwent WES. Seventy-one
de novo variants (mean 4 per index case), 77 AR variants (mean 4) and 253 potential
CH variants (mean 13) were curated. Of the 5 families recruited with more than one
symptomatic member, a likely pathogenic variant segregating with disease was found
in one family. The pedigree demonstrated multiple generations symptomatic of various
degrees of pustular acne and hidradenitis suppurtiva. A novel truncating variant in
NCSTN (c.1485C>T) encoding nicastrin p.Glu454X segregated with disease.
Conclusion: AADRY has curated the WES of 34 index cases, including 19 trios. A likely
pathogenic variant was discovered in one family with a highly penetrant dominantly
inherited dermatological phenotype. No clear genetic diagnosis has been made in the
remaining index cases, however a number of candidate novel variants are being evaluated.
Further work is now underway to gather data on patients with genetically defined AIDs
so that the retrospective cohort of patients with an established diagnosis is captured.
Disclosure of Interest
None Declared
P1082 Genotypic diversity observed within a large cohort of Armenian patients with
late-onset familial Mediterranean fever
Gernot Kriegshäuser1,2, Hasmik Hayrapetyan3,4, Stepan Atoyan3,4, Stefan Nemeth5, Christian
Oberkanins5, Tamara Sarkisian3,4
1Institute of Clinical Chemistry and Laboratory Medicine, General Hospital, Steyr;
2Clinical Institute of Medical and Laboratory Diagnostics, Medical University, Graz,
Austria; 3Center of Medical Genetics and Primary Health Care; 4Department of Medical
Genetics, Yerevan State Medical University, Yerevan, Armenia; 5ViennaLab Diagnostics,
Vienna, Austria
Correspondence: Christian Oberkanins
Introduction: Familial Mediterranean fever (FMF) as an autoinflammatory disease, results
from mutations in the MEFV gene mainly with an autosomal recessive mode of inheritance.
The age of onset of FMF varies, with about 60% and 90% of patients experiencing their
first attack before the age of 10 and 20 years, respectively. Hence, FMF with the
first attack occurring at the age of ≥ 40 years (i.e. late-onset FMF) is rare and
only a few small studies have addressed this disease subset.
Objectives: This work aimed at investigating the molecular genetic characteristics
of Armenian patients diagnosed with late-onset FMF.
Methods: Genomic DNA isolated from 354 Armenian late-onset FMF patients were analysed
for the 12 most common MEFV mutations plus SAA1 isoforms 1.1, 1.3 and 1.5 using multiplex
PCR and reverse-hybridisation. Mutational spectra and resulting genotypes were then
matched against the clinico-demographic profiles collected for these patients.
Results: Of all 354 patients, 194 (54.80%) were female and 160 (45.20%) were male.
The following genotypes were significantly associated with the late-onset variant:
M680I/E148Q (P=0.004), M694V/E148Q (P<0.001) and V726A/V726A (P=0.001). Of note, 12/354
(3.39%) patients were found to be homozygous for the M694V mutation.
Conclusion: Our data suggest that late-onset FMF is more prevalent in women and is
of greater genetic diversity than previously reported. Further studies including late-onset
FMF patients homozygous for MEFV mutation M694V are ongoing and may lead to the identification
of novel disease-modifying mechanisms.
Disclosure of Interest
None Declared
P1083 Genetic polymorphism of familial Mediterranean fever in Georgia - a snapshot
Karaman Pagava, Helen Phagava, Davit Tatoshvili
Tbilisi State Medical University, Tbilisi, Georgia
Correspondence: Karaman Pagava
Introduction: There are very few publications about FMF and MEFV mutations in Georgia.
Objectives: Determination of the MEFV mutations spectrum and their frequency in Georgia.
Methods: Review of the appropriate literature. 14 sources on the situation in Georgia
published from 1981 until now, were analyzed. 8 of them included genetic data. In
summary MEFV mutation was investigated in 202 clinically healthy neonates in Tbilisi
and 180 patients (children and adolescents) from different regions of Georgia.
Results: The carrier rate of MEFV mutations in neonates was remarkable: 31/202; 15.3%,
most frequently- E148Q (15/31), M680I (5/31), M694V (4/31). This could be explained
by high proportion of people of Armenian ethnicity and high frequency of interethnic
marriages. In patients the main mutations were: M694V (65.6%), V726A (23.3%), M6801
(20.6%). Overwhelming majority of patients had Armenian roots. This factor explained
the similarity of MEFV mutations in both countries. Some difference between data in
clinically healthy newborns and patients was found. Maybe the cause is the extent
to which a particular mutation is expressed. Additional research in this direction
is needed. Recently Georgian Society on Familial Mediterranean Fever, Autoinflammatory
and Autoimmune Diseases has been established. Hopefully it will help to create more
comprehensive registry of patients with these diseases and obtain new data about their
genetic and clinical polymorphism.
Conclusion: The up-to-date information regarding MEFV genes in Georgia is presented.
The awareness of FMF and the availability of appropriate testing should be promoted
further in Georgia.
Disclosure of Interest
None Declared
P1084 Exploratory study of MYD88 L265P and clonal haematopoiesis in 30 patients with
Schnitzler syndrome, an acquired systemic autoinflammatory disorder
Shelly Pathak1, Dorota Rowczenio2, Roger Owen3, Gina D. Doody4, Darren Newton4, Claire
Taylor4, Catherine Cargo3, Philip Hawkins2, Karoline Krause5, Helen Lachmann2, Sinisa
Savic1
1Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds;
2National Amyloidosis Centre, University College London, London; 3Department of Haematology,
St James’s University Hospital; 4Leeds Institute of Cancer and Pathology, University
of Leeds, Leeds, United Kingdom; 5Department of Dermatology and Allergy, Universitätsmedizin
Berlin, Berlin, Germany
Correspondence: Shelly Pathak
Introduction: Schnitzler syndrome (SchS) is rare, acquired, IL-1B mediated, autoinflammatory
disorder, for which the pathogenesis is unknown.
Objectives:
Explore the concept of ‘inflamm-ageing’ by looking for evidence of clonal haematopoesis,
as this phenomenon has been linked with pro-inflammatory changes of the immune system.
Investigate the prevalence of the MYD88 L265P mutation in SchS patients, given that
30% of SchS patients go onto develop WM.
To perform deep sequencing of NLRP3 region in an additional 11 SchS patients
Methods: Informed consent was provided by all subjects, in accordance with the Declaration
of Helsinki.
Exon-specific regions of 28 genes associated with MDS were amplified using the Fluidigm
custom-made 48x48 access array for Illumina library preparation. The sequencing was
performed on an Illumina MiSeq using an in-house analysis pipeline. Low level variants
were confirmed by repeat sequencing. For the female patients, inactivation of the
X chromosome (XCI) was assessed by determination of the androgen receptor (AR) locus
methylation status using the HUMARA assay. The XCI ratios are reported as a percentage:<80%
is considered random X-inactivation, and percentages >80% are deemed as skewed.
The Allele Specific Oligonucleotide-PCR (ASO-PCR) technique was used to identify patients
harbouring the mutant ‘C’ allele at chromosomal location 3:38182641, leading to the
downstream MYD88 Leu265Pro mutation.This PCR based assay discriminates between the
WT and mutated alleles by using 3 sets of primers, followed by direct amplification
producing 2 different sized products (400bp – WT; 250bp – mutated).
Results: Somatic mutations associated with CH were identified in 3/30 SchS patients:
two had different variants predicted as variants of unknown significance (VUS) in
the TET-2 gene and one had a pathogenic mutation in the STAG2 gene. Though the latter
may be a clonal hematopoiesis of indeterminate potential (CHIP) mutation. Of the aCAPS
cases one patient had two pathogenic variants in TET-2. As additional evidence of
CH, we utilised the HUMARA assay to identify X-allelic skewing in female patients,
identifying solely one patient in each cohort as ‘XCI-skewed’. MYD88 L265P variant
was detected in peripheral blood (PB) DNA of 9/30 SchS patients.Further deep sequencing
of the NLRP3 gene in 11 SchS patients failed to identify somatic variants.
Conclusion: The rate of CH in SchS and aCAPS is similar to what would be expected
for this age group. Therefore, CH does not appear to be a common abnormality underpinning
these conditions. The L265P MYD88 variant was not universally found in all SchS patients.
However, having not investigated bone marrow-derived DNA we cannot categorically exclude
the presence of the MYD88 variant in mutation negative cases. Lastly, including the
21 patients we have reported previously (1), we have now excluded somatic NLRP3 mutations
in 32 SchS patients. A molecular mechanism common to all SchS patients remains elusive.
It is possible that this could be a heterogeneous disorder, however given the uniform
clinical characteristics, including responsiveness to IL-1 inhibition, we favour the
likelihood of a common aetiology, yet to be discovered.
Disclosure of Interest
None Declared
P1085 E148Q mutation in family with familial Mediterranean fever
Tamara F. Sarkisian, Hasmik Hayrapetyan, Anna Yeghiazaryan, Ruzanna Karakhanyan
Center of Medical Genetics and Primary Health Care, Yerevan, Armenia
Correspondence: Tamara F. Sarkisian
Introduction: Familial Mediterranean Fever (FMF) is a chronic autosomal recessive
autoinflammatory disease with very high incidence and prevalence in Armenians. First
information about recurrent inflammatory syndrome or polyserositis in Armenians was
reported in ancient manuscripts of XII Century. It has been confirmed that MEFV (Mediterranean
Fever) gene mutations play the main role in occurrence of severity of this disorder.
MEFV gene encodes pyrin, the most important regulator of immunity processes. Mutated
pyrin is responsible for inflammasome formation and increased inflammatory response.
It was reported in “Infever Database” (2015) that more than 310 sequence variants
of MEFV gene are revealed in 10 exons of Mediterranean Fever gene. The carrier rate
of MEFV gene mutations is extremely high (about one in three) in Armenians. Distribution
and spectrum of MEFV gene mutations are responsible for mild and severe forms of recurrent
febrile and pain attacks, periodic episodes of fever, peritonitis, pleuritic, erysipelas-like
skin lesions, arthralgia. Although FMF is autosomal recessive condition, but in more
than 19% of our cohort of FMF patients have been shown to exhibit the same symptoms
with heterozygous genotypes. In some heterozygous cases we detected atypical clinical
forms of FMF.
Objectives: In some FMF patients “mild” MEFV mutations, such as P369S, A744S and E148Q,
are responsible for the determination of severity of attacks in FMF, along with environmental
or possible other genetic factors associated with inflammatory attacks. We have identified
E148Q mutation in exon 2 of MEFV gene in three individuals of three generations of
one family with confirmed clinical diagnosis of FMF.
Methods: They were genotyped using Viennalab Reverse Hybridization Strip Assay (Austria).
Genetic and clinical data of more than 36000 individuals, including FMF patients and
their family members, revealed statistically significance of phenotypes and distribution
ofMEFV mutations covering more than 98% of the cases.
Results: In this family report we present the three FMF patients, including two males
and one female of three generations. In the first generation 50 y.o. female has typical
clinical FMF with periodic episodes for 1-2 days duration of fever, abdominalgia,
thoracalgia, arthralgia, hepato- and splenomegaly. Disease manifested in age of 16
years old. Genetic investigation identified heterozygous E148Q mutation of exon 2.
Treatment with Colchicine decreased the intensity of attacks to one-two episodes annually.
The son of this patient also inherited the same heterozygous E148Q mutation.The disease
onset with first attacks was observed when the boy was in age of 7 years old. The
recurrent fever attacks of abdominal pain, myalgia had occurred for 5-6 days. Colchicine
treatment decreased the frequency of attacks to 2-4 annually. His son also inherited
the same E148Q heterozygous genotype from his grandmother and father. The boy was
born in 2018. The disease manifested in 8 months with fever attacks.
Conclusion: Overall E148Q mutation rate among healthy individuals in our population
is 3.4%. In heterozygous carriers of E148Q mutation our study shows an association
with typical clinical symptoms of FMF in 3% of patients, and with atypical form -
in 6% of FMF patients. Exon 2 mutations (E148Q etc) is correlated with milder disease
with almost no arthritis and no amyloidosis. This rare heterozygous genotype resulted
in genotype-phenotype associations.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1086 Familial Mediterranean fever: clinical significance of E148Q and P369S mutations
Tamara F. Sarkisian, Hasmik Hayrapetyan, Stepan Atoyan, Anna Yeghiazaryan, Gohar Shahsuvaryan
Center of Medical Genetics and Primary Health Care, Yerevan, Armenia
Correspondence: Tamara F. Sarkisian
Introduction: FMF represents a significant health care problem in Armenia, because
of high prevalence of the carriers of MEFV gene mutations (1:3) among population.
Clinical-genetic investigations of 50-90 new FMF cases are performed weekly. Personalized
treatment is based on MEFV genotypes and aimed to correct the effect of colchicine
therapy.
Objectives: Disease severity varies from mild, moderate, severe depending on the spectrum
of MEFV mutations. We present the evaluation of phenotypic features of FMF patients
with E148Q (exon 2) and P369S (exon 3) mutations, suggested that E148Q and P369S are
the mildest mutations, and some reports have questioned their association with FMF.
Methods: Over 36000 individuals, including FMF patients and healthy cohort, have been
referred for clinical observation and molecular-genetic detection of MEFV and SAA1
genes mutations. Reverse-hybridisation assay is performing for genetic testing using
the Viennalab StripAssay (Austria). Phenotypic, genotypic, and relevant information
for patients have been stored in a large database.
Results: the frequency of carriers of MEFV mutations among Armenians is extremely
high (about 20%: 1 in 3 individuals) with FMF prevalence of up to 3%. With the exception
of M694I all other common mutations were present in healthy individuals with different
frequencies. E148Q and P369S mutations are more frequent for healthy individuals in
comparison to affected FMF patients, suggesting their lower penetrance compared to
the others, but could still contribute to the overall FMF symptoms. Colchicine treatment
is required.
Among 30 individuals with E148Q/E148Q homozygous genotype 9 have typical FMF, and
3 – non-typical symptoms. Abdominal pain was seen in 77% of the patients, fever in
92.3%, pleuritis in 30.7%, arthralgia in 61.5%. Compound heterozygotes and complex
cases had a higher frequency of abdominal pain, fever, arthralgia, arthritis, myalgia,
and chest pain than subjects who were homozygous for E148Q, but none of these symptoms
reached statistical significance. None of the mentioned patients had developed renal
amyloidosis, but two with E148Q/E148Q had a family history of amyloidosis and one
had rapidly progressive glomerulonephritis secondary to vasculitis, which progressed
to chronic renal failure. Among heterozygous carriers of E148Q mutation 333 had typical
FMF, 1336 were without any symptom.
Homozygous genotype for P369S mutation was detected in only one healthy person. Number
of healthy P369S carriers was 159, and in 41 diagnosis of FMF was confirmed.
In cohort of healthy controls, we detected 10 genotypes with P369S complex alleles,
7 without clinical picture of FMF, 3 manifested mild disease, suggesting that P369S
might ameliorate the phenotypic effect of exon 10 mutations. Among E148Q/P369S compound-heterozygous
115 were healthy carriers, 34 are typical and 12 non-typical FMF.
In one family we confirmed FMF in 2 generations of E148Q/P369S compound-heterozygotes:
two sisters with their children.
Atypical FMF phenotypes was found in: 3 homozygotes, 90 heterozygotes with E148Q mutation,
10 heterozygotes with P369S mutation.
Conclusion: Genetic counselling, including modern clinical-genetic approach is recommended
for disease risk estimation in families with history of FMF, assessment of efficiency
of colchicine treatment, prognosis of development of complications. Using a population-based
study of healthy persons and FMF patients, we provide evidence that these alleles
are a disease-causing mutations and not are a benign polymorphisms among Armenians.
We suggest that in some cases other factors along with MEFV genotype, such as environmental
or possibly other genetic factors play role in the determination of the severity of
the inflammatory attacks in FMF.
Disclosure of Interest
None Declared
P1087 Severe prognosis of late onset CAPS associated with age related clonal hematopoiesis
Yael Shinar1, Rinat Cohen1, Victoria Marcu1, Itamar Goldstein1, Meital Nagar1, Gleb
Slobodin2, Ilan Ben-Zvi1, Michael Rozenbaum2
1Sheba Medical Center ,Ramat Gan; 2Bnai Zion Medical Center , Haifa, Israel
Correspondence: Yael Shinar
Introduction: Sporadic cases with adult Cryopyrin Associated Periodic Syndrome (CAPS)
are associated with a somatic mutation in the NLRP3 gene, often restricted to the
myeloid lineage.
Objectives: We investigatedif mutations in myeloprliferative genes that are known
to drive age related clonal heatopoiesis (ARCH) associated with the development of
CAPS in a late onset case.
Methods: We sequenced 26autoinflammatory and 52 myeloproliferative genes in peripheral
bloodDNA ofa 56 year oldpatient with late onsetCAPS, by the Next Generation Sequencing
(NGS) method. The pathogenic mutations were screened in DNA derived from FACS-sorted
CD3-positive T cells, CD14-positivemonocytes and granulocytes, and from single cells.
Results: A somatic NLRP3 mutation, NM_001243133.1:c.1709A>Gp.Tyr570Cys, was present
in DNA purified from granulocytes or monocytes (20% NLRP3 gene reads) but was hardly
detected in the patient's DNA from T cells (1%). Two pathogenic mutations linked with
myeloproliferative disorders were detected: A known frame shiftmutation in the Tet
methylcytosine dioxygenase 2 gene (TET2, in 31% ofthegene reads), and a known amino
acid substitution in the Serine/arginine-rich splicing factor 2 (SRSF2, in 43% of
the SRSF2 reads). Both had the same lineage pattern asthe NLRP3 mutation, yet a higher
somatic mosaicism rate than the NLRP3 mutation in peripheral blood cells (PBC). Co-occurence
of the NLRP3 mutation with one or two loss-of-function TET2 allele(s) was demonstrated
in several single myeloid cells. There was no evidence of hematologic malignancy in
the bone marrow or in a CT scan of the patient. Rather, the patient developed macrophage
activating syndrome (MAS) that was also the cause of death after 8 years of disease.
Conclusion: Our results suggest the need to evaluate sporadic late onset CAPS cases
for clonality of myeloproliferative genes, with prospect of dynamic and severe disease
evolution, including MAS. In the case of TET2deficiency mutations a proinflammatory
effect through the NLRP3 inflammasome may be suggested based on mice models. Clonal
autoinflammatory diseases may constitute a distinct entity within the autoinflammatory
diseases, characterized by clinical complexity and imposing therapeutic challenges.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
Y. Shinar Grant / Research Support from: Novartis Israel, R. Cohen: None Declared,
V. Marcu: None Declared, I. Goldstein: None Declared, M. Nagar: None Declared, G.
Slobodin: None Declared, I. Ben-Zvi: None Declared, M. Rozenbaum: None Declared
P1088 CNV analysis from targeted NGS data: case report on a patient with a large deletion
in the NLRP12 gene
Barbara Bangol, Kathrin Starz, Martin Ziegler, Daniel Becker, Jenny Schiller, Sophie
Eilitz, Hanns-Georg Klein
MVZ Martinsried GmbH, Martinsried, Germany
Correspondence: Kathrin Starz
Introduction: Diagnostic CNV (copy number variation) analysis in molecular genetics
with exon level resolution is performed mainly by hybridization techniques (e.g. multiplex
ligation-dependent probe amplification). Therefore, the examinable genomic region
is restricted to commercially available test kits in most cases.
Objectives: The amount of clinically relevant CNVs located beyond the examinable region
of these kits remains elusive. Hence, a bioinformatic pipeline for the detection of
CNVs from NGS sequencing data was established (MIDAS pipeline). The analysis is routinely
performed for patient samples in parallel to NGS testing for single nucleotide variations
and small insertions/deletions by targeted enrichment and sequencing of candidate
genes.
Methods: DNA samples from 115 patients with suspected autoinflammatory disease were
subjected to NGS panel diagnostics including the genes ELANE, IL1RN, IL36RN, LPIN2,
MEFV, MVK, NLRC4, NLRP3, NLRP12, NOD2, PSMB8, PSTPIP1, TMEM173, TNFRSF1A. With the
exception of MEFV, no commercial CNV detection kits are available for these genes.
In addition to routine NGS testing, binary alignment mapping files (BAM) were further
analyzed via the MIDAS CNV pipeline. Coverage of targeted regions was normalized with
control samples. CNV calls were performed using CoNVaDING, ExomeDepth and XHMM. Results
were further investigated if CNVs were called from two out of three callers.
Results: Testing in a two-year-old Polish girl presenting with recurrent fever of
unknown origin and an increased susceptibility to infections revealed a heterozygous
deletion of at least 321 bp comprising exon 5 of the NLRP12 gene (rsa[GRCh37] 19q13.42(54308439_54308760x1,
54310745x2). The deletion was confirmed by quantitative PCR (qPCR) and was not present
in 240 control individuals.
Conclusion: There are known truncating germline mutations in the NLRP12 gene, but
no larger deletions have been described in association with the rare familial cold
autoinflammatory syndrome 2 (FCAS2) so far. According to Richards et al. (2015) the
variant was classified as likely pathogenic, which supports the clinical diagnosis
of FCAS2 in the patient. The case described shows that application of CNV analysis
of NGS data may increase the diagnostic sensitivity for the molecular diagnostics
of hereditary recurrent fever. It is a cost efficient and convenient method to screen
for copy number variations beyond regions which are covered by commercially available
CNV detection kits. Since very few patients with FCAS2 have been identified, data
on the phenotypic presentation is limited. Interestingly, Kostik et al. (2018) described
several patients with clinical manifestations characteristic for primary immunodeficiencies
and showing increased susceptibility to infections, similar to the present case.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1089 Population based study of frequency of FMF gene mutation carrying in Armenia
Artashes Tadevosyan, Tigran Avagyan, Anush Budumyan, Hasmik Hayrapetyan, Gayane Amaryan
Public Health and Helth Care Organization, Yerevan State Medical University, Yerevan,
Armenia
Correspondence: Artashes Tadevosyan
Introduction: Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory
disorder that is very common among Armenian, Turkish, Jewish populations. However,
no study was conducted before among general Armenian population on epidemiology of
FMF gene mutations.
Objectives: To study frequency of carrying of FMF gene mutations among Armenian population.
Methods: Random sample of 290 unrelated persons residing in Armenia, 179 of whom were
female and 111 were male were selected. Blood samples were taken from them and analyzed.
Identification of FMF and SAA1 gene mutations for 12 more common types of mutations
based on PCR and reverse hybridization using ViennaLab diagnostic test was performed.
Results: This is the first population based study of carrying of FMF gene mutations
among Armenian ethnic population in Armenia. Out of 290 participants 98 persons have
at least one mutation, among which 59 were female carriers and 39 - male. That makes
up 33.45% of the total participants. Out of 98 carriers 87 had heterozygous mode of
inheritance, while 10 had compound-heterozygous and 1 had homozygous mode of inheritance.
Rate of mutation carriers among female participants was 1 out of 3. In female group
55 had heterozygous mode of inheritance (30.73%) and 4 had compound-heterozygous mode
of inheritance (2.23%). Following mutations were found in this group: M694V, M680I,
V726A, E148Q, K695R, A744S, R761H, F479L and P369S Highest number of cases of identified
in female group was M694V (Table1).
Rate of mutation carriers among male participants was 1 out of 3. In male group 32
had heterozygous mode of inheritance (28.83%), 6 had compound-heterozygous mode of
inheritance (5.4%) and 1 had homozygous mode of inheritance (0.9%). Following mutations
were found in this group: V726A, M694V, E148Q, M680I, M694I, A744S and F479L. V726A
was identified 17 times in male group (Table1).
Conclusion: The frequency of carrying the FMF gene mutation 1:3 is highest among ever
reported.
Most common type is heterozygous mode of inheritance, which constituted for 88.8%
among all carriers.
The most common mutation among all carriers is M694V - 32 cases, a little less - is
carriage of V726A mutation (30 cases). At the third place - is carriage of Е148Q mutation
(23 cases).
Acknowledgments
This work was supported by the RA MES State Committee of Science, in the frames of
the research project № SCS 15T-3D191.
Disclosure of Interest
None Declared
Table 1 (abstract P1089).
Number and rate (per hundred) of registered mutations
MEFV type
Among female carriers (number)
Among male carriers (number)
Among all carriers (number)
M694V
21(11.73)
11 (9.90)
32 (11.03)
V726A
13 (7.26)
17 (15.31)
30 (10.34)
E148Q
14 (7.82)
9 (8.10)
23 (7.93)
M680I
2 (1.11)
6 (5.40)
8 (2.76)
P369S
3 (1.67)
-
3 (1.03)
F749L
3 (1.67)
1 (0.90)
4 (1.38)
A744S
2 (1.11)
1 (0.90)
3 (1.03)
K695R
3 (1.67)
-
3 (1.03)
R761H/M694I
R761H-2 (1.11)
M694I-1 (0.90)
R761H -2 (0.69)/ M694I-1 (0.34)
P1090 Whole genome linkage and exome sequencing analysis in a CRMO family
Derya Yavuz1, Selcuk Yuksel2, Eda Tahir Turanli1
1Department of Molecular Biology and Genetics, Istanbul Technical University, Istanbul;
2Department of Pediatric Rheumatology and Pediatric Nephrology, Pamukkale University
, Denizli, Turkey
Correspondence: Eda Tahir Turanli
Introduction: Chronic recurrent multifocal osteomyelitis (CRMO), is an autoinflammatory
disorder with incidence varying between 1 – 4 per million and it is most likely due
to defects in TLR4/MAPK leading to in anti- and pro-inflammatory cytokine balance
(ORPHA: 324964, PMID:29080202). CRMO occurs in childhood and adolescence, characterized
with recurrent inflammation and lesions that are predominantly found in long bones.
Reported familial cases and associated inflammatory conditions indicate genetic predisposition
in the pathogenesis.
Objectives: In this study, we examined a consanguineous family with 2 affected and
1 healthy siblings and their healthy parents to identify the possible causative locus
or gene.
Methods: Whole genome SNP genotyping by using Illumina OmniExpress-24 BeadChip that
targets ~700,000 SNP markers was performed on all the family members that consists
of 2 affected sibs, 1 healthy sister and their healthy parents. Resulting genotyping
data was used for multipoint parametric linkage analysis that was performed under
recessive model with complete penetrance. One of the affected siblings was screened
by whole exome genotyping for assessment of possible disease-causing rare, homozygous
variants. Variants obtained after filtration of exome data was furthered verified
with the linkage analyses data.
Results: Linkage analyses revealed 137 homozygous regions out of which 44 are longer
than 200 kb. Non-synonymous and homozygous variants gathered from the exome data were
further filtrated according to 1000G and ExAC databases (MAF < 0.05), revealing 11
candidate variants in NBPF6, DNAH14, MMADHC, KIAA0232, BODIL1, PCDHGB2, PCDHGA6, ZNF316,
PWWP2B, CFAB46 and CARNS1. Also, variants in the genes that are listed in Infevers
database were checked which revealed 4 intronic variants in NLRP3, NLRC4, PSMA3 and
PSTPIP1 genes. Among these variants, rs12786101 in CARNS1 (c.C1145T) and rs55638726
in NLRC4 (g.32461493_32461494insC) were chosen as candidate variants.
Conclusion: One of the candidate variants that might be related to CRMO phenotype
is located in CARNS1 leading to a missense mutation whereas rs55638726 in NLRC4 is
found to be located in the splice site that might lead to aberrant splicing. However,
these variants were found in homozygous regions that were shared in all the family
members. Identification of disease causing potential of the detected variants are
still on-going.
Disclosure of Interest
None Declared
P1091 Detection of a rare variant on PSTPIP1 gene through three generations in a Turkish
family with systemic autoinflammatory disease
Merve Ö. Önen1, Serdal Ugurlu2, Ayse Balamir1, Eda Tahir Turanli1, Huri Ozdogan2
1Department of Molecular Biology and Genetics, Istanbul Technical University; 2Department
of Rheumatology, Istanbul University Cerrahpasa, Istanbul , Turkey
Correspondence: Eda Tahir Turanli
Introduction: Various monogenic recurrent fever syndromes share common clinical features.
Therefore differential diagnosis of systemic autoinflammatory syndromes (sAIS) is
a challenge, especially in familial Mediterranean fever prevalent countries.
Here we describe a family with Turkish descent, with 3 affected members belonging
to 3 successive generations (grandmother, daughter, granddaughter) with self-limited,
short episodes of fever, abdominal pain, oral ulcers, pharyngitis, arthralgia/arthritis,
calf pain with increased acute phase proteins which respond to colchicine prophylactic
treatment. None of the patients carry pathogenic MEFV variants.
Objectives: To identify a causative gene responsible for the autoinflammatory phenotype
transmitted in 3 successive generations, in 3 members of the same family.
Methods: The index patient, the grandmother, was screened with Fever panel including
the coding regions and UTRs of MEFV, MVK, TNFRSF1A, NLRP3, NOD2, CECR1, TMEM173, PSTPIP1,
NLRP12, LPIN2, PLCG2, CARD14, SLC29A3, IL10RA, NLRC4. After annotation candidate variants
were selected via filtering based on frequency and functionality. Candidate variant
(p.Arg228Cys) on PSTPIP1 gene was confirmed by Sanger sequencing in grandmother, daughter,
and grandchild. Analysis of the possible effect of the variant on protein and transcription
levels of PSTPIP1, MEFV and IL1b were performed through kit based-ELISA and Q-PCR
methods with the protein and cDNAs, isolated from PBMCs of our three patients and
five healthy controls.
Results: We detected a rare variant; p.Arg228Cys on PSTPIP1 gene, in the index patient
and confirmed the variant in her daughter and grandchild. Mutations in the PSTPIP1
gene is related with PAPA (pyogenic arthritis, pyoderma gangrenosum, acne) syndrome.
This rare variant is located on F-BAR domain of PSTPIP1 protein, as other PAPA-related
pathogenic variants, which is important for PSTPIP1 forming functional trimeric complex
with pyrin protein. This binding results in conversion of pro-IL1b to IL1b.Protein
levels of PSTPIP1, MEFV and IL1b of patients (44.78 ± 17.47mg/ml , 66.65 ± 31.81 mg/ml
, 201.6 ± 63.54 mg/ml respectively) were higher than healthy controls (18.62 ± 3.741
mg/ml, 21.33 ± 6.738 mg/ml, 150.5 ± 15.22 mg/ml) respectively. However, when we calculate
the fold change of transcript levels according to GAPDH endogenous gene, an increase
in patients compared to healthy controls was detected only for PSTPIP1 (0.2928 ± 0.1324,
0.2136 ± 0.068).
Conclusion: The systemic autoinflammatory phenotype inherited through three generations
in a Turkish family was related to p.Arg228Cys, a rare variant on PSTPIP1. However
the mutations in PSTPIP1 gene are associated with PAPA, besides the autosomal dominant
transmission, the phenotype of our patients is not compatible with the classical manifestations
of this syndrome. Some of these FMF-like disease phenotypes may be attributed to locus
heterogeneity such that similar phenotypes may be caused by mutations in different
genes of a specific pathway.
Disclosure of Interest
None Declared
Dermatology and Autoinflammation
P1092 Long-term treatment with ustekinumab for generalized pustular psoriasis in a
child with heterozygous mutation in the IL36RN and TYK2 gene
Troels Herlin1, Mette Christiansen2, Sofie E. Jørgensen3, Christian Høst1, Mia Glerup1,
Jens E. Veirum1, Dorte A. Larsen4, Lars Iversen5, Mia Glerup1, Birgitte Mahler1, Trine
H. Mogensen6
1Pediatrics; 2Clinical Immunology, Aarhus University Hospital; 3Biomedicine, Aarhus
University; 4Ophthalmology; 5Dermatology; 6Infectious diseases, Aarhus University
Hospital, Aarhus , Denmark
Correspondence: Troels Herlin
Introduction: Recessive mutations in the IL36RN gene have been identified as the genetic
determinants for early onset generalized pustular psoriasis which in its homozygous
form results in deficiency of interleukin-36-receptor antagonist (DITRA). Non-receptor
tyrosine-protein kinase Tyk2, member of the JAK family, is encoded by the TYK2 gene,
which has been identified as a psoriasis susceptibility locus.
Objectives: To describe the striking long-term effect of ustekinumab, a monoclonal
antibody against the p40 subunit of both IL-12 and IL-23, in a girl with DITRA phenotype
with heterozygous mutation in the IL36RN and TYK2 gene recalcitrant for several other
treatments.
Methods: Girl, now 5-year-old, being 1st child of unrelated Danish parents, prenatally
diagnosed with tetralogy of Fallot (ToF). Array CGH revealed normal karyotype. Pregnancy
and delivery were uneventful. Mother has been treated for hemorrhagic proctitis and
psoriasis vulgaris, father is healthy. When 3-months-old she presented with scaly
psoriasiform plaques. Shortly after operation for ToF at age 4 months she had a precipitous
flare of numerous pustules covering more than 80% of skin area. Skin biopsy was compatible
with pustular psoriasis.
Whole exome sequencing and Sanger sequencing was performed.
Results: Whole exome sequencing identified a heterozygous variant in the IL36RN gene
(c.338C>T, p.S113L) with a high CADD score of 27.8 as well as a heterozygous variant
in the TYK2 gene (c.157G>A, p.A53T), CADD score 25.1. IL36RN was Sanger sequenced
employing DNA from keratinocyte and melanocyte cultures from skin biopsies; the S113L
variant was identified in DNA but not present in mRNA.
Methotrexate treatment was initiated together with topical corticosteroids without
any effect on the cutaneous lesions. On suspicion of phenotypic equivalent to DITRA,
anakinra (4 mg/kg/day increased to 8 mg/kg/day) caused some improvement although never
complete regression of the pustular elements. After 8 weeks anakinra treatment was
shifted to infliximab 6.5 mg/kg/dose given three times with 2 weeks interval and thereafter
every 4 weeks. The skin lesions, as well as the general condition, improved markedly
within few days, but after 2 months she developed a marked flare of pustular skin
lesions. She developed an anaphylactoid reaction towards infliximab infusion and the
medication was stopped. Treatment with etanercept did not show any improvement, in
fact, she developed worsening of the pustulosis. Ustekinumab (0.9 mg/kg subcutaneously
every 9 weeks) was then given which had a marked and sustained effect. The treatment
with ustekinumab has been well tolerated and gradually anakinra, methotrexate and
topical corticosteroids could be stopped. After 1 year of treatment, ustekinumab was
paused to allow vaccination for MMR. However, after 5 months intermission she flared
again with numerous pustular lesions and ustekinumab treatment was restarted, again
with a striking efficacy. She has now been treated with ustekinumab for more than
48 months, the last 43 months as monotherapy.
Conclusion: Although only homozygous mutations in the IL36RN gene have been associated
with DITRA we believe that in our patient the combined heterozygous variants in the IL36RN and TYK2 gene
play an essential role in the development of early onset generalized pustular psoriasis,
not unlike DITRA syndrome. In contrast to anakinra and infliximab, which only demonstrated
a short-lived and partial effect, ustekinumab monotherapy, which has been well tolerated,
has enabled complete long-term remission for more than 4 years.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Non-monogenic SAIDs (clinical)
P1093 Performance of newly proposed periodic fever, aphthous stomatitis, pharyngitis
and cervical adenitis (PFAPA) syndrome criteria in regions endemic for famillial Mediterranean
fever (FMF)
Amra Adrovic, Mehmet Yildiz, Neslihan Gucuyener, Ipek Ulkersoy, Melisa Kanber, Sezgin
Sahin, Oya Koker, Kenan Barut, Ozgur Kasapcopur
Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul,
Turkey
Correspondence: Amra Adrovic
Introduction: The periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis
(PFAPA) syndrome is an autoinflammatory condition characterized by regularly recurrent
episodes of high fever lasting 3 to 6 accompanied by aphthosis, cervical adenitis,
and pharyngitis, in the absence of upper respiratory tract infections. Diagnosis of
PFAPA could be challenging since it shares common characteristics with other auto-inflammatory
conditions, including familial Mediterranean fever (FMF), hyper IgD syndrome etc.
A relevant number of patients with monogenic periodic fevers also meet the diagnostic
criteria for PFAPA syndrome. Especially in regions endemic for FMF, it would be important
to avoid useless genetic testing and to be able to identify PFAPA patients by using
clinical classification criteria. Despite the high specificity, widely used Marshall’s
criteria have been shown to have low specificity. An international consensus among
experts has been established recently, in order to define a set of classification
criteria for PFAPA syndrome with a better performance in term of sensitivity and specificity.
Objectives: We aimed to evaluate the performance of recently proposed PFAPA criteria,
in order to assess their utility in regions endemic for FMF.
Methods: Patients diagnosed with PFAPA syndrome, FMF and juvenile idiopathic arthritis
(JIA) were consecutively included in the study. PFAPA diagnosis has been established
by Marshall’s criteria. Patients with FMF and JIA were diagnosed according to Turkish
pediatric FMF criteria and ILAR criteria, respectively. Two investigators blindly
evaluated all of patients for the newly proposed PFAPA criteria.
Results: A total of 321 PFAPA, 118 FMF and 45 JIA patients with mean age of 7.23±2.9,
14.7±3.09, 13.5±4.6 years, respectively, were included in the study. A 45 % (146/323)
of PFAPA syndrome, 50% (59/118) of FMF and 58% (23/45) of JIA patients were female.
We found quite high sensitivity (90%) of newly proposed PFAPA criteria: 289 out of
321 (90%) patients followed up as PFAPA syndrome fulfilled newly proposed PFAPA criteria,
as well. When applied to patients diagnosed with FMF and JIA, 46 out of 118 (39%)
FMF and 10 out of 45 (22%) JIA patients also fulfilled newly proposed PFAPA criteria.
Specificity of recently proposed PFAPA criteria was found to be 61% and 77%, among
FMF and JIA patients, respectively. Positive predictive value was 86% and 97%, negative
predictive value was 69% and 50% for FMF and JIA patients, respectively.
Conclusion: Recently proposed PFAPA criteria have satisfactory high sensitivity. Specificity
of recently proposed criteria is still under expectation in regions endemic for FMF.
Multicentric studies with higher patients’ number in different regions are needed
in order to provide more relevant data on performance of newly proposed PFAPA criteria.
Disclosure of Interest
None Declared
P1094 Spine involvement in patients with non-bacterial multifocal osteomyelitis
Dmitry Alekseev1, Irina Nikishina1, Dmitry Zubkov1, Aleksandr Smirnov2, Olga Kostareva1
1Pediatric Rheumatology; 2Radiology, V.A. Nasonova Research Institute of Rheumatology,
Moscow, Russian Federation
Correspondence: Dmitry Alekseev
Introduction: Non-bacterial osteomyelitis (NBO) is a rare inflammatory disease of
the musculoskeletal system, which is difficult to diagnose and treat. Assumed auto-inflammatory
nature of the disorder.
Objectives: The analysis the features and outcome of axial skeleton (AxS) involvement
in patients (pts) who were observed in our department for the last 10 years with multifocal
NBO.
Results: Among the whole group of pts with NBO (n = 37) we identified 14 pts with
AxS involvement including the lesions of the vertebral bodies and sacroiliac joints;
the majority were girls (n = 10, 71.4%). Age at disease onset was 10.1 years in average
(from 1.4 to 13.3, Me 9.5). There are no significant differences in clinical and laboratory
features between children of different sex and age. Patients underwent standard rheumatologic
examination; in order to examine all localizations of the skeletal lesion, a scintigraphy
and/or “whole body” MRI scan was performed; a bone biopsy was performed on 5 pts.
Other possible causes of damage were excluded, especially infection and oncology.
AxS lesions were localized in different parts of the spine: cervical – in 5 pts (35.7%),
thoracic - 7 (50.0%), lumbar - 3 (21.4%), sacral - 1 (7.1%). Involvement of 2 spinal
regions was detected in 5 pts, 3 regions - in 1. There was a lesion of the adjacent
regions: cervical and thoracic - in 3 patients; thoracic and lumbar - in 1; cervical,
thoracic and lumbar - in 1. In 4 pts 3 vertebral bodies were affected, in 2 - 4, in
8 - 1, in 1 - 17; lesion of the adjacent vertebrae was revealed in 7 pts (50.0%).
MRI revealed inflammatory changes, with the presence of an increase in signal intensity
in STIR images. In 6 pnts - destructive damage of the vertebrae, in 4 pts – with a
decrease in the height of the vertebrae.Peripheral bone lesions were presented with
damage of the bones of the extremities in 6 pts, metaphysis mostly (in 3 - the proximal
femur, in 2 - the knee and ankle joints), in 1 patient - the distal radius, in 1 patient
– tarsal. 9 pts had chronic arthritis of the limbs joints: in 5 pts oligoarthritis
with lesions of the hip and knee joints, in 2 pts with polyarthritis with lesions
of the hip, knee, ankle joints. Definite evidences of the sacroiliitis was found in
12 pts (85,7%), in 7 pts (50%) the diagnosis of Juvenile ankylosing spondylitis (JAS)
fulfilled to New-York modified criteria were established, including severe variant
with total ankylosis of sacroiliac and joints, vertebral bodies and multiple syndesmophytes
in - 4 pts. But HLA B27 antigen was present just in 5 among 14 pts. Psoriasis of the
palmar-plantar localization - in 1 patient; acnae conglobata - 1. Inflammatory bowel
disease, uveitis - not identified. Laboratory parameters of activity were detected
in the active period of the disease in 6 pnts: ESR acceleration up to 40 mm/h, increase
in CRP - up to 73 mg/l; these patients had manifestations of chronic arthritis.
Treatment included NSAIDs (all), methotrexate (n=4), sulfasalazine (n=3), bisphosphonates
(n=5), TNF inhibitors (n=6). Orthopedic measures: regimen with restriction of movements;
during the destruction of the vertebrae, a corset was used (n=3), an operation with
the fixation of the vertebrae with metal construction (n=3).
Conclusion: (1) AxS involvement in pts with NBO is a prognostic unfavorable sign associated
with the rapid development of an advanced stage of JAS, including the development
of syndesmophytes and ankylosis of intervertebral joints.
(2) Detection of highly active, according to MRI, sacroiliitis in children requires
further examination for multifocal NBO.
Disclosure of Interest
None Declared
P1095 DNASE1L3 variant in hypocomplementemic urticarial vasculitis syndrome identifies
a different clinical phenotype
Marco Ranalli1, Chiara Passarelli2, Virginia Messia3, Manuela Pardeo3, Emanuela Sacco3,
Antonella Insalaco3, Marina Vivarelli4, Fabrizio De Benedetti3, Claudia Bracaglia3
1Pediatric Department, La Sapienza University of Rome; 2Unit of Laboratory of Medical
Genetics; 3Division of Rheumatology; 4Division of Nephrology, IRCCS Ospedale Pediatrico
Bambino Gesù, Rome, Italy
Correspondence: Claudia Bracaglia
Introduction: Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare disease
characterized by persistent urticarial lesions and hypocomplementemia associated with
systemic features involving musculoskeletal, pulmonary, renal and gastrointestinal
systems. Systemic lupus erythematosus (SLE) develops in >50% of patients with HUVS,
although the pathogenesis is unknown.
Objectives: We describe 6 paediatric patients with HUVS, three of whom carry a homozygous
variant of DNASE1L3 and present a peculiar clinical phenotype.
Methods: A Targeted Resequencing using a panel including genes already known to be
mainly associated to Interferonopathies Lupus-like (DNASE1, DNASE2, DNASE1L3, TREX1)
on the Illumina NextSeq® platform was performed. All variants identified were confirmed
by Sanger sequencing and, when possible, family members were tested to study the segregation
of identified variants. We applied in silico studies only to variants with an allelic
frequency ≤1%.
Results: All patients described are Caucasian and 3 of them are female. Two patients
presented at onset with extended cutaneous manifestation, joints and abdominal involvement
with cholecystitis. They did not develop renal or pulmonary involvement. In contrast,
the other four patients presented a more severe disease. All of them developed renal
involvement (from microhaematuria up to nephrotic syndrome) with renal biopsy showing
mesangial glomerulonephritis in three patients and pauci-immune glomerulonephritis
(ANCA negative) in one. Moreover, two of them developed also pulmonary vasculitis
(Table 1). A homozygous DNASE1L3 variant (c.290_291delCA) was identified in three
of these patients. All of them were treated with glucocorticoid and dapsone at onset.
Cyclophosphamide, mycophenolate mofetil and azathioprine were used in patients with
renal involvement. None of them developed SLE.
Conclusion: HUVS is very rare disease in childhood. Approximately 50% of HUVS patients
develop SLE. Genetic susceptibility to SLE is recognized and DNASE1L3-related SLE
have been reported. Özçakar et al. have described 5 children from two families with
HUVS who carry the same variant on DNASE1L3 that we report here (1). Our patients
confirm that variant in DNASE1L3 can cause HUVS and support the hypothesis that this
variant is responsible of a more severe phenotype with major organ involvement (renal
and pulmonary). Patients with HUVS need to be followed very strictly for the risk
to develop SLE. Presence of variant in DNASE1L3 can identify patients with more severe
disease and high risk to develop major organ involvement. These patients need more
aggressive and possibly life-long immunosuppressive treatment.
Reference
(1) Ozçakar ZB et al. DNASE1L3 Mutations in Hypocomplementemic Urticarial Vasculitis
Syndrome. Arthritis Rheum. 2013 Aug;65(8):2183-9.
Disclosure of Interest
M. Ranalli: None Declared, C. Passarelli: None Declared, V. Messia: None Declared,
M. Pardeo: None Declared, E. Sacco: None Declared, A. Insalaco: None Declared, M.
Vivarelli: None Declared, F. De Benedetti Grant / Research Support from: Novartis,
Novimmune, Hoffmann- La Roche, SOBI, AbbVie, Pfizer, C. Bracaglia: None Declared
Table 1 (abstract P1095).
Patients’ clinical characteristics
Pt 1
Pt 2
Pt 3
Pt 4
Pt 5
Pt 6
Age at onset
9 y 6/12
3 y 10/12
9y 5/12
14y 3/12
3y 6/12
3y 1/12
Joints
Yes
Yes
Yes
No
Yes
Yes
Abdominal
Yes
Yes
Yes
No
Yes
Yes
Pulmonary
No
Yes
Yes
No
No
No
Renal
Yes
Yes
Yes
Yes
No
No
Antibody anti-C1q
+
+
+
+
+
+
Anti-dsDNA
absent
absent
absent
absent
absent
absent
C3 (nv 90-180 mg/dl)/C4 (nv 10-40 mg/dl)
57/7
63/6
52/2
57/7
19/1
57/1
DNASE1L3 variant
+
+
Ongoing
+
-
-
P1096 A case of idiopathic recurrent pericarditis treated with anakinra but unresponsive
to canakinumab
Francesca Ricci, Silvia Ghetti, Rossana Razza, Camilla Dallavilla, Giulia Verzura,
Alessandra Manerba, Marco Cattalini
University of Brescia and Spedali Civili di Brescia, Pediatric Clinic, Brescia, Italy
Correspondence: Marco Cattalini
Introduction: Recurrent pericarditis complicates up to 30% of acute pericarditis cases.
First choice initial therapy are non-steroid anti-inflammatory drugs (NSAIDS) and
colchicine. Corticosteroids have been used in case of partial response to first-line
therapy, allowing rapid control of inflammation but with a high rate of steroid-dependency.
Quite recently Anakinra, a recombinant human interleukin-1 competitive receptor antagonist
that blocks both IL-1a and b, have been demonstrated to be a valid option in such
cases. When to start Anakinra, and how to taper it in case of remission are still
open questions, as if other anti-IL1 treatments may also be an option.
Objectives: We present herein a case of recurrent pericarditis well controlled by
Anakinra, that became Anakinra-depent and relapsed after switching to Canakinumab,
a recombinant human interleukin-1beta competitive receptor antagonist.
Results: Results: in September 2008, S.S., a 14-years old boy (weight 69,8 kg, height
160 cm) was admitted in our Emergency Department complaining of three days of acute
chest pain that increased in supine position, fever and dyspnoea. A chest X-ray showed
heart enlargement. Past medical history revealed that in the previous eight months,
S. presented three similar episodes of chest pain, that were effectively home-treated
with NSAIDS. Physical examination showed fair general condition, paleness and friction
rubs at the cardiac auscultation. Lab tests revealed elevated CRP (270 mcg/ml) and
ESR (79 mm/h). At trans-thoracic echocardiography revealed a diffuse pericardial effusion
of 300 cc. Serologic studies didn’t suggest a clue for the aetiology of episode. Treatment
with naproxen (250 mg twice a day for 7 days) and prednisone (initial dosage 30 mg/die)
lead to rapid control of symptoms, inflammatory markers and US findings within few
days. From there on, any attempt to taper steroids, even of few mg, led to rapid relapse
of symptoms, inflammatory markers, and pericardial effusion. For this reason colchicine
was added to initial treatment (1,5mg once a day) with no improvement and, after 3
months from the onset, anakinra (at the dosage of 100 mg/die) was introduced, with
prompt normalization of the clinical picture and US findings. Steroids were withdrawn
and in the following nine years numerous attempt were made to taper Anakinra but,
every time the interval between injection was extended to 4 days, SS experienced a
relapse. Genetic tests for TRAPS and Familial Mediterranean Fever resulted negative.
In June 2018, we tried to modify the therapy by substituting anakinra with canakinumab,
in order to reduced the number of injections. Unfortunately, 48 hours after the administration
of canakinumab 150 mg, the patient experienced a flare with thoracic pain and high
inflammatory markers. The flare was managed by steroids (prednisone 40mg a day) and,
after two weeks, a second dose of Canakinumab was administered. Even after this up-titration
it was not possible to taper steroids. Therefore, after an adequate period of wash-out,
Anakinra was reintroduced with rapid and stable disease control and steroid withdrawal.
Conclusion: our case confirms that Anakinra may be a good option for recurrent pericarditis
unresponsive to first line treatment, but drug withdrawal may be difficult. Although
limited to this case, it seems that canakinumab is not a valid option. One may speculate
that recurrent pericarditis (at least in some cases) is an IL-a – mediated disease
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1097 Efficacy of canakinumab as first-line biologic agent in adult-onset still’s
disease
Giulio Cavalli, Alessandro Tomelleri, Corrado Campochiaro, Elena Baldissera, Giacomo
De Luca, Lorenzo Dagna
Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UniRAR), Vita-Salute
San Raffaele University, Milan, Italy
Correspondence: Giulio Cavalli
Introduction: Adult-onset Still’s disease (AOSD) is a rare auto-inflammatory condition
characterized by fever, arthritis, skin rash, and multi-organ inflammation. The pathogenesis
of AOSD is centrally mediated by the pro-inflammatory cytokine interleukin (IL)-1β;
anakinra, a recombinant inhibitor of the IL‑1β receptor, has thereby become the cornerstone
of biologic therapy for AOSD. More recently, a new agent blocking IL‑1β has become
available, that is, the monoclonal antibody canakinumab.
Objectives: So far, canakinumab has been used in the treatment of AOSD following failure
of multiple lines of biologic therapy, including anakinra. Here, we describe the use
of canakinumab as first-line biologic agent in 4 patients with AOSD, and report the
highly promising results of this treatment approach.
Methods: Four patients with severe, DMARD-refractory AOSD received canakinumab at
the approved dose of 4 mg/kg once every 4 weeks following failure of conventional
treatment with corticosteroids and methotrexate. Patient characteristics and response
to therapy were recorded.
Results: In all patients, treatment with canakinumab led to striking and rapid clinical
responses, within days of initiation. Fever and skin rash disappeared first and did
not recur, followed by progressive and sustained improvement in arthritis. Inflammatory
organ involvement also responded to treatment: for example, we observed resolution
of pericardial inflammation in two patients, as revealed by cardiac ultrasound; another
patient had hepatosplenomegaly, which also reverted to normal upon treatment. A striking
reduction in serum pro-inflammatory markers C-reactive protein, erythrocyte sedimentation
rate, and ferritin mirrored the efficacy on clinical manifestations. These effects
amounted to a significant decrease in the modified Pouchot score for measuring disease
severity (average score before canakinumab treatment: 6; after: 1.25; statistical
significance of difference evaluated with Mann-Whitney: p=0.02), and allowed for tapering
or discontinuation of concomitant therapy: specifically, corticosteroid treatment
was completely discontinued in two patients and substantially reduced in two patients,
whereas methotrexate was stopped in one patient.
Conclusion: In this study, first-line biologic therapy of AOSD with canakinumab resulted
in rapid and marked efficacy, ultimately leading to full clinical remissions in all
patients, and allowing for robust steroid-sparing effects.
Disclosure of Interest
None Declared
P1098 CARRA autoinflammatory disease network development- improving care and fostering
research in systemic autoinflammatory diseases (SAIDS)
Julie Cherian1, Theresa L. Wampler Muskardin2, Marinka Twilt3, Ronald M. Laxer4, Jonathon
S. Hausmann5, Cagri Yildirim-Toruner6, Maria J. Gutierrez7, Nadine Saad8, Grant S.
Schulert9, Evan J. Propst10, Greg Licameli11, Akaluck Thatayatikom12, Gil Amarilyo13,
Liora Harel14, Ian C. Michelow15, Peter F. Wright16, Yuriy Stepanovskiy17, Lakshmi
N. Moorthy18, Karen Durrant19, Polly J. Ferguson20, Lori B. Tucker21, Fatma Dedeoglu22,
Sivia K. Lapidus23 and CARRA Autoinflammatory Network Development Work Group
1Pediatrics, Stony Brook Children’s Hospital,Stony Brook, NY; 2Medicine and Pediatrics,
NYU School of Medicine, NY, United States; 3Pediatrics, Alberta Children's Hospital,
Calgary, AB; 4Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada; 5Pediatrics,
Boston Children's Hospital, Beth Israel Deaconess Medical Center, Boston, MA; 6Pediatrics,
Nationwide Children's Hospital, Columbus, OH; 7Pediatrics, Johns Hopkins University
School of Medicine, Baltimore; 8Pediatrics, Hospital for Special Surgery, NY; 9Pediatrics,
Cincinnati Children's Hospital, Cincinnati, OH, United States; 10Otolaryngology, Hospital
for Sick Children, Toronto, ON, Canada; 11Otolaryngology, Boston Children's Hospital,
Boston, MA; 12Pediatrics, University of Florida, Gainesville, FL, United States; 13Pediatrics,
Schneider Hospital, Tel Aviv University; 14Pediatrics, Schneider Hospital,Tel Aviv
University , Tel Aviv, Israel; 15Pediatrics, Alpert Medical School of Brown University,
Providence, RI; 16Pediatrics, Dartmouth-Hitchcock Medical Center,NH, United States;
17Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine; 18Pediatrics,
Rutgers/RWJ Medical School, New Brunswick, NJ; 19Pediatrics, Kaiser Permanente San
Francisco Medical Center, San Francisco, CA; 20Pediatrics, University of Iowa Carver
College of Medicine, Iowa City, IA, United States; 21Pediatrics, BC Children's Hospital,
UBC Vancouver, BC, Canada; 22Pediatrics, Boston Children's Hospital, Boston, MA; 23Pediatrics,
Joseph M. Sanzari Children's Hospital Hackensack Meridian Health, Hackensack, NJ,
United States
Correspondence: Julie Cherian
Introduction:
International registries have significantly enhanced the understanding of the genetics,
phenotype, prognosis, and treatment responses in Systemic Autoinflammatory Diseases
(SAIDs) in the studied populations, and such understanding would be further enhanced
by expanding these efforts to include a genetically heterogeneous Northern American
cohort.
Objectives:
To explore the value of developing a Childhood Arthritis and Rheumatology Research
Alliance (CARRA) Autoinflammatory Disease Network in enhancing quality of care, therapeutic
monitoring, and determining outcomes in SAIDs.
Methods: A team within CARRA composed of pediatric rheumatologists, infectious disease
physicians, immunologists, otolaryngologists, geneticists, parents/patients with autoinflammatory
disorders, and members of the Autoinflammatory Alliance met in person and via teleconference
to discuss the benefits of autoinflammatory disease networks from 2016 to the present.
Physicians who were involved in already-established autoinflammatory disease clinics
in North America shared the benefits of having such programs. A comprehensive literature
search on the topic using keywords such as “EuroFever”, “pharmacosurveillance”, and
“autoinflammatory registry” were reviewed. Nominal group technique was employed.
Results:
A consensus was reached regarding the benefits, feasibility, and intent of developing
a CARRA Autoinflammatory Disease Network that will be instrumental for providing quality
care for children affected by SAIDs and their families. The network will provide improvements
in areas of clinical care, enhanced research, patient and family access to accurate
and useful disease-related education, and facilitation of international collaborations.
The group’s literature search highlighted the benefits of this approach in rare diseases
in preventing diagnostic delay leading to increased morbidity and mortality, understanding
the epigenetics of SAIDs that remain poorly understood, and providing an opportunity
for pharmacosurveillance in a cohort of patients potentially exposed to biologics.
Conclusion:
The development of a CARRA Autoinflammatory Disease Network will facilitate earlier
diagnoses, education, and access to expert as well as multidisciplinary quality care.Additionally,
this network will create an infrastructure for future clinical and translational investigations
into long-term outcomes in SAIDs, epidemiological studies, comparative effectiveness
trials, and implementation of optimum standards of care for SAIDs.Given the genetically
diverse populations in North America, an autoinflammatory network would facilitate
collaborations with international colleagues to benefit patients worldwide.
Disclosure of Interest
None Declared
P1099 The Helios (Hacettepe University Electronic Research Forms) registry: use of
biologic drugs in autoinflammatory diseases
Selcan Demir1, Ezgi D. Batu1, Fuat Akal2, Erdal Sağ1, Ummusen Kaya Akca1, Elif Arslanoğlu
Aydın3, Emil Aliyev3, Kübra Yüksel3, Armağan Keskin3, Yelda Bilginer1, Seza Ozen1
1Department of Pediatric Rheumatology, Hacettepe University, Medical Faculty; 2Department
ofComputer Engineering, Hacettepe University; 3Department of Pediatrics, Hacettepe
University, Medical Faculty, Ankara, Turkey
Correspondence: Selcan Demir
Introduction: Autoinflammatory diseases (AID) are characterized by a dysregulation
of innate immunity leading to uncontrolled inflammation. The treatment in AID is critical
to control the disease activity, to prevent complications, and to improve the health-related
quality of life. Biologic drugs have revolutionized the treatment and outcomes in
AID.
Objectives:Herein we aim to present the clinical characteristics of children to whom
biologic drug therapy was initiated for the management of AID.
Methods: A web-based registry called the Helios Registry (Hacettepe univErsity eLectronIc
research fOrmS) has been formed to evaluate the data of all children on biologic treatment.
We have been enrolling patients since August 2018 retrospectively and prospectively.
We have analyzed the data about the general characteristics of the patients, treatment,
the biologic drug used, and adverse effects. Only the patients with the following
diagnoses were included: systemic juvenile idiopathic arthritis (SJIA), familial Mediterranean
fever (FMF), cryopyrin associated periodic syndrome (CAPS), and chronic recurrent
multifocal osteomyelitis (CRMO).
Results: Of 60 patients included, 19 had FMF (31.7%), 24 had sJIA (40%), 10 had CAPS,(16.7%),
and 7 had CRMO (11.7%). Their median age was 10.7 (2-20) years old and disease duration
was 2.8 (0-6) years, at the time of biologic drug initiation. 58.3% were currently
on canakinmab, 20% anakinra, 10% tocilizumab, 10% etanercept, and 1.7% adalimumab.
63.3% of our patients had previously used at least one other biologic drug. The rate
of glucocorticoid use before biologic treatment was 56.6%. The median duration of
glucocorticoid treatment after initiating biologic drugs was 7.4 months.56 (93%) patients
achieved remission on biologic therapy. There were 15 patients (25%) who received
tuberculosis prophylaxis due to positive tuberculin skin test (diameter≥10 mm) and
there was no Quantiferon test positivity. Thirteen adverse events (AE) had been noted.
2 of them were serious events as anaphylaxis due to tocilizumab infusions. The rest
of the adverse events were mild thrombocytopenia (n=2), varicella infection (n=1),
and local side effects (n=8). The median number of the infections per year was one
and there were no death or malignancy.
Conclusion: The most commonly prescribed biologic drugs were IL-1 inhibitors especially
for patients with IL-1-mediated AID (FMF, CAPS, and SJIA). The biologic treatment
in AID seems effective and reasonably safe.
Acknowledgment
This registry was supported by SOBİ
Disclosure of Interest
None Declared
P1100 Pediatric Behcet’s disease with sinus venous thrombosis: three center experience
from Turkey
Selcan Demir1, Ceyhun Açarı2, Özge Basaran3, Erdal Sağ1, Yelda Bilginer1, Şevket Erbil
Ünsal2, Seza Ozen1
1Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara;
2Department of Pediatric Rheumatology, Dokuz Eylül University Faculty of Medicine,
İzmir; 3Department of Pediatric Rheumatology, Ankara Child Health and Disease Hematology
Oncology Training and Research Hospital, Ankara, Turkey
Correspondence: Selcan Demir
Introduction: Behçet’s disease (BD) is a multisystem vascular-inflammatory disorder including
the cutaneous, articular, gastrointestinal, and/or central nervous systems (CNS).Adult
BD patients with CNS involvement mostly present with parenchymal form, including meningoencephalitis,
headache and pleocytosis of the cerebrospinal fluid while non-parenchymal form is
more common among pediatric BD patients and younger age. Non-parenchymal form usually
presents with cerebral venous sinus thrombosis (CVST) and intracranial hypertension. Neurological
symptoms in children and adolescents can be confused with many other disorders and
may be the initial symptom of BD.
Objectives: To report our experiences of the juvenile Behçet’s Disease patients with
cerebral venous sinus thrombosis (CVST) and to review previous studies reporting the
clinical characteristics and outcomes of Juvenile Behçet’s Disease with CVS
Methods: The patients who met Pediatric Behçet's Disease (PEDBD) classification criteria
for juvenile Behçet’s Disease from 3 referral centers in Turkey were reviewed retrospectively.
Disease activity was assessed by BD current activity form (BDCAF). A systematic review
of literature of all published data was conducted.
Results: The study group consisted of 12 juvenile BD patients with CVST. At the time
of CVST diagnosis, the most common symptom was headache (%100), followed by vomiting
(25%), blurred vision (16.6-7%), and disturbances in eye movements (16.7%). Six (50
%) patients presented with sinus venous thrombosis as an initial symptom. Transverse
sinus was the most frequently affected sinus (9/12, 75%) followed by superior sagittal
sinus (8/12, 66.6%) and sigmoid sinus (1/12, 8.3%). The median (minimum-maximum) BDCAF
was 6 (5-8). Four children (33.3%) had another venous thrombosis apart from CVST.
All patients received pulse methylprednisolone for three consecutive days continued
with oral prednisolone. Steroid treatment was tapered and discontinued minimum in
six months. Eleven patients received azathioprine concomitant to steroid treatment
at the time of CVST. All the patients received anticoagulant therapy concomitantly.
Only one patient had relapse. Median (min-max) follow-up period was 4 years (1-10).In
the literature review, we identified nine articles, describing 35 pediatric CVST patients
associated with BD. Thirty patients achieved remission, while five patients had residual
neurologic deficit.
Conclusion: Further multicenter studies with more patients and prospective follow-up
may help us to understand the whole spectrum in these patients.
Disclosure of Interest
None Declared
P1101 PFAPA- the Irish experience in a tertiary autoinflammatory clinic
Ana-Louise Hawke1, Jayne MacMahon1, Emma Jane MacDermott1, Karina Butler2, Ronan Leahy3,
Patrick Gavin2, Orla Killeen1
1Paediatric Rheumatology; 2Paediatric Infectious Disease; 3Paediatric Immunology,
Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
Correspondence: Ana-Louise Hawke
Introduction: Periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis
(PFAPA) syndrome is the most common autoinflammatory disorder in childhood, with multifactorial,
polygenic causes postulated.
Children usually present before the age of 5 years with periodic fevers and one or
more associated symptoms of stomatitis, pharyngitis and adenitis, flares usually resolving
in adolescence.
Treatment options include corticosteroids for flares and colchicine, tonsillectomy
and increasingly biological agents to prevent disease flare.
Objectives: The aim of this study was to appraise the presentation and management
of children with PFAPA attending a tertiary Autoinflammatory Clinic since it’s establishment
in 2016.
Methods: A retrospective observational chart review of all children with PFAPA, confirmed
or likely, attending Autoinflammatory clinic at Our Lady’s Children’s Hospital, Crumlin
Dublin from January 2016.
Data were collected on basic demographics, age at presentation, route of referral,
symptoms and signs and inflammatory markers during disease episodes and non-episodes.
Details of genetics analysis if performed, were included. Information was also gathered
on any treatment methods used and their effect including oral corticosteroids, colchicine,
biological agents and tonsillectomy. Results were analysed using Microsoft Excel.
Results: 13 children were identified as having PFAPA, including 2 sets of siblings.
The median age of disease onset was 16 months, ranging from 4 months to 4 years of
age. The route to referral was through Immunology (4 patients), Rheumatology (6 patients)
and Infectious disease (3 patients) clinics. All children presented with episodic,
recurrent febrile episodes with a median duration of 3-4 days and a range of associated
features. (See table 1) 3 children presented with the triad of stomatitis, adenitis
and pharyngitis.
Sixty nine percent of patients had documented raised inflammatory markers during a
flare, with 84% having high serum amyloid A levels, the highest documented being 1220mg/l
(normal <10). 69% of patients had normal inflammatory markers and 76% normal serum
amyloid A documented during disease quiescence.
Genetic testing in 6 children was negative for other causes of Hereditary Autoinflammatory
disorders- TRAPS FMF.
2 sisters were found to have a benign variant NLRP mutation. Serum IgD levels normal
in 9 and raised in 1 patient.
11 patients were initiated with treatment that included a stat of 3-day trial of oral
corticosteroids, all of whom reported some improvement in symptoms, but 2 reporting
rebound flares. 11 were treated with Colchicine, 9 of whom reported some benefit.
Tonsillectomy was performed in 5 patients, 3 who found benefit. Anakinra was used
to treat 2 and 1 patient was commenced on Adalimumab.
Conclusion: This study gives an over view of the burden of disease imposed by PFAPA
on an Irish population. While all the children presented with fevers, not all had
the classic triad of aphthous stomatitis, pharyngitis and cervical adenitis.Raised
CRP ESR were seen in the majority of patients and 84% had raised amyloid levels during
disease flare. The majority of patients had prompt relief of symptoms with an initiation
trial of corticosteroid. Colchicine being frequently used with some success to prevent
occurrence of flares. Tonsillectomy and biological agents were also used in some resistant/severe
cases.
Disclosure of Interest
None Declared
Table 1 (abstract P1101).
Number of patients
Associated Symtoms:
Stomatitis
8
Tonsillitis/Pharyngitis
8
Cervical Adenitis
7
Lethargy
6
Rash
4
Anorexia
4
GI upset
12
Periodicity of disease flare
<2 weeks
1 patient
Flare Duration
2-3 days
5 patients
2-4 weeks
10 patients
4-5 days
7 patients
4-6 weeks
2 patients
6-7 days
1 patient
Systemic-onset JIA and AOSD
P1102 Hepatitis A virus vaccination in autoinflammatory diseases under canakinumab
and tocilizumab treatment
Kenan Barut1, Amra Adrovic1, Sezgin Sahin1, Mehmet Yıldız1, Oya Koker1, Gamze Yalcin1,
Omer Faruk Beser2, Bekir Kocazeybek3, Pelin Yuksel3, Ozgur Kasapcopur1
1Pediatric Rheumatology, Istanbul University Cerrahpasa, Cerrahpasa Medical School;
2Pediatric Gastroenterology, Okmeydani Education and Training Hospital; 3Microbiology,
Istanbul University Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
Correspondence: Kenan Barut
Introduction: Autoimmune, autoinflammatory mechanism and drugs used in treatment increase
the risk of liver disease in patients with chronic rheumatic diseases. Hepatitis A
vaccine is a highly effective vaccine that prevents both the formation and spread
of clinical hepatitis. In childhood chronic rheumatic diseases, vaccination is of
great importance. The risk of various infections increases with the immunosuppressive
effect of both the disease and the drugs.Therefore, vaccination of these diseases
is of high importance for the prevention of infectious diseases. Systemic juvenile
idiopathic (SJİA) arthritis is a juvenile idiopathic arthritis (JİA) subtype with
autoinflammatory pathogenesis. Steroid, methotrexate and anti-interleukin 1 and 6
are used for the SJİA treatment. Anti-interleukin 1 treatments are also used in the
treatment of Cryopyrin-associated periodic syndromes (CAPS), which is also characterized
with autoinflammatory pathogenesis.Studies on the efficacy and safety of vaccines
in autoimmune and autoinflammatory diseases are limited.
Objectives: The aim of this study was to investigate the efficacy and safety of hepatitis
A vaccine in patients with autoinflammatory disease on anti-interleukin 1 and 6 treatment.
Methods: This study was carried out in Pediatric Rheumatology outpatient clinic and
Healthy Child clinic between June 2017 and November 2018. A total of 39 patients with
autoinflammatory diseases on anti IL-1 and IL-6 therapy were initially evaluated but
25 of them were excluded due to anti-HAV IgG positivity. At the end, 24 patients withautoinflammatory
diseases on anti IL-1, anti IL-6 therapyand 39 healthy participants who were seronegative
for hepatitis A received two doses of the hepatitis A vaccine in a 0 and 6 month schedule.
Hepatitis A virus (HAV) IgG antibodies were measured before vaccination and one month
after last dose of the vaccine. Anti-HAV IgG titer as S/ CO;1.1, IU/L was considered
positive and protective.
Results: Total 24 patients with autoinflammatory condition (13 females, 11 males)
and 39 healthy controls( 18 female, 21 male) were included in the study.
Among patients with diagnosis of autoinflammatory disease, 19 were SJİA and 5 were
CAPS patients. The mean age was 14.1±3.7 and 12.2±3.3 years respectively. Canakinumab
was used in 15 (62.5%) and tocilizumab in 9 (37.5%) all patients. Among all SJİA patients,
10 (52.6%) were treated with canakinumab and 9(47.4%) were treated with tocilizumab.
All patients with CAPS (n: 5) were using canakinumab. Among SJIA cases, 15(75%) were
also using methotrexate and 14(70%) prednisolone.Anti-HAV IgG concentrations were
measured one month after the last dose of hepatitis A vaccine. There was statistically
significant difference between patients with autoinflammatory condition and healthy
controls regarding the anti-HAV IgG titer (mean 5.3±1.5 IU/L) versus (10.5±7 IU/L)
p<0.05. The rate of anti-HAV IgG seropositivity (cut-off 1.1 IU/L) in autoinflammatory
disease (24/24 (100%) was significantly different comparing to healthy controls (33/39,
84.6%) (p=0.04). There was no disease flare of disease nor the adverse event detected
in any patients after vaccination.
Conclusion: Anti-HAV IgG seroconversion was detected in patients with autoinflammatory
disease on anti-IL1 and anti - IL6 therapy 1 month after the last dose of hepatitis
A vaccine. The response to vaccine did not differ between healthy children and patients
with autoinflammatory disease under canakinumab and tocilizumab. In this study hepatitis
A vaccine was found to be safe in autoinflammatory diseases with canakinumab and tocilizumab
treatment.
Disclosure of Interest
None Declared
P1103 Risk score of macrophage activation syndrome in patients with systemic juvenileidiopathic
arthritis
Simone Carbogno1, Denise Pires Marafon2, Giulia Marucci3, Manuela Pardeo3, Antonella
Insalaco3, Virginia Messia3, Emanuela Sacco3, Fabrizio De Benedetti3, Claudia Bracaglia3
1Pediatric Area, University of Milan; 2Pediatric Unit, Fondazione IRCCS Ca’ Grande
Ospedale Maggiore Policlinico, Milan; 3Division of Rheumatology, IRCCS Ospedale Pediatrico
Bambino Gesù, Rome, Italy
Correspondence: Claudia Bracaglia
Introduction: Macrophage Activation Syndrome (MAS) is a severe, life-threatening,
complication of rheumatic diseases in childhood, particularly of systemic Juvenile
Idiopathic Arthritis (sJIA), occurring in approximately 25% of the patients with sJIA.
The mortality rate of MAS is still significantly high. A score that identify sJIA
patients who are at high risk to develop MAS would be useful in clinical practice.
There are no parameters available to identify from onset sJIA patients with high risk
to develop MAS in their disease course.
Objectives: To evaluate whether routine laboratory parameters at disease onset may
predict the development of MAS in patients with active sJIA. To define a risk score
of MAS for sJIA patients using these parameters.
Methods: Laboratory parameters of disease activity and severity (WBC, N, PLT, Hb,
ferritin, AST, ALT, gGT, LDH, TGL, fibrinogen, D-dimer and CRP), were retrospectively
evaluated in 86 sJIA patients referred to our Division of Rheumatology from 1998 to
2017 with at least one year of follow-up. Laboratory parameters were evaluated during
active sJIA, without MAS, at time of hospitalization (T1) and before treatment for
sJIA was started (T2). Patients were divided in two groups: group 1 (patients without
history of MAS), group 2 (patients with at least one MAS episode during disease course).
To calculate a MAS risk score, laboratory parameters, collected at T2, with a statistical
significant difference between the two groups of patients were selected.
Results: Thirty-three patients, that fulfilled the 2016 classification criteria for
MAS [1] at time of sampling, were excluded from the analysis. Therefore, we analysed
laboratory parameters of 53 patients with sJIA, 33 of whom without history of MAS
(group 1) and 20 who developed at least one episode of MAS during disease course (group
2). Levels of ferritin, AST, LDH, gGT and TGL, collected at T2, were statistically
significant higher in patients with a history of MAS compared to those without a history
of MAS. For each of these parameters an arbitrary cut-off was defined. In order to
define the final score an arbitrary rate was attributed to each parameter. Sensitivity
(Se), specificity (Sp), positive predictive value (PPV) and negative predictive value
(NPV) were calculated to define the best scoring system. The scoring system with the
best sensitivity was chosen (Table 1). A MAS risk score >3 identified 19 out of 20
sJIA patients with a history of MAS and 4 out of 33 sJIA patients without history
of MAS.
Conclusion: In conclusion we developed a MAS risk score based on routine laboratory
parameters that are available worldwide, that can help clinicians to identify these
patients early in the disease course. A validation in a larger population is ongoing.
Reference
[1] Ravelli A et al. 2016 Classification Criteria for Macrophage Activation Syndrome
Complicating Systemic Juvenile Idiopathic Arthritis: A European League Against Rheumatism/American
College of Rheumatology/Paediatric Rheumatology International Trials Organisation
Collaborative Initiative. Ann Rheum Dis. 2016 Mar;75(3):481-9.
Disclosure of Interest
S. Carbogno: None Declared, D. Pires Marafon: None Declared, G. Marucci: None Declared,
M. Pardeo: None Declared, A. Insalaco: None Declared, V. Messia: None Declared, E.
Sacco: None Declared, F. De Benedetti Grant / Research Support from: Novartis, Novimmune,
Hoffmann- La Roche, SOBI, AbbVie, Pfizer, C. Bracaglia: None Declared
Table 1 (abstract P1103).
Laboratory parameters and cut-off used to create the MAS risk scorein sJIA patients
Laboratory parameters
Cut-off
Rate
Ferritin (ng/ml)
>900
1
AST (UI/L)
>35
1
LDH (UI/l)
>550
1
gammaGT (UI/L)
>30
2
Triglycerides (mg/dl)
>150
2
Sensitivity (Se)
0.950
CI95% 0.842-0.988
Specificity (Sp)
0.879
CI95% 0.753-0.948
Positive predictive value (PPV)
0.826
CI95% 0.692-0.912
Negative predictive value (NPV)
0.967
CI95% 0.865-0.995
P1104 Adult onset Still’s disease complicated with haemophagocytic syndrome: successfull
treatment with IVIG and Tocilizumab
Ayse Cefle, Fatma Tuncer, Ayten Yazici
Department of Internal Medicine Division of Rheumatology, Kocaeli University Faculty
of Medicine, Kocaeli, Turkey
Correspondence: Ayse Cefle
Introduction: Adult onset Still's disease (AOSD) is anacute febrile syndrome observed
in young adults. Typically, many organs are affected. Haemophagocytic syndrome is
a life-threatening condition with high mortality rate. The rate of occurrence of the
condition in AOSD patients is 5-10%.
Objectives: A 24-year-old female patient with fever, rash, joint pain having started
1.5 months ago was admitted to our hospital. In physical examination; She had hepatosplenomegaly
and multiple LAPs in bilateral cervical region as well as tenderness on the left wrist
and right ankle. The rash was concomittant with fever. CRP, erythrocyte sedimentation
rate, white blood cell and ferritin elevation were determined. Hepatitis markers,
HIV, brucella, syphilis, CMV, toxoplasma, EBV were found to be negative. The anti-nuclear
antibodies, rheumatoid factor and anti-CCP were negative,
Methods: In the thorax CT, multiple lymph nodes were observed in the mediastinal (13
mm), bilateral hilar, axillary (15 mm largest) and bilateral lower neck. The patient's
PET CT revealed increased metabolic rate in the neck, mediastinum, abdominopelvic
region, mildly diffused increased metabolism in the bone marrow, and increased metabolism
in the basal sections of both lungs. It was reported that lymphoproliferative disease
should be included in the differential diagnosis. Right servical lymph node excisional
biopsy was reported as reactive lymphoid hyperplasia. Bone marrow biopsy came as normocellular.
Her bronchoscopy was normal. Thereforemalignancy and infection were excluded. Prednizolon
60 mg/d and methotrexate 15 mg/w were started.
Results: The patient developed pancytopenia after two weeks and exhibited an increase
in her triglyceride, D-dimer, LDH and hypofibrinogenemia developed. The patient had
no atypical cells in the peripheral smear. IVIG as 2g/kg was added to the treatment
with the diagnosis of haemophagocytic syndrome. After IVIG, her fever reduced, leukopenia
thrombocytopenia improved, her sedimentation CRP reached normal limits. IVIG was administered
3 times with an interval of four weeks. However, one month after, she was admitted
to our clinic with common myalgia, subfebrile fever, sore throat, swelling of the
elbow, rash on the back. Leukocytosis with neutrophil dominance, increased levels
of ferritin, LDH, eryhtrocyte sedimentation rate and CRP were noted. Her methylprednisolone
dose was increased and Tocilizumab treatment (8 mg/kg/4w) was begun. After three months,
clinical and laboratory findings were normal.
Conclusion: Macrophage activation syndrome is a reactive form of haemophagocytic syndrome
associated with rheumatic diseases. 71% of macrophage activation syndrome cases occur
within the first month of AOSD diagnosis. Fever, cytopenia, hypertriglyceridemia,
increased ferritin, LDH and liver enzymes, HSM, LAP,coagulopathy and elevation of
fibrin degradation products are observed. The syndrome is characterized with haemophagocytosis
in bone marrow and RES. Glucocorticoids, cyclosporine, anakinra, tocilizumab and IVIG
are administered.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1105 Drug retention rate and predictive factors of drug survival for interleukin-1
inhibitors in systemic juvenile idiopathic arthritis
Carla Gaggiano1, Jurgen Sota2, Antonella Insalaco3, Rolando Cimaz4, Maria Alessio5,
Marco Cattalini6, Romina Gallizzi7, Maria Cristina Maggio8, Giuseppe Lopalco9, Francesco
La Torre10, Claudia Fabiani11, Manuela Pardeo3, Alma Nunzia Olivieri12, Paolo Sfriso13,
Carlo Salvarani14, Salvatore Grosso1, Claudia Bracaglia3, Fabrizio De Benedetti3,
Donato Rigante15, Luca Cantarini2
1Clinical Pediatrics, Department of Molecular Medicine and Development; 2Research
Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department
of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena; 3Division
of Rheumatology, Department of Pediatric Medicine, Bambino Gesù Children's Hospital,
IRCCS, Rome; 4Rheumatology Unit, Meyer Children's Hospital, University of Florence,
Florence; 5Department of Pediatrics, University of Naples Federico II, Naples; 6Pediatric
Clinic, University of Brescia, Brescia; 7Department of Pediatrics, Azienda Ospedaliera
Universitaria Policlinico “G. Martino”, University of Messina, Messina; 8Universitary
Department “Pro.S.A.M.I.”, University of Palermo, Palermo; 9Rheumatology Unit, Department
of Emergency and Organ Transplantation, University of Bari, Bari; 10Pediatric Rheumatology
Section, Pediatric Oncoematology Unit, Vito Fazzi Hospital, Lecce; 11Ophthalmology
Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena;
12Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda
Università degli Studi di Napoli, Naples; 13Rheumatology Unit, Department of Medicine,
University of Padua, Padua; 14Rheumatology Unit, Department of Internal Medicine,
Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio
Emilia; 15Institute of Pediatrics, Periodic Fever Research Center, Università Cattolica
Sacro Cuore, Fondazione Policlinico A. Gemelli, IRCCS, Rome, Italy
Correspondence: Carla Gaggiano
Introduction: The advent of biologic agents has revolutionized therapeutic approaches
in systemic juvenile idiopatic arthritis (sJIA) as their introduction has been shown
to modify disease course and improve overall outcomes, particularly when initiated
early. Few studies have reported the drug retention rate (DRR) of biologic drugs in
JIA, and none of them has specifically investigated the DRR of interleukin (IL)-1
inhibitors on sJIA.
Objectives: The primary aim of the study was to examine the overall DRR of IL-1 blockers
in sJIA patients. Secondary aims of our study were to: (i) explore the influence of
biologic line of treatment, adverse events (AEs), type of anti-IL-1 agent and the
concomitant use of conventional disease modifying anti-rheumatic drugs (cDMARDs) on
DRR; (ii) find eventual predictive factors associated with events leading to drug
discontinuation. The corticosteroid sparing effect and the impact of disease duration
and treatment delay on survival constituted ancillary aims.
Methods: sJIA patients – diagnosed according to the revised International League of
Association for Rheumatology (ILAR) criteria – treated with anakinra (ANA) and canakinumab
(CAN) were enrolled in 15 Italian tertiary referral centers. Demographic, clinical
and therapeutic data collected from medical records were retrospectively collected
and statistically analyzed.
Results: Seventy seven patients were enrolled for a total of 86 treatment courses.
The cumulative retention rate of the IL-1 inhibitors at 12-, 24-, 48-, and 60-months
of follow-up was 79.9, 59.5, 53.5, and 53.5%, respectively, without any statistically
significant differences between ANA and CAN (p = 0.056), and between patients treated
in monotherapy compared to the subgroup co-administered with conventional immunosuppressors
(p = 0.058). On the contrary, significant differences were found between biologic-naive
patients and those previously treated with biologic drugs (p = 0.038) and when distinguishing
according to AEs occurrence (p = 0.04). In regression analysis, patients pre-treated
with other biologics (HR = 3.357 [CI: 1.341–8.406], p = 0.01) and those experiencing
AEs (HR = 2.970 [CI: 1.186–7.435], p = 0.020) were associated with a higher hazard
ratio of IL-1 inhibitors withdrawal. The mean treatment delay was significantly higher
among patients discontinuing IL-1 inhibitors (p = 0.0002).
Conclusion: Our findings suggest an excellent overall DRR for both ANA and CAN that
might be further augmented by paying attention to AEs and employing these agents as
first-line biologics in an early disease phase.
Disclosure of Interest
None Declared
P1106 Clinic-laboratory profile of macrophage activation syndrome in children with
systemic juvenile idiopathic arthritis
Sandesh Guleria1, Johnson Nameirakpam1, Anjani Gummadi1, Anju Gupta1, Amit Rawat1,
Prateek Bhatia2, Deepti Suri1, Surjit Singh1
1Pediatric Allergy and Immunology; 2Pediatric Hemato-Oncology, Postgraduate Instiute
of Medical Education and Research, Chandigarh, Chandigarh, India
Correspondence: Sandesh Guleria
Introduction: Systemic juvenile idiopathic arthritis (SJIA) is an auto-inflammatory
disorder with a propensity to develop macrophage activation syndrome (MAS). MAS is
an emergent, fulminant, life-threatening condition which can be fatal if not recognized
early.
Objectives: To study the clinic-laboratory profile of MAS in children with SJIA
Methods: Case records of children of SJIA who had MAS, diagnosed at the Advanced Pediatrics
Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, during
the period 2017-2018, were reviewed. Findings pertaining to history, clinical examination
and laboratory investigations were recorded. Diagnosis of MAS was based on criteria
given by Ravelli et al (2016).
Results: A total of 13 children (1-18 years) with 15 MAS events were included in the
study. Two children had 2 episodes each of MAS during this period. Mean age was 6.7+
4.8 years with male to female ratio of 1.17. Five children (38.5%) had MAS, at or
during hospital admission on their first presentation. Common clinical features noted
were fever (100%), pallor (100%), hepatomegaly and/or splenomegaly (73.3%), rash (46.7%),
lymphadenopathy (46.7%), arthritis (33.3%), irritability (26.7%), mucocutaneous bleeding
(20%) and jaundice (13.3%). In laboratory investigations (Table 1), all children had
anaemia and elevated C-reactive protein (CRP). Leucopenia and leucocytosis was seen
in 2 (13.3%) and 8 (53.5%) children respectively. Four (26.6%) children had thrombocytopenia
(< 150 x 109/L), 6 (40%) had platelet count < 181 x 109/L and three children (20%)
had thrombocytosis. Hypertriglyceridemia (93.3%), hypofibrinoginemia (73.3%), elevated
aspartate aminotransferase (73.3%) and alanine aminotransferase (40%) were other prominent
laboratory parameters. All children had high serum ferritin levels with mean of 8960.6
+ 13662.12 ng/ml. Nine children had serum ferritin/ESR (ratio) of > 80. Three (20%)
children died. Two children, who died, had very high serum ferritin levels (52000
ng/ml and 42845 ng/ml).
Conclusion: MAS is a life threatening multisystemic complication of SJIA with high
mortality rate (20%). Fever, pallor, organomegaly and persistent rash are prominent
clinical features of MAS. Leucopenia and thrombocytopenia may not be early features
of MAS but low or normal platelets can differentiate MAS from a disease flare in which
we almost always get thrombocytosis. Very high serum ferritin, Hypertriglyceridemia,
hypofibroginemia and transaminitis are better clue for MAS and serum ferritin levels
may be a prognostic marker.
Disclosure of Interest
None Declared
Table 1 (abstract P1106).
Laboratory parameters in children of SJIA with MAS
Variables
No. of patients
Mean + SD (n=15)
Anaemia
15 (100%)
84 + 19 g/L
Leucopenia
2 (13.3 %)
14.2 + 11.7 x 109/L
Elevated CRP
15 (100%)
99.5 + 63.3 mg/L
Platelet < 181 x 109/L
6 (40%)
283.5 + 182.4 x 109/L
Elevated AST
11 (73.3%)
136.3 + 137.3 IU/L
Elevated ALT
6 (40%)
109.6 + 101.3 IU/L
Hypofibrinogenemia (<3.6 g/L)
11 (73.3%)
323 + 189 mg/dl
Hypertriglyceridemia(>156 mg/dl)
14 (93.3%)
235.9 + 132 mg/dl
Hyperferritinemia (ng/ml)
15 (100%)
8960.6 + 13662.12
ALT, alanine aminotransferase; AST, aspartate aminotransferase;CRP, C-reactive protein;
ESR, erythrocyte sedimentation rate
P1107 Serum soluble CD25: an useful biomarker of macrophage activation syndrome in
systemic juvenile idiopathic arthritis
Sandesh Guleria1, Anju Gupta1, Amit Rawat1, Prateek Bhatia2, Avinash Sharma1, Deepti
Suri1, Surjit Singh1
1Department of Pediatrics, Division of Allergy and Immunology; 2Department of Pediatrics,
Division of Hemato-oncology, Postgraduate Instiute of Medical Education and Research,
Chandigarh, Chandigarh, India
Correspondence: Sandesh Guleria
Introduction: Systemic juvenile idiopathic arthritis (SJIA) is an auto-inflammatory
disorder secondary to innate immune dysfunction with a propensity to develop macrophage
activation syndrome (MAS), a life-threatening condition. sCD25 has been used as a
sensitive biomarker for the diagnosis of Hemophagocytic lymphohistiocytosis which
has similarities in clinical features and pathogenesis to MAS.
Objectives: To assay serum soluble CD25 in children with systemic juvenile idiopathic
arthritis (SJIA) and to compare levels of sCD25 in children with inactive disease,
active disease and those with macrophage activation syndrome (MAS).
Methods: Thisprospective study was conducted in a tertiary care referral centre in
North India from January 2017 to June 2018. All patients fulfilling the International
League of Associations for Rheumatology (ILAR) 2001 criteria for SJIA were eligible
for enrolment. At enrolment, all patients were examined clinically for signs of disease
activity. Appropriate investigations were carried out and sCD25 was analyzed by using
commercially available sCD25 / IL-2R ELISA kit.
Results: A total of 35 children (1-18 years) with 43 events were included in the study.
Mean age at enrolment in the study was 7.3+3.59 years with male to female ratio of
2.5. Based on clinical features and investigations, events were categorized into 3
groups; SJIA with inactive disease (15; 34.9%), SJIA with active disease (15; 34.9%)
and SJIA with MAS (13; 30.2%). Mean sCD25 levels in the study population were 10,966.02
+ 10,854.93 pg/ml. Children with inactive disease, active disease and disease with
MAS had mean + SD serum sCD25 levels of 4710.6 + 1817.04 pg/ml, 7604 + 2376.24 pg/ml,
and 22062.9 + 14335.97 pg/ml respectively. Although, Mean level of sCD25 in children
with active disease was higher than those with inactive disease, but no significant
difference could be found. sCD25 levels significantly (p value 0.0001) varied between
MAS and other 2 groups. sCD25 cut off level of 10,385 pg/ml was found to have sensitivity
of 100% and specificity of 96.7% in differentiating MAS in SJIA from disease flare
and inactive disease. There was no correlation of sCD25 with demographic parameters,
Total leucocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP),
platelet counts, urea, creatinine, prothrombin time, activated partial prothrombin
time and fibrinogen levels. A correlation of sCD25 was found with levels of haemoglobin
(p-value .01), ferritin (p-value .001), aspartate aminotransferase (AST) (p-value
.000), alanine aminotransferase (ALT) (p-value .000), alkaline phosphatase (ALP) (p-value
.005) and triglycerides (p-value .001). Higher sCD25 levels were found in patients
who had low Hb, elevated ferritin, elevated AST, ALT, ALP and serum triglyceride levels.
Conclusion: sCD25 is a useful biomarker in differentiating MAS in SJIA from disease
flare and inactive disease with sensitivity and specificity of 100% and 96.7% respectively
at a cut off level of 10,385 pg/ml. Coupling sCD25 with other laboratory parameters
may be useful for early diagnosis of MAS in SJIA.
Disclosure of Interest
None Declared
P1108 Patient with CASP1 variant with severe systemic JIA and recurrent MAS treated
by dual blockade with anakinra and tocilizumab
Troels Herlin1, Sofie E. Jørgensen2, Mette Christiansen3, Sofie E. Jørgensen2, Christian
Høst1, Sofie E. Jørgensen2, Christian Høst1, Mette Christiansen3, Christian Høst1,
Mette Christiansen3, Dorte A. Larsen4, Mia Glerup1, Dorte A. Larsen4, Trine H. Mogensen5,
Birgitte Mahler1, Trine H. Mogensen5, Trine H. Mogensen5
1Pediatrics, Aarhus University Hospital; 2Biomedicine, Aarhus University; 3Clinical
Immunology; 4Ophthalmology; 5Infectious diseases, Aarhus University Hospital, Aarhus
, Denmark
Correspondence: Troels Herlin
Introduction: Macrophage activation syndrome (MAS) is a severe complication of rheumatic
disease in childhood, particularly in systemic juvenile idiopathic arthritis (sJIA).
An increasing body of evidence suggests a genetic background. Human procaspase-1 variants
have been associated with febrile episodes and may contribute to inflammation via
binding of receptor interacting protein kinase 2 (RIP2) and thereby activate NF-kB
signaling.
Objectives: To describe the genetic, immunological and therapeutic aspects of recalcitrant
sJIA and recurrent MAS in a patient with a variant in the CASP1 gene.
Methods: A 15-year-old, previously healthy girl presented Oct 2016 with a typical
clinical and biochemical picture of systemic JIA.
Based on recurrent MAS, whole exome sequencing (WES) was performed on DNA extracted
from whole blood. Peripheral blood mononuclear cells (PBMCs) from patient and a healthy
control were stimulated with NF-kB inducers (TNFa and LPS or left untreated). Phosphorylated
IkBa, as a measure of NF-kB activation, was measured by Luminex technology. Proinflammatory
cytokines (IL-6, CXCL10, MIP-1a and TNFa) were measured in the supernatants using
Mesoscale U-plex multiplex assays.
Results: WES identified a rare heterozygous variant in the CASP1 gene (c.482G>A, p.R161H,
CADD score 32; gnomAD frequency 0.000004) inherited from her healthy father and a
rather frequent heterozygousvariant in the UNC13D gene (c.2335G>A, p.V779M, CADD score
15.3; gnomAD frequency 0.003). Patient PBMCs demonstrated increased NF-kB activation.
Upon stimulation with TNFa and LPS the PBMCs produced extremely high levels of IL-6
and CXCL10 compared to control, whereas the levels of MIP-1a was comparable to control.
Initially, she responded well to anakinra 2 mg/kg/day and corticosteroids. Three months
later she flared with intense pruritus, arthritis and quotidian fever and was changed
to tocilizumab. Shortly after she precipitated with the picture of MAS and ferritin
rise to 26,000 μg/L, elevated LDH, high triglyceride and low fibrinogen. Bone marrow
was normal, spinal fluid showed mild pleocytosis, 36 leukocytes per μL. Etoposide
and dexamethasone treatment were started according to the HLH-2004 protocol. Nevertheless,
she developed another two episodes of MAS attacks with ferritin peaks >66,000 μg/L
and two CNS attacks with generalized seizures (no cells in spinal fluid, but MRI with
widespread bilateral cortical involvement). Despite treatment with canakinumab, dexamethasone,
high-dose anakinra (8 mg/kg/day), several 3-day pulses with 1 G i.v. methylprednisolone
and IVIG the condition deteriorated with repeated hyperferritinemia, fever, and elevated
acute phase reactants.
Based on the findings of increased expression of IL-6 in stimulated PBMCs i.v. tocilizumab
8mg/kg was added every second week to high-dose anakinra, which had a marked clinical
and biochemical response. All blood tests rapidly normalized and gradual tapering
to low-dose anakinra and subcutaneous tocilizumab for the next 16 months did not precipitate
new flares.
Conclusion: To the best of our knowledge, this is the first description of a CASP1 variant
associated with sJIA and recurrent MAS. We suggest that the Arg161His contributes
to the phenotype, since it is located in the catalytic domain of procaspase-1 and
therefore might stabilize the ASC Pyroptosome. The observed increase in NF-kB activation,
possibly explained by procaspase-1 variants inducing stronger interaction with RIP2
than wild-type procaspase-1, may have contributed to the increased expression of proinflammatory
proteins, such as IL-6.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1109 Validation and clinical application of MRP8/14 serum levels as biomarker for
the diagnosis of systemic juvenile idiopathic arthritis in fever of unknown origin
Carolin Pretzer1, María Miranda-Garcia1, Rainer Berendes2, Gerd Horneff3, Jasmin Kuemmerle-Deschner4,
Gerd Ganser5, Hans-Iko Huppertz6, Kirsten Minden7, Johannes-Peter Haas8, Annette Jansson9,
Michael Borte10, Catharina Schuetz11, Prasad Oommen12, Michael Frosch13, Christoph
Kessel1, Bernhard Schlueter14, Annette Richter-Unruh15, Helmut Wittkowski1, Johannes
Roth16, Dirk Foell1, Dirk Holzinger17
1Department of Pediatric Rheumatology and Immunology, University Hospital Children’s
Muenster, Muenster; 2St. Marien Children's Hospital, Landshut; 3Asklepios Clinic Sankt
Augustin, Sankt Augustin; 4University Children's Hospital Tuebingen,, Tuebingen; 5St.
Josef-Stift Sendenhorst Hospital, Sendenhorst; 6Prof.-Hess Children's Hospital and
Gesundheit Nord Klinikverbund Bremen, Bremen; 7Charité University Medicine and Epidemiology
Unit, German Rheumatism Research Centre, Berlin; 8German Center for Pediatric and
Adolescent Rheumatology, Garmisch-Partenkirchen; 9Department of Rheumatology and Immunology,
Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich; 10Paediatric
Rheumatology, Immunology and Infectiology, Hospital St. Georg, Leipzig; 11Department
of Pediatrics and Adolescents Medicine, University Hospital Ulm, Ulm; 12Department
of Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital,
Medical Faculty, Heinrich-Heine-University, Duesseldorf; 13German Pediatric Pain Centre,
Children's and Adolescents’ Hospital, Datteln; 14Center for Laboratory Medicine, University
Hospital Muenster; 15Department of Paediatrics, University of Muenster; 16Institute
of Immunology, University Hospital Muenster, Muenster; 17Department of Pediatric Hematology-Oncology,
University Hospital Essen, Essen, Germany
Correspondence: Dirk Holzinger
Introduction: The differential diagnosis of fever of unknown origin (FUO) is a major
challenge especially for differentiation of systemic-onset juvenile idiopathic arthritis
(SJIA) and infectious diseases and can be supported by biomarker analysis.
Objectives: In a pilot study the analysis of MRP8/14 serum levels has been demonstrated
as an excellent tool for the diagnosis of SJIA, allowing early differentiation with
a specificity of 95%. Based on this, the analysis of MRP8/14 serum levels has been
offered to pediatric rheumatologists and we aimed to validate these findings in samples
from daily clinical practice and establish the analysis by a commercial enzyme-linked
immunosorbent sandwich assay (ELISA) and an on-site lateral flow immunoassay (LFIA).
Methods: In total, 3,002 patients with inflammation of unknown origin were enrolled
within 6 years. A full data set was available from 1,935 cases, including symptoms,
laboratory parameters (CRP, ESR, leucocytes) and final diagnosis. These cases were
divided into two cohorts: (A) For validation of the MRP8/14 test performance with
the enzyme-linked immunosorbent sandwich assay (ELISA) used previously as well as
a first testing of a commercial ELISA and an innovative point-of-care lateral flow
immunoassay (LFIA); and (B) for validating the findings with the latter assays.
Results: MRP8/14 serum levels of patients with SJIA (12,100 ± 2,670 ng/ml, mean±SEM)
were elevated compared to other diagnoses (including infections, vasculitis and other
autoinflammatory diseases; 3,020 ± 510 ng/ml) irrespective of fever and anti-inflammatory
treatment (p <0.001) in 942 samples. In the group of untreated patients with fever
(n=195) MRP8/14 levels in SJIA (19,930 ± 5,260 ng/ml) were even higher compared to
other diagnoses (4,730 ± 1,160 ng/ml). Sensitivity and specificity of MRP8/14 to differentiate
SJIA vs. other diseases were 72% and 89% respectively (cut-off 9,160 ng/ml). The MRP8/14
levels correlated closely in the commercial ELISA (sensitivity 74%, specificity 87%) and
LFIA (sensitivity 77%, specificity 88%). The performance of the commercial ELISA and
the LFIA could be confirmed in an independent cohort (n=162). Overall performance
was stable in both cohorts: commercial ELISA (sensitivity 79%, specificity 88%) and
LFIA (sensitivity 83%, specificity 87%).
Conclusion: MRP8/14 serum analyses could be validated as a helpful tool for the diagnosis
of SJIA in FUO in daily clinical practice. The results of the experimental assay could
be confirmed with a commercial ELISA and LFIA making these tests available for routine
use. The LFIA enables a quick diagnostic screening test at the point of care.
Disclosure of Interest
None Declared
P1110 Do juvenile idiopathic arthritis patients with systemic onset in the risk of
low anti-vaccine antibody: the preliminary report?
Natalya Lubimova1, Olga Goleva2, Irina Fridman2, Margarita Dubko3, Vera Masalova3,
Ludmila Snegireva3, Eugenia Isupova3, Ekaterina Gaidar3, Andrey Santimov3, Olga Kalashnikova3,
Susanna Kharit2,3, Mikhail Kostik3
1Children’s City Hospital#2 n.a. St. Mary Magdalene; 2Pediatric Research and Clinical
Center for Infection Diseases; 3Saint-Petersburg State Pediatric Medical University,
Saint-Petersburg, Russian Federation
Correspondence: Mikhail Kostik
Introduction: Patients with juvenile idiopathic arthritis with systemic onset (soJIA)
may have lower protective levels of anti-vaccine antibodies due to high inflammatory
activity, frequent using of the systemic corticosteroids and biologics.
Objectives: The aim of our study was to evaluate the protective levels of anti-vaccine
antibodies in patients with soJIA compare to non-systemic ones.
Methods: In the present study were included data 7 soJIA and 82 non-systemic JIA patients
who received scheduled vaccination before the age of 2 years and before JIA onset
against measles, parotitis, hepatitis B, diphtheria and rubella. In all patients,
the IgG anti-vaccine antibodies levels were detected with ELISA. In each patient,
we evaluate the type of the disease, onset age, duration of JIA, treatment with corticosteroids,
methotrexate, and biologics.
Results: We have not found differences in the anti-vaccine antibody levels in soJIA
compare to non-systemic, but median levels of the ant-hepatitis B and anti-diphthreia
antibody were 12 and 3 times lower, consequently (table 1). The protective levels
of anti-measels antibodies was in 4 (57%) vs 47 (57%). p=0.65; anti-parotitis antibody
5(71%) vs 63 (77%), p=0.37; ant-diphtheria 2 (29%) vs 42 (51%), p=0.23; ant-hepatitis
B 2 (29%) vs 46 (56%), p=0.23; anti-rubella antibody 7 (100%) vs 80 (99%), p=0.77
in soJIA compare to non-systemic JIA, relatively. The number and levels of soJIA patients
with protective anti-hepatitis B and anti-diphtheria antibody were lower compares
to non-systemic JIA patients (data insignificant). There was no correlation with antibody
concentration and corticosteroids applying, despite soJIA more frequently received
them. We have found negative correlation between levels of ant-measels antibodies
and JIA duration (r = -0.36, p=0.001), JIA duration (r=-0.26, p=0.02) and treatment
with biologics (r=-0.25, p=0.024). Also was detected negative correlation between
anti-parotitits antibody (r=-0.25, p=0.021) and anti-diphtheria antibody levels (r=-0.25,
p=0.021) with JIA duration and and anti-diphtheria antibody levels (r=-0.29, p=0.009)
with methotrexate using.
Conclusion: patients with systemic JIA may have the risk of lower anti-vaccine antibodies,
which required more close monitoring of levels of these antibodies. Further investigations
needed.
Disclosure of Interest
None Declared
Table 1 (abstract P1110).
The levels of anti-vaccine antibody in soJIA and non-systemic JIA patients
Parameter
soJIA (n=7)
Non-systemic JIA (n=82)
P
JIA duration, years
3.0 (1.6; 5.1)
4.9 (2.9; 8.3)
0.019
Systemic corticosteroids, n (%)
7 (100
20 (24)
0.000007
Metotrexate, n (%)
7 (100.0)
75 (91)
0.41
Biologics, n (%)
7 (100.0)
47 (57)
0.019
Anti-measels IgG, Me/ml
0.18 (0.0; 1.64)
0.17 (0.0; 0.45)
0.649
Anti-parotitis IgG, Me/ml
1.3 (0.0; 5.1)
2.7 (1.0; 5.0)
0.373
Anti-diphtheria IgG, Me/ml
0.04 (0.0; 0.2)
0.13 (0.03; 0.3)
0.231
Anti-hepatitis B IgG level, Me/ml
0.9 (0.0; 10.2)
11.6 (0.0; 41.9)
0.231
Anti-rubella IgG, Me/ml
200.0 (18.4; 200.0)
57.7 (33.4; 98.0)
0.618
P1111 Have patients with juvenile idiopathic arthritis patients with systemic onset
particular features for monocyclic course?
Mikhail Kostik, Maria Rumyantseva, Eugenia Isupova, Irina Chikova, Margarita Dubko,
Vera Masalova, Ludmila Snegireva, Tatyana Kornishina, Tatyana Likhacheva, Ekaterina
Gaidar, Andrey Santimov, Olga Kalashnikova
Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
Correspondence: Mikhail Kostik
Introduction: Juvenile idiopathic arthritis with systemic onset (soJIA) may have a
monocyclic, polycyclic or relapsed course. There were not known soJIA course predictors.
Objectives: Our study aimed to evaluate initial clinical or laboratory features of
the patients with soJIA who had a monocyclic course without biologics.
Methods: In the present study were included data about 130 soJIA patients. After selection,
we identified a subgroup of the soJIA patients (n=22) who successfully achieved remission
off-biologic medication and were stable in the remission off-medication at least two
years. The second group consisted of the patients who required biologics (n=83). The
remained 25 patients excluded due to missing data or who did not meet the selection
criteria. We evaluated routine clinical (fever, rash, hepatosplenomegaly, serositis,
lymphadenopathy, MAS, joint involvement) and laboratory (WBC, PLT, Hb, ferritin, ALS,
AST, LDH, GGTP, ALP, albumin, sodium, triglycerides, ESR, CRP, prothrombin, fibrinogen)
soJIA features in the onset of the disease.
Results: Patient with monocycling course have no any differences except the ferritin
level: 275 (133; 698) ng/ml vs 950 (150; 3240) ng/ml, (p=0.04), time to achievement
remission 17.7 (8.2; 38.0) months vs 60.2 (36.0; 99.0) months (p=0.00002) and rare
elbow involvement 4.6% vs 30.9% (p=0.01). The parameters, associated with possible
monocycling course are in the table.
Conclusion: Patients with soJIA initially have quite similar clinical presentations
independently the further clinical course. The prediction of a possible course of
soJIA is a difficult problem. Patients with soJIA with the monocyclic course were
younger and had less intense laboratory activity. Further investigations required.
Disclosure of Interest
None Declared
Table 1 (abstract P1111).
The parameters, associated with the possible monocyclic course in soJIA patients
Parameter
AUC (95%CI)
Se
Sp
OR (95% CI)
p
CRP≤3.1 mg/dl
0.59 (0.48; 0.69)
0.53
077
3.6 (1.3; 10.3)
0.014
ESR≤ 53 mm/h
0.62 (0.51; 0.71)
0.9
0.43
6.8 (1.5; 31.3)
0.006
Ferritin ≤1340 ng/ml
0.69 (0.58; 0.79)
1.0
0.46
-
0.003
Active joints < 8
0.5 (0.4; 0.6)
0.82
0.39
4.6 (1.3; 16.8)
0.013
Onset age <7 years
0.57 (0.47; 0.66)
0.86
0.4
4.2 (1.5; 15.3)
0.022
No elbow involvement, n (%)
-
0.96
0.31
9.4 (1.2; 73.6)
0.012
P1112 Single center experience of biological therapy in patients with systemic juvenile
idiopathic arthritis associated with macrophage activation syndrome
Maria I. Kaleda, Irina P. Nikishina
Pediatrics, V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
Correspondence: Irina P. Nikishina
Introduction: Macrophage activation syndrome (MAS) is a severe complication of systemic
juvenile idiopathic arthritis (sJIA) which associated with high risks of the multiple
organ failure and mortality. The investigation of safety of Biologics (B) in patients(pts)
with risk of MAS is important in real clinical practice to improve the prognosis.
Objectives: to analyze the results of all cases of therapy with B in pts with sJIA and
history of MAS.
Methods: the study included all pts of single center with sJIA (in accordance to ILAR
classification criteria) who developed the MAS diagnosed according to Classification
Criteria for MAS 2016 before or under the treatment with B.
Results: We observed 102 consecutive pts with sJIA, 29 pts (28%) fulfilled the criteria of
MAS (Tab.1).
A total of 37 episodes of MAS was recorded. The total number of B course in this pts was
51 (tocilizumab – 28, canakinumab – 9, anakinra – 2, rituximab – 5, infliximab – 4, etanercept –
2, abatacept – 1). 24 pts (82.7%) had episodes of MAS before starting of B (16 – at
onset of sJIA). 13 episodes of MAS was observed during the B therapy (1 on anakinra,
1 - canakinumab, 11 – tocilizumab), in 5 pts among them - for the first time. 8 episodes
developed due to deviation of the treatment’s schedule, 2 – associated with flare
of sJIA, 2 – associated with acute respiratory infection, 1 – after surgical treatment
for chronic osteomyelitis of the clavicle. First features of MAS were bright rash
with itching, lower platelet counts, high triglycerides. Pts who developed MAS while were treated
with B had rare episodes of fever, a tendency for serum ferritin and CRP decreasing
opposite to pts who developed MAS before B, but had no other differences in clinical
or laboratory features. Glucocorticoids (per os+iv), intravenous immunoglobulin and cyclosporin were
used to treat MAS. Lethal outcome was in 6.7% of sJIA cases with MAS (1.9% of all sJIA pts). 25 pts
continue treatment with B (tocilizumab – 19, canakinumab – 6) after the resolution
of the acute manifestation of MAS with high efficacy (more than 70-90% response by ACRpedi). Two
pts discontinued treatment for organizational reasons.
Conclusion: Pts with a history of MAS require an earlier prescription of B due to
the greater disease activity. It is necessary to consider the probability of a lower
frequency of fever and lower level of ferritin and CRP in case of MAS during B therapy. We
didn’t observe association between treatment of B and increased risk of MAS, but risk
of MAS increase in case of disorder of protocol of the treatment.
Disclosure of Interest
None Declared
Table 1 (abstract P1112).
Сlinical and demographic characteristics of patients
Characteristics
All patients with sJIA (102)
Patients with sJIA and MAS (29)
Girls /boys (girls to boys ratio)
59/43 (4:3)
18/11 (5:3)
The median age at onset, months
45.5 [26.0; 69.5]
31.0 [18.0; 69.0]
The median disease duration prior to treatment with BA, months
26.5 [9.2; 62.3]
11 [3.0; 30.1]
Number of systemic manifestations
3.9 [2.7; 4.5]
4.8 [3;6]
Pts with rash, %
56
100
Number of active joints
12 [5; 25]
8 [3; 18]
Unusual or unsolved case reports
P1113 Behect disease in pediatrics; a solitary sign can be enough
Hanan M. Abd El-Lateef
Pediatric Rheumatology Immunology department, Ain Shams University, Cairo, Egypt
Introduction: Involvement of the perineal region including vulvovaginitisin prepubertal
girls is a common but quite challenging condition because it encompass a wide variety
of conditions with subtle differences especially in the absence of systemic manifestations
Objectives: Considering autoinflammatory disorders as an important differential diagnosis
in cases of perineal ulcers in prepubertal females.
Methods: An 8 years old prepubertal female patient who presented with recurrent painful
non itchy perineal ulcerations that interfered with her normal daily activitiesand
copious non foul vaginal discharge of five months duration with failure of local topical
therapies and systemic antibiotics. No other symptoms were reported.
Results: On physical examination,patient was average built for age andvitally stable.
Examination of the perineal region revealed evidence of subcentimetric scars , an
irregular deep ulcer 16 cm at its widest extension with necrotic base and clean margin
involving perianal region and extending to labia majorus. Systemic examination revealed
no evidence of arthritis, neurological manifestations, muscloskeletal involvement
, other dermatologic or mucosal lesions and no organomegaly . Ophthalmological examination
was free. Gynecological consultations excluded sexual abuse. Routine Laboratory evaluation
showed a within normal CBC picture , ESR 50 mm/1st hr and CRP 48mg/dl. Immunological
profile showed a within normal levels serum immunoglobulins assay , CD markers and
negative immune markers (ANA , Anti-DNA , ANCA) . Swabs from both the ulcer base and
the vaginal discharge cultures were sterile. The diagnosis of Behçet disease versus
Genital Crohn's was raised .Double contrast CT pelviabdomen with barium meal follow
through showed skipping lesions of edematous bowel wall highly suspicious of Crohn's
disease. Anegative ASCA test and a positive HLA-B51 tip the scales and favour the
diagnosis of Behçet disease. The investigations showed no involvement of cardiovascular,
renal, pulmonary, urologic, joint or central nervous systems. Patient showed marked
clinical improvement on Pulse methylprednisolone steroid therapy (1gm/day) for 5 days
followed by full dose oral prednisone (60mg/day) but with a progressive severe relapse
of the ulcerations on the early withdrawal of the oral therapy (50 mg/day) . Azathioprine
was added to the full dose oral steroid therapy for three months but lesions were
still full dose steroid- dependant .The last attack was associated with a large pyoderma
gangrenosum-like lesion on the anterior tibialsurface of the left leg that responded
markedly on pulse steroid therapy.
Infliximab (Anti-TNFα ) was added (6mg/kg/dose) at 0, 2 and 6 weeks with cautious
gradual withdrawal of oral steroids . Patient showed marked clinical and laboratory
improvement and was maintained on 15mg oral prednisone per day with a stable remitting
course. Further close follow up is done.
Conclusion: Behçet disease (BD) is a relapsing inflammatory disorder with multi-system
involvement , heterogeneous clinical presentations and variable degrees of vascuilitis.BD
shares a considerable overlap with other autoinflammatory disorders including Crohn's
disease making diagnosis occasionally challenging . Perineal ulcers is a rare presentation
in the pediatric age group and being an isolated clinical presentation confirms that
in pediatrics the number of symptoms may be too few to apply any classification of
diagnosis to a single patient. The severity of the ulcers , the relapsing nature ,
failure of azathioprine as asteroid sparing therapy lead to applying TNF-α inhibitors
which proved a great efficacy to maintainremission.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1114 Childhood pyoderma gangrenosum: diagnostic challenges and managements of two
cases from Libya
Awatif Abushhaiwia1, Nairuz Abushhiwa2, Mohammed Kamel3, Lailasabei4, Mabruka Zletni5,
Hafsa Dawi6
1Pediatric Rheumatology, Tripoli Children’s Hospital; 2Pathology, Tripoli Faculty
of Medicine, Tripoli, Libya; 3Adult Rheumatology, Dr Fakhry Hospital, Alkhobar, Saudi
Arabia; 4Community Medicine, Tripoli Faculty of Medicine; 5Pediatric Rheumatology,
Tripoli Children’s Hospital; 6Dermatology, Central Tripoli Hospital, Tripoli, Libya
Correspondence: Awatif Abushhaiwia
Introduction: Pyoderma gangrenousm (PG) is an idiopathic Ulcerative, non-infective
chronic inflammatory skin disorder of unknown etiology.The most common reported underlying
diseases in pediatrics are inflammatory bowel disease, followed by hematologic disorders,
vasculitis, immune deficiencies and pyogenic arthritis, pyoderma gangrenosum and acne
(PAPA) syndrome. More than half of the cases occur with no underlying disease. The
most frequently treatment should be tailored according to the underlying etiology.
It includes systemic steroids, corticosteroid sparing agents such as dapsone, cyclosporine,
azathioprine and currently TNF –alpha inhibitors such as etenrecpt, adalimumab and
infliximab is a promising treatment of refractory PG. Response to treatment is high
with cure rates reaching 90%. A high index suspicion and a through workup are mandatory
in the management of pediatrics PG.
Objectives: To describe the clinical presentation, laboratory testes and challenges
with treatment trials in two pediatric cases.
Methods: clinical information was gathered from the history, which was taken from
their parents after an informed consent
Results: for the first time we report two pediatric cases in Libya who diagnosed with
refractory pyoderma gangrenousm with no associated systemic diseases except PAPA which
can’t be excluded since no genetic tests available in all public hospitals in Libya,
we report PG in two Libyan children of 2 year-old and 5 year-old, they presented with
skin lesions beginning as a small pustule that progressed to very painful large ulcer
with irregular borders. There were healed ulcers with scaring present on chest, both
upper and lower extremities and abdominal wall.Laboratory testes for both cases showed
an increase in white blood cell counts mainly neutrophils, anemia, increased platelets
count, elevated erythrosedmintation rate, and elevated C-reactive protein.No hematological
abnormalities were seen in peripheral blood smears except neutrophilic response, the
red cell indices were suggestive of iron deficiency anemia.Cultures for bacteria and
fungi from skin lesions, and blood cultures were repeatedly negative. Immunoglobulin
assay (IgG, IgM, IgA, IgE) was normal. The antinuclear antibody, cytoplasmic antibody,
and antiphospholipid antibodies, tests for hepatitis B, C and HIV were all negative.
They didn’t have symptoms suggest ulcerative colitis, their colonoscopy was normal.
Histopathology from their skin was consistent with pyoderma gangrenousm.
Both cases were moderate response to high dose of oral prednisolone 2mg\kg per day
complicated, however by growth retardation and cushingnoid habitus and minimal response
to corticosteroid sparing agent azathioprine. Anti TNF-alpha inhibitors etenrecpt,
which has been available at hospital since March 2018, we used it in case 2 because
he was inadequate response to azathioprine.
Both cases showed briefly remitted on azathioprine with relapsed at least 2-3 episodes
per year. The ulcer lesions healed with cribriform scaring within 6-8 weeks in each
episode.
Conclusion: Pyoderma gangrenousm has recently been included within the spectrum of
auto- inflammatory diseases, which are characterized by recurrent episodes of sterile
inflammation, without circulating autoantibodies and autoreactive, which can be diagnosed
by genetic tests, which is unfortunately not available in public hospitals in Libya.We
couldn’t either be able to start other biological treatment because of the civil war
crisis in Libya.
Disclosure of Interest
None Declared
P1115 A girl with a developmental delay and Lupus-like phenotype associated with both
neuroblastoma and an MDA5 gain-of-function mutation (Aicardi-Goutières Syndrome 7,
AGS7)
Stefan Berg1, Dara McCreary2, Gunilla Drake af Hagelsrum3, Nina Björkander3, Despina
Eleftheriou2
1Pediatric Immunology and Rheumatology, The Queen Silvia Children's Hospital, Gothenburg,
Sweden; 2UCL GOS Institute of Child Health, London, United Kingdom; 3Pediatric Neurology,
The Queen Silvia Children's Hospital, Gothenburg, Sweden
Correspondence: Stefan Berg
Introduction: Monogenic autoinflammatory diseases (AID) with central nervous system
(CNS) involvement are often difficult to diagnose and patients may be subjected to
expensive and often invasive diagnostic patient pathways. Securing a molecular diagnosis
is of major importance in these cases for treatment, prognosis, and genetic counselling.
We describe a 7-year-old girl of non-consanguineous Swedish/Lebanese descent with
severe developmental delay. Her psychomotor development was normal until 10 months
of age. At the age of 10 months she presented with myoclonus and increased muscletone
of both legs. She developed a progressive encephalopathy, behavioural change and sleep
disturbance during the following months. Cerebral MRI showed white matter disease with
high signal on T2 weighted imaging and atrophy. CSF showed normal proteins but minor
lymphocytosis, and slight increase in neurological damage markers NFL and Tau (normal
GFA-p). Extensive work-up did not reveal a clear diagnosis. Cerebral CT was not performed.
At the age of 20 months a neuroblastoma was detected, leading to a diagnosis of atypical
opsoclonus-myoclonus syndrome (OMS) despite the absence of opsoclonus, for which she
was treated with cyclophosphamide, steroid pulses, IVIG and rituximab. By this time
she demonstrated severe psychomotor delay with no speech and a dyskinetic syndrome.
At the age of 6 years she developed skin rash and vasculitis-like lesions on her toes,
which developed to also involved the face and upper limbs. Her ESR was increased (47
mm/h), but CRP was normal (<1 mg/L). Titres of several autoantibodies were raised
(ANA, anti-dsDNA and anti-ribo-p). Lumbar puncture showed slightly increased lymphocytes
(7, ref <4 x 106/L), and slightly elevated levels of Tau protein (normal NFL and GFA-p),
with no increase of protein and no oligoclonal bands in the face of slight increase
of IgM-index. Skin biopsy demonstrated findings compatible with SLE. Treatment with
MMF and monthly i.v. corticosteroid pulses were required to control her features,
resulting in a marked improvement of skin rash and normalization of inflammatory markers.
Objectives: To use next generation sequencing to establish a genetic diagnosis in
this case.
Methods: An NGS panel targeting 256 genes was used developed and validated as described
elsewhere.
Results: A pathogenic variant (p.R779H, c.G2336A) was found in the IFIH1gene encoding
MDA5 consistent with a diagnosis of an interferonopathy syndrome, Aicardi-Goutières
syndrome 7 (AGS7). IFN score is pending and we are planning to start JAK inhibition
Conclusion: We present a child with severe developmental delay having both a classic
neuroblastoma and AGS7. She presented with neurodevelopmental delay at the age of
10 months and was found to have a neuroblastoma at the age of 20 months. She was considered
to have an atypical OMS even though she didn’t demonstrate opsoclonus. Her developmental
delay was more severe than usually seen in OMS. The findings of lupus-like features
years later made us consider another cause for her neurological delay. The genetic
finding of a pathogenic variant in IFIH1is fully compatible with a type I interferonopathy
(AGS7). The fact that she also had a neuroblastoma may also have contributed to her
neurological features, although this is not clear. To our knowledge, there is no connection
between AGS and neuroblastoma described so far.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1116 Cold urticaria associated with a novel Phospholipase-Gamma-C2 (PLCƔ2) mutation
Hanna Bonnekoh1,2, Niklas AMahnke1,2, Jörg Scheffel1,2, Marcus Maurer1,2, Karoline
Krause1,2
1Department of Dermatology and Allergy; 2Autoinflammation Reference Center Charité
(ARC2), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität
Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
Correspondence: Hanna Bonnekoh
Introduction: Phospholipase-Gamma-C2 (PLCƔ2) is a member of the phospholipase C family
and plays a key role in the transmembranous signaling of B-lymphocytes, natural killer
cells and mast cells. Mutations in PLCG2 were associated with rare dominantly inherited
diseases characterized by a variable clinical phenotype including cold urticaria,
neutrophilic dermatitis, immunodeficiency and autoimmune features or autoinflammation
(PLAID/APLAID). The known mutations comprise in frame loss mutations of exon 19 and
exon 20-22 and a missense mutation (p.Ser707Tyr) within the PLCG2 gene.
Methods: We studied four members of a three-generation family, three of whom were
affected by cold-induced urticarial rash. Genetic analysis of the index patient comprised
screening for autoinflammatory periodic fever syndrome genes by Sanger sequencing
(NLRP3, NLRP12 and PLCG2) and was followed by segregation analysis of further family
members. We assessed clinical history and laboratory results including routine laboratory
markers, immune status, autoantibodies, immunoglobulins, inflammatory markers (C-reactive
protein, S100A8/9) and performed cold contact provocation testing.
Results: All three affected family members presented with early onset cold-induced
urticarial rash since birth associated with an autosomal-dominant inheritance. The
patients reported occurrence of pruritic wheals to cold contact and cold evaporation
as well as systemic reactions in response to extensive cold. Direct cold contact provocation
testing was negative. Treatment with antihistamines could partially reduce the cold-associated
skin-symptoms. Laboratory analysis revealed elevated serum S100A8/9 as well as elevated
serum IgE levels and reduced IgM levels. Genetic analysis of the index patient showed
a heterozygous variant c.2054+5G>T (located in the intronic splice region 18) in PLCG2
which was confirmed in the two other affected family members.
Conclusion: We identified a novel mutation variant in PLCG2 associated with a phenotype
of cold-induced urticarial rash and immune dysregulation. As the substitution is located
in the intronic splice region 18, it may cause aberrant splicing and result in truncated
mRNA or mRNA decay. Further studies including the identification of the amino acid
sequence as well as functional analysis of the PLCƔ2 protein are necessary to clarify
the impact of this novel variant.
Disclosure of Interest
None Declared
P1117 Missense variants in SERPINF1 are associated with a novel auto-inflammatory
disease presenting with persistent fever and multifocal neutrophilic periostitis
Marta Bustaffa1, Marta Rusmini2, Marco Cattalini3, Sara Signa1, Riccardo Papa1, Alice
Grossi2, Roberta Caorsi1, Stefano Volpi1, Paolo Picco4, Alessandro Plebani3, Angelo
Ravelli4, Nicoletta Zoppi5, Marco Ritelli5, Marina Colombi5, Maja Di Rocco4, Isabella
Ceccherini2, Marco Gattorno1
1International Center for Autoinflammatory Disease and Primary Immunodeficiencies
- Clinics of Pediatrics and Rhumatology; 2UOC of Genetics, G. Gaslini Institute, Genova;
3Clinica Pediatrica, Univerity of Brescia, Brescia; 4Clinics of Pediatrics and Rhumatology,
G. Gaslini Institute, Genova; 5Division of Biology and Genetics, Department of Molecular
and Translational Medicine, Univerity of Brescia, Brescia, Italy
Correspondence: Marta Bustaffa
Introduction: Caffey disease is a rare condition of early infancy characterized by
hyperostotic periostitis, acute inflammation and swelling of soft tissues. It is self-limiting
and usually caused by the c.3040C>T p.Arg836Cys mutation in COL1A1. Besides Caffey
disease, COL1A1 mutations are reported in Osteogenesis Imperfecta (OI), with a well-known
pathogenic mechanism. On the contrary, a link between the molecular defects of Caffey
disease and its inflammatory, self-limiting phenotype is not properly understood.
Another gene associated with OI is SERPINF1, whereas no inflammatory phenotypes are
described related to SERPINF1 mutations.
Objectives: To describe a case with many common characteristics with Caffey disease,
but with a more severe course, steroid-dependency and no spontaneous regression.
Methods: The proband is a previously healthy 11-month-old girl born from non-consanguineous
parents in a community with high risk of endogamy. She presented with persistent fever,
elevation of inflammatory markers along with severe pain, functional limitation and
progressive swelling of all four limbs. X-ray and MRI documented an aggressive periostitis
involving several long bones. Pain was not controlled despite combined antalgic therapies,
requiring i.v. morphine administration. Bone biopsy revealed a neutrophilic inflammatory
process consistent with acute suppurative osteomyelitis, although broad-spectrum antibiotics
were ineffective and an infectious origin was excluded. 41 NGS panel and genetic analysis
of COL1A1 excluded DIRA, MKD, Majeed and Caffey disease. With suspicion of a possible
auto-inflammatory condition, Anakinra was started and allowed slight clinical improvement
but elevation of acute phase reactants and bone swelling persisted.
Results: Considering the ineffectiveness of different treatments, high dose steroid
therapy was introduced with dramatic improvement, maintained even when oral prednisone
was started with slow tapering. Anakinra was confirmed as a possible steroid-sparing
agent. Serial X-ray displayed persistent improvement until the age of 2 years, when
radiology assessment revealed a subclinical disease progression and recurrence of
swelling of the left wrist occurred when steroid discontinuation was tried. In the
attempt to stop the subclinical disease progression, steroid therapy was maintained
to the minimal effective dose. Anakinra treatment was tapered and finally discontinued
without any flare. WES revealed compound heterozygosity for 2 missense variants in
SERPINF1 (A131D and P132R), inherited from parents. Immunofluorescence analyses of
patient’s dermal fibroblasts revealed disorganized collagen type I, III and V in the
extracellular matrix, endorsing a possible pathogenic role of both SERPINF1 variants.
Biphosphonate treatment was considered because of osteopenic risk due to prolonged
steroid treatment and its potential use in OI. 4 doses of neridronate were administered
within 9 months and subsequent X-rays displayed improvement of osteopenia and stability
of the dysmorphic feature of left wrist.
Conclusion: We describe a patient with a clinical picture characterized by fever and
multifocal neutrophilic hyperostosis without spontaneous regression, presenting dramatic
response to high dose corticosteroid and subsequently to bisphosphonate. We suggest
that this is a new variant of Caffey disease caused by SERPINF1 missense variants.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1118 Late-onset SAPHO syndrome revealing chronic myelomonocytic leukemia
Laura Damian1, Simona Grad2, Felicia Mustatea1, Bianca Balan1, Gheorghe Cobzac3, Calin
Bolosiu4, Liliana Bene5, Adrian Trifa6, Delia Dima7, Adriana Albu8
1Rheumatology, Emergency Clinical County Hospital Cluj; 2Gastroenterology, “Iuliu
Hatieganu” University of Medicine Cluj; 3Nuclear Medicine; 4Radiology; 5Immunology,
Emergency Clinical County Hospital Cluj; 6Genetics, “Iuliu Hatieganu” University of
Medicine Cluj; 7Hematology, “I. Chiricuta” Oncologic Institute; 82nd Internal Medicine
, “Iuliu Hatieganu” University of Medicine Cluj, Cluj-Napoca, Romania
Correspondence: Laura Damian
Introduction: Chronic multifocal osteitis (CMO) and its adult variant, SAPHO syndrome
(an acronym of synovitis, acne, hyperostosis, pustulosis, osteitis) are rare polygenic
bone autoinflammatory disorders. However, their radiological features are not pathognomonic,
as periostitis, bone sclerosis and cysts may be found in other systemic bone diseases,
including myeloid neoplasia. Acquired gain-of- function JAK2 (617F) mutations, frequently
found in myeloproliferative neoplasms, are sometimes associated to bone marrow fibrosis.
JAK2 inhibitors may improve marrow fibrosis in myelofibrosis. JAK inhibition was also
successfully employed in a case of refractory SAPHO syndrome.
Objectives: To present the difficult case of a patient with the clinical picture of
a late-onset, incomplete SAPHO syndrome in whom aJAK2-positive myeloproliferative
syndrome was found.
Methods: A 57-year male patient, with no personal or familial history of acne, psoriasis
or spondylarthritis, presented with cervical and anterior chest wall intense bone
pain, tibio-tarsal arthritis and left plantar fasciitis.
Results: The laboratory revealed inflammation (ESR 88 mm/h, CRP 18 mg/dl, leukocytosis
– WBC 10500 with 70% polymorphonuclear neutrophilsand 11% monocytes), with normal
alkaline phosphatase, plasma protein electrophoresis,PSA, CA 19-9 and CEA neoplastic
markers.HLA-B27 was negative, as well as the tests for Chlamydia, Mycoplasma, Ureaplasma,
Borrelia and hepatitis B, C and HIV serology. Ferritin was 501 ug/l. The radiographs
showed left tibial periostitis, asymmetric periarticular bone demineralization, bone
cysts, asymmetric sacroiliitis and a dorsal crush fracture. Bone scintigraphy revealed
cervical, dorsal sternoclavicular and tibio-tarsal enhancement, with a” bullhead”
appearance considered pathognomonic for SAPHO syndrome. Abdominal ultrasound, chest
radiograph and CT were unremarkable. He received NSAIDs, sulfasalazine and methotrexate,
supplemented afterwards with corticosteroids, cyclosporine and alendronate, with clinical
improvement, but persistence of ESR elevation and monocytosis (up to 26%). The bone
marrow biopsy showed all series, hypolobulated megakaryocytes and areas of myelofibrosis.
The JAK2 (V617F) mutation was positive (allele burden 1%).BCR-ABL was negative. Cytogenetic
analysis of the bone marrow revealed a normal karyotype. No free immunoglobulin chains
were found. The final diagnosis was chronic myelomonocytic leukemia.
Conclusion: A late-onset and incomplete SAPHO clinical picture, in the presence of
persistently abnormal blood counts, may prompt a search for hematologic malignancies.
Common putative mechanisms of osteitis and bone fibrosis may be involved, making plausible
a role of JAK inhibition for osteitis therapy.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
L. Damian Grant / Research Support from: Dr. Damian has a travel grant from Pfizer.,
S. Grad: None Declared, F. Mustatea: None Declared, B. Balan: None Declared, G. Cobzac:
None Declared, C. Bolosiu: None Declared, L. Bene: None Declared, A. Trifa: None Declared,
D. Dima: None Declared, A. Albu: None Declared
P1119 Bloody stools and cryopyrin-associated periodic syndrome (CAPS)-- association
or coincidence?
Mariana Correia Marques1, Jonathan S. Hausmann1,2, Edwin Anderson1, Fatma Dedeoglu1
1Boston Children's Hospital, 2Beth Israel Deaconess Medical Center, Boston, United
States
Correspondence: Fatma Dedeoglu
Introduction: NLRP3 plays a role in intestinal homeostasis and has been implicated
in the development of inflammatory bowel disease (IBD). Mutations in NLRP3 also cause
the autoinflammatory disease cryopyrin-associated periodic syndrome (CAPS). Despite
the involvement of NLRP3 in both IBD and CAPS, there are no reports of patients with
CAPS who develop colitis and other manifestations of IBD.
Objectives: We report on 3 patients who initially presented with bloody stools and
were later diagnosed with CAPS.
Results: Patient 1 had a history of recurrent painful hives since she was young, triggered
by weather changes, stress, illness, or sun, but not cold. At 10 years of age, she
developed recurrent uveitis, which was treated with topical steroids. She also had
recurrent arthralgias. In her early 20’s she was diagnosed with Crohn’s disease when
she developed abdominal pain and ileitis confirmed by colonoscopy. She was treated
with mesalamine as needed during ileitis flares. At around the same time, she developed
episodes of painful swelling of hands and feet, in addition to daily episodes of fever,
fatigue, hives, nausea, and chills, lasting several hours. She had elevated inflammatory
markers. She took hydroxychloroquine with no effect. In her 30’s she was diagnosed
with CAPS with mutation A441V on the NLRP3 gene. She was started on canakinumab with
resolution of most of her symptoms except for her arthritis and conjunctivitis, for
which she remained on methotrexate.
Patient 2 is the son of patient 1. He had occasional fevers before 1 year of age,
but at 1 year of age, he started having episodic hives and fevers, often triggered
by weather changes but not cold. He had recurrent episodes of bloody stools and diarrhea,
which did not improve after dietary restrictions. At around age 2, he started having
episodes of ankle arthritis in addition to conjunctivitis without other signs of ocular
inflammation.He had normal growth and development. He did not have a colonoscopy.
After his mother was diagnosed with CAPS, he was tested and found to be positive for
the same NLRP3 mutation. Anakinra was started on an as-needed basis to be used during
episodes with good response.
Patient 3 developed feeding intolerance at around 6 months of age, which improved
during his toddler years but recurred at 4 years of age, with the development of diarrhea,
vomiting, abdominal pain, bloody stools, elevated inflammatory markers, and weight
loss requiring NG tube feeding. He was seen by gastroenterology, and his Prometheus
IBD panel was consistent with Crohn’s disease. He was empirically treated with steroids
and sulfasalazine. A colonoscopy performed post-treatment did not confirm a pathologic
diagnosis. He then developed recurrent episodes of fever and arthralgias lasting 1-2
days before self-resolving. He also suffered from recurrent headaches and there was
a question of developmental delays and/or ADHD. At 9 years of age, whole exome sequencing
showed the low-penetrance mutation R490K on the NLRP3 gene. His asymptomatic father
was also found to be positive for the same mutation. Patient 3 was then referred to
rheumatology. Further history revealed he had had urticarial rashes induced by heat
and cold about twice per year. His hearing testing was normal. He was treated with
anakinra, followed by canakinumab, with a good response except for rare breakthrough
fevers, and for persistence of the gastrointestinal symptoms, including occasional
bloody stools.
Conclusion: Patients with CAPS may present with overlapping IBD symptoms such as bloody
stools, and failure to thrive that may mask the usual CAPS features, causing delays
in diagnosis.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1120 The challenge of treating pulmonary vasculitis in Behçet’s disease: two pediatric
cases and literature review
Selcan Demir1, Erdal Sağ1, Ümmüşen Kaya Akca1, Tuncay Hazırolan2, Yelda Bilginer1,
Seza Ozen1
1Pediatric Rheumatology; 2Radiology, Hacettepe Medical Faculty, Ankara, Turkey
Correspondence: Selcan Demir
Introduction: Behçet’s Disease (BD) is a multisystemic autoinflammatory disease and
the most severe complication of BD is pulmonary artery involvement (PAI). Data regarding
treatment and outcomes of pediatric patients with PAI is very limited.
Objectives: Herein, we report two pediatric patients with BD presenting with PAI and
treated successfully with aggressive immunosuppressive treatment.
Results: Case 1
A 15-year-old boy was admitted to a hospital with abdominal pain and feverAn abdominal
Doppler ultrasonography (USG) showed stenosis of vena cava inferior (VCI) with a thrombus.
Transthoracic echocardiography (TTE) detected that the thrombus extended from VCI
to the right atrium. When he started to have hemoptysis, he was referred to our hospital.
TTE showed a mass in RV. The computed chest and abdominal tomography angiography (CTA)
showed bilateral aneurysmatic dilatation with thrombi in the pulmonary arteries and
thrombosis in vena hepatica. The pathergy test was negative and the HLA B5 was negative.
According to the ICBD, the patient had been diagnosed as BD due to genital ulcers
and vascular involvement. He was given pulse methylprednisolone 500 mg 3 days along
and followed by oral prednisolone 1 mg/ kg/day, intravenous cyclophosphamide at a
dose of 500 mg (15 mg/kg) every 3 weeks for a total of 6 cycles, and Interferon-α2a
(IFN-α2a) 3 times a week. Within one month, hemoptysis and fever disappeared, and
CRP and ESR values normalized.After a three-month treatment, TTE and CTA revealed
that thrombi shrank significantly. The dosage of prednisolone was tapered gradually
and stopped 2 years later. Immunosuppressive treatment was continued with adalimumab.
The patient has been followed in remission for nearly 6 years.
Case 2
A fifteen-year-old boy was referred to our hospital for the evaluation of fever for
over 4 months and a thrombus in his right ventricle. He had a medical history with
cough, fever, intermittent hemoptysis and weight loss (14 kg) for the past 3 months.
Physical examination revealed acne-like rashes over face and back, ulcers on the buccal
mucosa, a 3/6 systolic ejection murmur at the left upper parasternal area.A CTA confirmed
the thrombus in RV and showed bilateral multiple aneurysms along the pulmonary artery
and its branches. According to ICBD, the patient was diagnosed with BD due to having
aphthous ulcers, pseudofolliculitis, and vascular involvement. Iv methylprednisolone
(500 mg/day) for 3 days was followed by oral prednisolone 1 mg/ kg/day, which was
subsequently tapered. Iv cyclophosphamide at a dose of 500 mg was also given every
3 weeks for a total of 6 cycles, followed by oral azathioprine (AZA). Concomitant
subcutaneous IFN-α2a was given two times per week for 6 months. Within two weeks,
cough and fever disappeared, CRP and ESR values normalized. After 1 year the pulmonary
artery aneurysm disappeared and cardiac thrombosis resolved and returned nearly normal.
We have been following the patient with AZA for four years without recurrence.
Conclusion: We present two pediatric patients with pulmonary involvement of BD. PAI
is a life-threatening condition and should be managed with more aggressive medical
therapy.Early diagnosis and aggressive immunosuppressive treatment are very important
in PAI. We strengthened our treatment with IFN-α2a. There is no data in the literature
regarding the use of IFN-α-2a in PAI treatment along with low dose cyclophosphamide.
There were no mortality or recurrences within the 6 and 4 years follow up period.
An aggressive immunosuppressive therapy leads to better prognosis in this most dreadful
complication of BD.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1121 Late diagnosis of cryopyrin-associated periodic syndrome - without gene confirmation
- is there any other explanation?
Raquel Faria1, António Lamas2, Ana Campar1, Graziela Carvalheiras1
1Unidade de Imunologia Clínica – CHUPorto; 2Serviço de Medicina - CHUPorto, Porto,
Portugal
Correspondence: Raquel Faria
Introduction: Cryopyrin-associated periodic syndrome (CAPS) is a rare and heterogenous
inherited autoinflammatory disease entity: a spectrum of clinical phenotypes associated
with NLRP3 mutations. It is characterized by the presence of raised inflammatory markers
and typical manifestations: urticaria-like rash, cold-triggered episodes, sensorineural
hearing loss, arthralgia/myalgia, chronic aseptic meningitis and skeletal abnormalities.
Results: A 64-year-old woman presented psychomotor agitation and a recent diagnosis
of left subclavian artery thrombosis with digital ischemia. She had a long history
(since adolescence) of acute severe systemic inflammatory response syndrome, early-onset
sensorineural hearing loss, seronegative arthritis refractory to NSAIDs, steroids,
azathioprine and leflunomide, articular deformities of the wrists, knees and feet,
bilateral tibial enchondromas and frontal bossing; recurrent episodes of uveitis (anterior
and posterior), resulting in blindness; recurrent headaches associated with aseptic
meningitis and negative temporal artery biopsy; and chronic kidney disease, category
G4/A3 (KDIGO). There was no history of recurrent fever, cold-triggered episodes or
rash and no family history of autoimmune or autoinflammatory disease. Markedly elevated
serum amyloid A, ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein).
Negative autoimmune panel. Non-nephrotic proteinuria and small kidneys on ultrasound.
Cerebrospinal fluid analysis revealed elevated protein and glucose levels, without
associated pleocytosis. Imaging, micro and mycobacteriologic studies were negative
for infectious foci. Pre-mortem genetic analysis results were only available post-mortem,
with negative NLRP3 mutation findings by PCR and Sanger sequencing.
Conclusion: This case report highlights the challenging diagnosis of an adult patient
with severe manifestations and organ failure, that fulfils the clinical picture of
an autoinflammatory disease, with longstanding uncontrolled inflammation resulting
in irreversible organ damage (neurological, osteoarticular, ocular, among others)
and complications (prothrombotic state, e.g.). Despite negative NLRP3 mutations, alternative
inflammasome mutations (e.g. NLRP12) or mosaicism (not evaluated in the analysis)
could explain it. The pattern of manifestations is highly suggestive of CAPS, fulfilling
the diagnosis criteria proposed by Kuemmerle-Deschner et al. (2016), and represents
a phenotype of increased severity in the CAPS spectrum in an adult patient. Given
the patient’s age and clinical course, one may hypothesize an “attenuated” phenotype,
possibly associated with genetic mosaicism. The diagnostic challenge of autoinflammatory
diseases complicates early diagnosis and control of inflammation, which are critical
to prevent irreversible organ damage, thus becoming of vital importance the recognition
of autoimmune disease patterns and phenotypes.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1122 Late onset of tumor necrosis factor receptor associated periodic syndrome (TRAPS)
due to somatic mosaicism
Raquel Faria1, Luís Magalhães2, Daniel Oliveira1, António Marinho1, Ana Campar1
1Unidade de Imunologia Clínica – CHUPorto; 2Serviço de Medicina - Hospital da Arrábida,
Porto, Portugal
Correspondence: Raquel Faria
Introduction: Somatic mosaicism has been described as one of the major mechanism for
autoinflammatory syndromes with late onset in adults.
Results: Case description:
We describe a 57 yo previously healthy woman, that after menopause (previous 9 years)
developed recurrent 5-10 days episodes of high fever (39ºC), flutuant periorbital
edema, abdominal urticarial rash, arthralgia/arthritis, myalgia, abdominal pain (no
vomiting, rarely diarrhea), gengival pain, occasional cervical pain and “feeling flu-ish”.
The episodes became more severe and frequent, the flu-like symptoms persisted every
day. Fever responded to NSAIDs, not the rest, arthritic flares appear twice a month
and she was not compliant to steroids. Blood analysis documented ESR >80mm/1st hour
on attacks and 50mm/1st hour between attacks, C reactive protein 170mg/dL on attacks
and 70mg/dL between attacks; and serum amyloid A ~90mg/dL between flares. Extensive
infectious and autoimmune work lab panel was negative. The Eurofever Classification
Criteria scored 74 points to CAPS (cryopirinopathies) and 88 points for TRAPS (Tumor
Necrosis Factor Receptor Associated Periodic Syndrome). A PCR and Sanger sequencing
detected c.176G>A (p.Cys59Tyr) in TNFRSF1A, in 20% of the whole blood sample in EDTA
(compatible with somatic mosaicism) – validated pathogenic mutation. Colchicine 1mg/day
had no effect on clinical symptoms or inflammatory markers. All her symptoms remitted
and C reactive protein and serum amyloid A normalized wtih anakinra 100mg/day subcutaneous.
No other family member (living parents or sibling) had ever had any fever or inflammatory
symptoms.
Conclusion: The suspicion level for monogenic autoinflammatory diseases in adults
should be high as the clinical picture might be atypical and of slower progression.
Genetic testing should include mosaicism screening mainly in adults and a close collaboration
with attending clinical physicians is crucial for the final diagnosis.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1123 Hyperzincaemia and hypercalprotectinemia syndrome: more than just autoinflammation?
Andrea Uva1, Claudia Bracaglia1, Silvia Federici1, Camilla Celani1, Manuela Pardeo1,
Christoph Kessel2, Fabrizio De Benedetti1, Antonella Insalaco1
1Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, Rome, Italy; 2Department
of Pediatric Rheumatology & Immunology, University Children’s Hospital, Muenster,
Germany
Correspondence: Silvia Federici
Introduction: Hyperzincaemia and hypercalprotectinemia (HandH) syndrome has been described
as a new rare entity characterized by recurrent infections, dermatological involvement,
increased inflammatory markers, hepatosplenomegaly and anemia. Little is known about
its heterogeneous presentation, pathophysiology and treatment.
Objectives: To describe three cases with HandH syndrome
Methods: Serum calprotectin (MRP8/14) was measured according to Buehlmann assay (ELISA)
and plasmatic zinc by atomic absorption spectrometry
Results: Three patients were referred to our centre because an history characterized
by recurrent episodes of skin rash, severe oral aphtosis and increased level of serum
amyloid A (SAA). Patient 1 presented, since the age of ten years, with recurrent episodes
of fever and rash; skin biopsy showed a picture consistent with a lymphocytic lichenoid
vasculitis resembling erythema multiforme. Patient 2 presented at birth, with hemolitic
anemia and thrombocytopenia. At the age of 5 she was admitted to another hospital
due to EBV related hemophagocytic limphohystiocytosis (HLH). At the age of 8, she
was first seen at our center because of a persistent desquamant erythematous rash
with recurrent abdominal pain and recurrent arthritis. Intestinal biopsy showed small
intestine inflammation (erosions in the digiunum). Patient 3 presented with recurrent
episodes of fever, rash, two episodes of transient hip synovitis and muscoloskeletal
pain. A bone scintigraphy was performed resulting normal. Patients 1 and 2 suffered
from recurrent infections (pneumonia, otitis, skin abscesses). Immunological studies
revealed in patient 2 a reduction of memory B cells and a reduced response to Toll
like receptor 9 agonist. Of note, all the patients presented in their medical history
at least one episode of vasculitis: patients 1 and 3 suffered from Schonlein-Henoch
purpura at the age of 11 and 3 respectivelyand patient 2 had at the age of 2 years
an undefined vasculitis (evaluated elsewhere). Laboratory tests showed in all patients
elevated inflammatory markers, zinchemia and serum calprotectin (table)
Conclusion: We report three patients with high serum levels of calprotectinemia and
zinch presenting with a clinical phenotype consistent with previously reported cases.
The presence of vasculitis in all of the patients suggests that it may represent the
first symptom of this condition. Vasculitis could lead to an increase of serum calprotectin
already proposed as a marker of vascular impairment. Moreover, considering the immunological
defect detected in one of our patient, we speculate that recurrent infections described
in this syndrome may underline an immune-dysregulation process in which the role of
zinc metabolism needs to be assessed
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P1123).
See text for description
Patient 1
Patient 2
Patient 3
Age at 1st evaluation (years)
14.3
7.8
4.9
Sex
F
F
M
Clinical features
Recurrent fever, recurrent infection, vasculitis, skin rash, musculoskeletal pain
Hemolitic anemia,thrombocytopenia, HLH, vasculitis, recurrent infections, recurrent
fever, arthritis, skin rash, gastrointestinal involvement
Recurrent fever, skin rash, vasculitis, arthritis, musculoskeletalpain
SAA
13-23
27,5-76,4
20
Zinchemia(mcg/dl)
(n.v. 80-125)
132-143
102-233
147
Serum MRP8/14 (ng/ml)
(n.v. < 2900)
22431
10383
10363
P1124 Inherited deficit of proteoglycan mimicking septic arthritis
Angelo Florio1, Riccardo Papa1, Roberta Caorsi1, Alessandro Consolaro1, Tuula Rinne2,
Roberto Gastaldi3, Angelo Ravelli1, Marco Gattorno1, Paolo Picco1
1Clinica Pediatrica e Reumatologia , IRCCS Istituto Giannina Gaslini, Genova, Italy;
2Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands;
3Clinica Pediatrica ed Endocrinologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
Correspondence: Angelo Florio
Introduction: Aggrecanopathies are a heterogeneous group of skeletal disorders caused
by ACAN gene mutations leading to aggrecan dysfunction: this latter is a proteoglycan
with a pivotal role in extracellular matrix of the growth-plate cartilage organization.
Clinically, aggrecanopathies displayed bone dysplasias, idiopathic short stature and
facial dysmorphisms. Herein we report a patient with a prevalent inflammatory articular
involvement, e.g. osteochondritis dissecans (OCD) mimicking a septic arthritis.
Methods: A 14-year-old boy displayed pain and swelling at the right elbow. Echo-scan
revealed an effusion in both coronoid and olecranon recess. Acute phase reactants
were negative. Since non-steroidal anti-inflammatory drugs were ineffective, the patient
was admitted in our Institute, a month later clinical onset.
On physical examination, acute arthritis at right elbow was present, which appeared
painful, warm, not erythematous. Laboratory test showed slight elevated inflammatory
markers (C reactive protein 1.7 mg/dl, normal value <0.5). Arthrocentesis of the right
elbow was performed: sterile synovial fluid was found. Magnetic resonance images of
the right elbow displayed bone fragment detachment from humeral condyle with thickening
of the synovium and persistent local effusion: the diagnosis of OCD was pointed out.
It is worth nothing that patient showed minor dysmorphisms (i.e. dolicocephaly, hypotelorism,
arched palate and brachydactyly of the IV finger of both hands). Furthermore parents
referred that the child presented a previous episode of OCD when he was 12: the symptoms
resolved with non-bearwighting and non-steroidal anti-inflammatory therapy.
The patient went under regular endocrinologist follow-up for short stature since he
was 8. At the age of 10 (height cm 123 – SDS 2.4) Growth Hormone (GH) stimulation
tests were performed showing only partial response to insulin tolerance test (GH peak
6.27 ng/mL). Bone age was delayed of 12 months. Human recombinant GH replacement therapy
was started without a significant growth-velocity improvement.
Results: Although our patient came to observation because of suspected elbow septic
arthritis, we re-considered the diagnosis: namely, i. recurrent episodes of osteochondritis
dissecans; ii.short stature poorly responsive to human recombinant GH treatment, iii.
Mild facial, skeletal dysmorphisms led us to hypothesize a form of aggrecanopathy.
Molecular analysis of the ACAN gene was performed revealing a novel missense variant
c.6970T>C, p.Trp2324Arg. A similar mutation in the G3 domain (c.7249G>A) has been
previously described and has been connected to aggrecanopathy.
Conclusion: Aggrecan, an important sub-unit of proteoglycan in cartilage, is synthetized
by ACAN gene. Aggrecan-related bone diseases range from severe spondylo-epi-metaphyseal
dysplasia to familial osteochondritis dissecans usually associated with short stature.
In our experience, a patient with a novel mutation of ACAN gene seems to cause an
atypical form of aggrecanopathy mimicking inflammatory and/or septic arthritis associated
with slight short stature and bone dysmorphisms. Intra-familial molecular analysis
allowed us to recognize other three subjects (mother and 2 siblings) affected only
by brachydactily. Further studies need to confirm the role of this variant of ACAN
gene as cause of inflammatory arthropathy.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1125 LRBA deficiency in a patient with chronic arthritis
Şerife Gül Karadağ, Ayşe Tanatar, Mustafa Çakan, Haifize Emine Sönmez, Figen Çakmak,
NurayAktay Ayaz
Pediatric Rheumatology, Health Sciences University Kanuni Sultan Süleyman Training
and Research Hospital, Istanbul, Turkey
Correspondence: Şerife Gül Karadağ
Introduction: Lipopolysaccharide-responsive, beige-like anchor protein (LRBA) deficiency
causes common variable immunodeficiency (CVID) disorders and autoimmunity. Patients
with LRBA deficiency may present with a wide spectrum of clinical manifestations.
Herein, we report a patient with LRBA deficiency associated chronic arthritis
Results: A 20-year-old male patient was admitted to our hospital with swelling in
knees and ankles for two months. He was initially diagnosed with Evans syndrome when
he was four years old. Subsequently, he was diagnosed with Crohn’s disease due to
chronic diarrhea at 18-years old. He also suffered from recurrent infections since
infancy. He also was followed by endocrinology department due to hypothyroidism. When
he was 20-years old, he was referred to our outpatient clinic due to chronic arthritis.
In laboratory work-up, he had elevated acute phase reactants and direct coombs positivity.
Romatoid factor, anti-nuclear antibody and HLA-B27 were negative. Initially, he was
considered to have chronic arthritis due to Crohn’s disease and sulfasalazine was
started. In third months, adalimumab was administered due to the inadequate response.
Immunodeficiency due to coexistence of endocrinopathy, autoimmune cytopenia and recurrent
infections was suspected. Therefore, expression of LRBA protein was found to be low.
Mutation in LRBA gene was evaluated with Sanger sequence. A homozygous mutation in
LRBA gene was detected (c.2818dupC;p.Gln940Profs*5).Abatacept (CTLA4 fusion protein)
and intravenous immunoglobulin was started. Now, he is in remission.
Conclusion: The association of LRBA deficiency and autoimmunity has previously described.
However, the data about the association LRBA deficiency and arthritis is limited.
The new finding of this rare disease might further expand the phenotypic spectrum.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1126 Unusual case of recurrent periodic macrophage activation
Khulood Khawaja1, Tawfiq T. Hen2
1Adult and Pediatric Rheumatology, Al-Mafraq Hospital; 2Pediatrics, Shaikh Khalifah
Medical City, Abu-Dhabi, United Arab Emirates
Correspondence: Khulood Khawaja
Introduction: Macrophage activation syndrome (MAS) is a multisystem inflammatory disorder,
can be fatal. Most commonly complicating systemic juvenile idiopathic arthritis (JIA)
Objectives: To discuss treatment pathway of recurrent MAS in systemic JIA when initial
therapy fails.
Methods: Case presentation of severe and recurrent periodic MAS in a child with systemic
JIA
Results: 12-year-old girl presented with 3 weeks history of fever, lethargy and rash.She
was having fever in the evening with erythematous rash over her shoulders, face and
trunk.She then developed pain in multiple joints with swelling in both knee joints.She
had ultrasound scan of her knees, which confirmed effusions and synovial thickening.There
had been no preceding infections or travel. Parents are consanguineous.3 siblings fit
and well. No family history of significance.
Initial examination, temperature 38.3°C, she had acanthosis nigricans in axillary
areas and behind her neck.No dysmorphic features.Conjunctivanormal.No hair or nail
abnormality.She had faint rash over her face and shoulders.Musculoskeletal examination,
pediatric gait, arm, leg and spine examination:She was struggling to hop and walk
on her heels.Arms:She hadminimal effusions in her wrists with pain on extreme flexion
and extension.Legs:She had effusion in both knees and ankles.Spine:Normal.TMJ:Normal. Examination
of other systems unremarkable (later developed mild hepatospleenomegaly)
Initial bloods:ANA negative, double stranded DNA negative, C3 and C4 negative, ENA
negative, rheumatoid factor positive.Sugar okay, thyroid function okay, hepatitis
B and C serology negative, Quantiferonnegative, Renal function normal. ESR 115 and
CRP 129.
USS of knees, ankles and wrists confirmed synovitis.CHAQ score 0.5, pain VAS 6, general
VAS 7,
Initially treated as JIA with systemic features and was started on Methotrexate 15mg/m2
weekly, joint injections with steroids of wrists, knees and ankles then oral prednisolone
reducing dose. She improved. Rash resolved. No fever but continued to complain of
joint pains. She was changed to Anti TNF; etanercept (50mg weekly) and small dose
of steroids . She also had inadequate response so was changed to IL-6 blocker; tocilizumab.She
was well for 6 months then developed MAS presenting with fever, lethargy and feeling
nauseated with raisedferritin of >10,000, cytopenia, hyperglyceremia, hypofibrogenemia
and raised triglycerides. Bone marrow aspirate normal. Treatment changed to IL-1 blocker
Anakinra 100mg daily. She was well on anakinra for 4 months then presented again with MAS
requiring IV methyl prednisolone and IV fluids. Has had monthly attacks for 5 months
(one with seizure) then every 2 weeks in the last 2 months. Cyclosporin 100mg twice
daily was added to her treatment with no benefit. She also had IVIG 2g/kg with no
benefit. She was assessed by Oncology and neurology; no concern of malignancy. HLH
genetic testing: PRF1, UNC13D, STX11, STXBP2.,SH2D1A, XIAP (BIRC-4), RAB27A, LYST,
ITK, GATA2, AP3B1, BLOC1S6, CD27, SLC7A7 all negative. Brain imaging normal. TRAPS,NLRP3
genetic testing neative. She is currently awaiting the result of whole gene sequencing.
In terms of treatment, cyclophosphamide was started 375mg/m2. Had first dose. Planning3
doses every 2 weeks then 4 doses every month.
Conclusion: Our patient had multiplepreseentations of MAS, first following several
months of treatment with tocilizumab then Anakinrathen 5 presentations monthly only
responding to systemic steroids then every 2 weeks for the last 4 presentations.
No clear guidelines to treat MAS once standard therapy unsuccessful. Further work
is needed to study the genetics of such patients by collaborative work amongst multiple
centres.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1127 AA amyloidosis in recipients of cadaveric derived pituitary growth hormone –
potential effect of an amyloid enhancing factor?
Helen J. Lachmann, Dorota Rowczenio, Janet A. Gilbertson, Hadija Trojer, Islam Noor,
Thirusha Lane, Julian D. Gillmore, Ashutosh D. Wechalekar, Philip N. Hawkins
National Amyloidosis Centre, UCL Division of Medicine and Royal Free Hospital NHS
Foundation Trust, London, United Kingdom
Correspondence: Helen J. Lachmann
Introduction: The development of Creutzfeldt–Jakob disease (CJD) in individuals who
had been treated during childhood with human cadaveric pituitary-derived growth hormone
(c-hGH) was first reported in 1985 and resulted in its immediate withdrawal and replacement
with recombinant protein. Subsequently amyloid-β protein (Aβ) deposits have been described
in individuals with CJD and prior exposure to c-hGH. Recently misfolded Aβ peptide
was identified in archived vials of human c-hGH, which induced Aβ pathology in an
experimental model (Purro et a Nature 2018) supporting its role in the transmission
of CJD.These observations are reminiscent of the concept of amyloid enhancing factor
(AEF), in experimentally induced AA amyloidosis, in which administration of tiny amounts
ofamyloidotic material is associated with massively accelerated AA amyloid deposition.
Objectives: To look for evidence of prior exposure to c-hGH in patients with AA amyloidosis.
Methods: We searched our database of 625 patients with AA amyloidosis seen between
1990 and 2017 using the key words pituitary, craniopharyngioma and growth hormone.
Only patients whose records suggested exposure to GH prior to 1985 were included.
Results: 10 cases were identified; accounting for 1.6% of all AA amyloidosis and 8.4%
of cases of AA of unknown aetiology. 8 were female, 8 were north European ethnicity
and the median age at histological diagnosis of AA amyloidosis was 47.9 yrs with a
median time since commencing c-hGH of 35 yrs. c-hGH was started in the 1960’s in 4
cases, the 1970’s in 4 cases and the 1980’s in 2 cases. The indications for GH were:
craniopharyngioma in 4, one case each of resection of ependymona, nasal pharyngeal
tumour and encephalocoele, 3 cases of unexplained hypopituatism. Chronic inflammation
was assessed by serial blood tests after the diagnosis of AA amyloid; only 1 case
had severe sustained inflammation with a median SAA 131 mg/L; 4 had medians SAAs of
between 20 and 54 mg/L and the others had only low level inflammation with median
SAA below 20mg/L. No clear cause of inflammation was identified in the cohort although
50% were obese and 3 had body mass index above 45 kg/m2. Genetic testing was performed
in all – in no cases did this result in a diagnosis of a systemic autoinflammatory
disorder. Six European patients were homozygous for SAA1.1 (66.7% compared to a reported
frequency of 42.7 - 57.9%in European controls), a known predisposing factor for AA
amyloidosis. One patient had a fall in SAA after bariatric surgery and one responded
completely to anakinra. The other patients had no specific treatment aimed at supressing
their SAA production. Five patients eventually required dialysis – 2 of them had subsequent
renal transplants; median survival from diagnosis with amyloid is 132 months and 3
patients have died.
Conclusion: We report 10 patients with AA amyloidosis of unknown aetiology, who were
exposed to c-hGH in childhood. We hypothesise that the c-hGH may have contained material
that seeded conversion of healthy low concentrations of SAA into AA amyloid fibrils.
It is of interest that 6 of this cohort had an additional risk factor in the form
of SAA1.1 homozygosity suggesting that a combination of factors may contribute to
amyloid formation in individuals who have low levels of circulating potentially amyloidogenic
protein.
Disclosure of Interest
None Declared
P1128 Progressive necrotic ulcerative lesions: challenging diagnosig?
Angela Mauro1, Francesca Orlando2, Maria Tardi3, RobertoRega3, Martemucci Luigi3,
Rita Sottile3
1Pediatrics, Rheumatology Unit, Department of Pediatrics, “Santobono-Pausilipon” Children
Hospital, Naples, Italy; 2 Pediatrics; 3Pediatrics, Rheumatology Unit, Department
of Pediatrics, “Santobono-Pausilipon” Children Hospital, Naples, Naples, Italy
Correspondence: Angela Mauro
Introduction: Pediatric ulcers are less common compared to adult population. No data
about prevalence are available. Differential diagnosis is broad, including autoinflammatory,
hematologic, infectious andautoimmune causes. .
Objectives: We describe a case of progressive necrotic ulcerative lesions in a 7-
month caucasian boy
Methods: A 7-month-old Caucasian boy was admitted to our Department with purpuric
and telangiectatic lesions on his right hand and left wrist without fever. After one
month these lesions evolved in necrotic ulceration of the skin .He was born at term
to unrelated parents after a pregnancy complicated by premature contractions.At the
age of 9 months he developed a large necrotic lesion (4x4 cm) on the right foot and
other similar smaller lesions on the knees. He had purpuric and telangiectatic lesions
on the left foot and the medial face of the left leg. Laboratory assessments were
performed to exclude infectious diseases (Mycoplasma, Chlamydia, HBV, HCV, HAV, Treponema
Pallidum, Rickettisa conorii, Widal-Wright, BorrelliaBurgdoferi, TORCH, EBV) The inflammatory
markers (ERS, SAA, CRP), prothrombotic risk factors (PT, APTT, fibrinogen, protein
S, protein C), C3, C4, immunoglobulins, antiphospholipid antibodies, ANA, ANCA, ASCA,
anti-Dna, celiac disease antibodies, Quantiferon, hemoglobin electrophoresis, blood
culturesand urine analysis were negative or in the normal range.The analysis of CERC1
gene was negative for the main mutaions.It was also tested CD18, blood T-lymphocyte
subpopulations. cryoglobulins, interferon signature (negative) and CGH ARRAY, karyotype,
and for zinc deficiency (ongoing).Skin lesion cultures were positive forProteus mirabilis
andStaphylococcus aureus.Ultrasonography of lower limbs resultednegative except for
arteritis of the small vessels on the right foot lesion.
Echocardiography showed interatrial communications ostium secundum type with slight
left-right shunt.Abdomen Ultrasoundwas negativeChest radiography (fatta in faseacuta?):hyperinflated
lungs, aincrease interstitial markingof the right and left retrocardiacfields. . Flat
diaphragm. Expansive ribs.Brain MRI: negativeElectromyography: slight neurogenic problemsSkin
biopsy: microscopic epidermis partly necrobiotic, focal spot parakeratosis and spongiosis
with vesicles formation. In the dermis, presence of edema and erythrocyte extravasation
in the papillae, small thrombosed vessels, sometimes with fibrinoid necrosis and only
focal lymphocytic infiltrated, PASS-Giemsa negative staining, negative Z-Nilsen staining
Results: Findings consistent with livedoid vasculopathy, cryoglobulinemia and gangrenous
ecthyma. For gangrenous ecthymahe started Teicoplanin, Meropenem and Fluconazole with
a subsequent improvement of the skin lesions and a decrease of necrotic eschars and
lesion re-epithelialization, but after 15 days he presented new purpuric lesions on
his legs, right heel, and hands.
Conclusion: Do you have any input about this patient?
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P1129 An undefined systemic autoinflammatory disease complicated by MAS or an unidentified
primary HLH?
Roberta Naddei1, Francesca Orlando1,2, Carolina Porfito1, Teresa Lastella1, Marinabiondina
Amico1, Maria Alessio1
1Pediatric Rheumatology Unit, Mother and Child Department, University of Naples Federico
II; 2Department of Pediatrics, Santobono-Pausilipon Children’s Hospital, Naples, Italy
Correspondence: Roberta Naddei
Introduction: Systemic auto-inflammatory diseases (SAIDs) are a rare group of illnesses
characterized by unprovoked episodes of fever and systemic inflammation. Many patients
receive a diagnosis of undefined SAID because they have clinical features not fitting
a specific diagnosis or genetic tests are negative.
Objectives: To describe clinical presentation of a patient affected by recurrent episodes
of fever characteristics resembling hemophagocytic lymphohistiocytosis.
Methods: Case report.
Results: The patient (male, age 30 months) referred to our Unit at the age of 3 months.
At 1 month, he underwent a surgical repair of ventricular septal defect. At 3 months,
he was admitted to a hospital for fever and maculopapular rash, with marked elevation
of acute phase reactants (Protein C-reactive, PCR, 108 mg/L). Empiric antibiotic therapy
was started, but no evidence of infectious diseases was disclosed.At the tenth day
of fever, laboratory examinations found thrombocytosis and increase of ferritin (5034
ng/ml), lactate dehydrogenase (1059 U/l), aspartate and alanine aminotransferase (254
and 124 U/l) and triglycerides (266 mg/dl). In the suspicion of atypical Kawasaki
disease, even if no coronary artery aneurysm was detected, treatment with intravenous
Immunoglobulin and aspirin was started with disappearance of fever; because of persistent
cutaneous rash and ferritin, triglycerides, platelets and PCR high levels, he was
transferred to our Unit. On admission, physical examination revealed neck and inguinal
enlarged lymph nodes. No organomegaly was detected. Laboratory investigations also
revealed increased neutrophils (17830/mm3), normocytic anemia (hemoglobin 7,5 g/dl),
hypoalbuminemia and hyponatremia. Fibrinogen levels were normal. Bone marrow aspiration
revealed no signs of hemophagocytosis or cellular atypia. Intravenous methylprednisolone
pulse therapy (30 mg/kg for three days) was started followed by daily oral prednisone
(2 mg/kg/day), with clinical resolution and laboratory improvement. After six-months
tapering, steroid therapy was withdrawn. Two months later, the patient newly present
fever, rash and increase of PCR and ferritin. Anakinra (2 mg/kg/day) was started with
improvement of clinical condition. Nevertheless, because of the persistent elevation
of inflammatory markers, anakinra dosage was increased up to 4 mg/kg/day during the
follow-up. Besides, the mother of child revealed difficulty to adhere daily subcutaneous
therapy. At the age of 2 years, he presented a new episode of fever and rash with
high ferritin level (2364 ng/ml); anakinra was stopped and canakinumab (4 mg/kg/4
weeks) was started with initial dramatic clinical and laboratory improvement. Fifteen
days after the first injection of canakinumab, the patient newly presented fever,
without rash. IL18 was raised (184000 pg/ml). Therapy with prednisone (2 mg/kg/die)
was added with fever disappearance. During the follow-up, in therapy with canakinumab
and prednisone, the patient never obtained normalization of inflammatory markers and
fever presented two or three weeks after canakinumab injection.
So, during the last episode of fever, canakinumab was stopped and cyclosporine was
added to steroid therapy. Since the introduction of cyclosporine, the patient has
not presented fever and inflammatory markers have normalized.
During the follow-up, the patient underwent Next Generation Sequencing for HLH and
SAID; no mutation was identified, except for a heterozygous CECR1 variant.
Conclusion: This patient presents recurrent hyperinflammation episodes, resembling
HLH/MAS, with low response to anti-IL1 agents. Genetic tests for HLH and SAID are
negative; what are we missing? Should we attempt IL18 blockade?
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Allied Health Professionals
P1130 Towards European harmonisation of healt care for patients with rare immune disorders:
ERN RITA result from the registries survey
Riccardo Papa1, Andrew Cant2, Christoph Klein3, Mark Little4, Nico M. Wulffraat5,
Marco Gattorno1, Nicolino Ruperto1 and on behalf of RITA ERN Council
1Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy;
2Great North Children's Hospital, & Institute for Cellular Medicine, University of
Newcastle, Newcastle upon Tyne, United Kingdom; 3Department of Pediatrics, Ludwig-Maximilians-University
Munich, Munich, Germany; 4Department of Nephrology and Kidney Transplantation, Beaumont
Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland; 5Department of Pediatrics,
Section Pediatric Rheumatology, Wilhelmina Children's Hospital, University Medical
Centrum Utrecht, Utrecht, Netherlands
Correspondence: Riccardo Papa
Introduction: Rare Immunodeficiency, AutoInflammatory and AutoImmune Disease (RITA)
network is a European Research Network that brings together the leading centres for
rare immune disorders (RID).
Objectives: To know the state of the art about diseases registries and research networks
in Europe regarding patients with RID.
Methods: On April 2018 an on-line survey was sent to all 126 RITA members, of whom
45 are healthcare providers and 8 patients/family organizations. All data were collected
and analysed using Excel program.
Results: Ninety RITA members (71%) replied. Collectively, 27 members are coordinating
25 registries, 53 members are participating in 38 registries, and 27 members knew
the existence of 16 registries without participating. Only two members are not involved
in any registries.
Data about 53 different registries were collected across 14 European countries. Almost
50% of registries collect data on autoimmune disorders, while others are dedicated
to primary immunodeficiencies and autoinflammatory diseases (respectively 15 registries,
28%, and 12 registries, 23%). Fifteen registries (28%) enrolled patients with a single
specific disorder: in particular, three registries are devoted to systemic lupus erythematosus,
two registries to Kawasaki disease or Behcet disease, and single registry to juvenile
dermatomyositis, juvenile systemic sclerosis, juvenile idiopathic arthritis (JIA)-related
uveitis, systemic JIA, Blau syndrome, sarcoidosis, Guillain-Barre syndrome, and myasthenia
gravis.
More than 55000 patients with RID are enrolled. The majority of registries (36; 68%)
enrol only patients from national territories. Among the internationals, six collect
data on autoimmune disorders (Pharmachild, BrainWorks, EuroMyositis, EULAR web library,
UKIVAS registry and JIR cohort), five on primary immunodeficiencies (ESID, EBMT, SCETIDE,
PCID and HLH registry), and three are devoted to autoinflammatory diseases (Eurofever,
Infevers, and ImmunAID), despite also ESID registry and JIR cohort collect data on
autoinflammatory diseases.
Data usually collected in these registries are demography, diagnosis, clinical manifestations,
laboratory tests and treatment, while genetic and imaging data are less frequently
reported (respectively in 38% and 9% of registries). A treatment safety profile is
reported in 29 registries (55%). Collectively, fifteen biobanks are counted.
Conclusion: The survey highlighted the pivotal role of national and international
organizations in Europe to collect and organize clinical data on immune diseases,
allowing the rapidly growing knowledge on these rare disorders, creating research
networks and providing significant numbers of data to support new discoveries in the
field. RITA network could improve the coordination of these numerous entities, supporting
initiatives of collaboration. As a first attempt, the present survey revealed that
the collection of key parameters about patient safety, as well as outcome data and
quality of life measures should be improved among the registries of RITA network.
Disclosure of Interest
None Declared
Poster presentations – Tuesday 2 April
Guided poster tour 2A
PT2A01 The French pediatric cohort of castleman disease
Charlotte Borocco1,2, Claire Ballot-Schmit3, Oanez Ackermann4, Nathalie Aladjidi5,
Jeremie Delaleu6, Vannina Giacobbi-Milet7, Sarah Jannier8, Eric Jeziorski9, Yves Perel5,
François Maurier10, Christophe Piguet11, Eric Oksenhendler12,13, Isabelle Kone-Paut1,2,14,
Caroline Galeotti1,2,14
1Pediatric Rheumatology; 2CEREMAIA, Bicetre Hospital, Le Kremlin-Bicêtre; 3General
Pediatrics, Jean Minjoz Hospital, Besançon; 4Pediatric hepatology, Bicetre Hospital,
Le Kremlin-Bicêtre; 5Pediatric Oncology and Hematology, Pellegrin Hospital, Bordeaux;
6Internal Medicine, Tenon Hospital, Paris; 7Pediatric Oncology and Hematology, Le
Mans Hospital, Le Mans; 8Pediatric Oncology and Hematology, Hautepierre Hospital,
Strasbourg; 9General Pediatrics, Arnaud de Villeneuve Hospital, Montpellier; 10Internal
Medicine, Metz Private Hospital, Metz; 11Pediatric Oncology and Hematology, Limoges
Hospital, Limoges; 12Clinical Immunology, Saint-Louis Hospital; 13National Reference
Center for Castleman Disease, Paris; 14National Reference Center for Castleman Disease,
Le Kremlin-Bicêtre, France
Correspondence: Caroline Galeotti
Introduction: Castleman disease (CD) is a very rare non-malignant lymphoproliferation
of undetermined origin. CD diagnosis is difficult and often delayed because of insidious
onset, low awareness and clinical heterogeneity. Two major disease phenotypes can
be distinguished: unicentric CD (UCD) and multicentric CD (MCD). Diagnosis confirmation
is based on histopathological findings on an involved lymph node.
Objectives: We attempted to survey all cases of paediatric CD identified in France
so far, in order to set up a national registry aimed to improve CD early recognition,
treatment and follow-up, within the context of a new reference centre (http://www.castleman.fr).
Methods: In 2016, we e-mailed a questionnaire to members of the French paediatric
immunohaematology society, the French paediatric rheumatology society and the French
Reference Centre for Castleman Disease to retrospectively collect cases of paediatric
CD (first symptoms before age 18 years). Anatomopathological confirmation was mandatory.
Results: We identified 23 patients (12 girls and 11 boys) diagnosed with UCD (n=17)
and MCD (n=6) between 1994 and 2018 in 14 centres.
The average age at first symptoms was 11.5 years for UCD and 8.3 years for MCD. The
mean diagnosis delay was 8.2 months for UCD and 5.2 years for MCD.
In UCD, the initial symptoms were: isolated lymph nodes (n = 10) or lymph node associated
with other symptoms (n = 7), fever was present in 3 patients.
Patients with MCD presented with fever (n=5), abdominal lymph nodes (n=5), failure
to thrive (n=3), hepatomegaly and/or splenomegaly (n=3), arthralgia (n=2), abdominal
pain (n=2), fatigue (n=2), facial oedema (n=1), isolated lymphadenopathy (n=1), trunk
rash (n=1), vascular hepatopathy with oesophageal varicose veins (n=1), diarrhoea
(n=1) or cholestasis (n=1). One patient had a Duchenne muscular dystrophy. No patients
had HIV or HHV8 infection. The 6 patients met all the diagnosis criteria proposed
by Fajgenbaum et al in 2017 for idiopathic MCD.
One MCD patient with recurrent fevers, had a heterozygous mutation in MEFV gene. Another
UCD patient experienced fever episodes and pericarditis two years after surgery. Genetic
tests revealed one heterozygous mutation in IL10RA gene (V406L) and one in IL36RN
gene (S113L). Nevertheless, our patient did not have any psoriasis or inflammatory
bowel disease.
Treatment of UCD was mainly surgical resection, steroids, and radiotherapy. Treatments
of MCD were tocilizumab, rituximab, anakinra, steroids, chemotherapy and splenectomy.
Overall survival after an average of 6 years of follow-up, was 100 % for both unicentric
and multicentric forms.
Conclusion: Paediatric CD seems still underdiagnosed with a significant diagnosis
delay specially for the MCD but new international criteria will help in future. In
UCD, surgery is the main treatment. New drugs are used specially for the MCD, but
more studies need to be conduct in children. The global survey is better in children
than adults.
Disclosure of Interest
None Declared
PT2A02 Use of whole-body magnetic resonance to identify potential diagnostic clues
in children with fever of unknown origin (FUO)
Sara Signa1,2, Roberta Caorsi1, Giorgio Stagnaro3, Francesca Minoia1, Paolo Picco1,
Angelo Ravelli1,2, GM Magnano3, Maria B. Damasio3, Marco Gattorno1
1Clinics of Pediatrics and Rheumatology, G.Gaslini Institute; 2DINOGMI, University
of Genoa; 3UO of Radiology, G.Gaslini Institute, Genoa, Italy
Correspondence: Sara Signa
Introduction: Whole-body magnetic resonance imaging (WBMRI) is a fast and accurate
method to detect diseases throughout the entire body without exposure to ionizing
radiation. Possible emerging applications for this technique include rheumatologic
field and evaluation of fever of unknown origin (FUO).
Objectives: To evaluate the ability of WBMRI to identify significant potential diagnostic
clue (PDC) in patients presenting a non specific inflammatory clinical picture.
Methods: We retrospectively collected cases of pediatric patients followed in a single
pediatric rheumatology center who underwent WBMRI between January 2010 and December
2015 for the following indications: i) FUO (temperature greater than 38.3°C for more
than three weeks or failure to reach diagnosis after one week of investigations),
iii) recurrent fever (febrile episodesseparated by periods of normal temperature),
iii) Inflammation of unknown origin, IUO (an illness of at least 3 weeks’ duration,
with raised inflammatory markers and fever below 38.3°C).WBMRI studies were acquired
with coronal and sagittal planes (slice thickness 5mm) with acquisition of several
image sets with automatic direct image realignment after acquisition creating a whole-body
scan.Sequences include short τ inversion recovery (STIR) and T1-weighted. All studies
have been evaluated twice, the second time according to a predefined checklist, defined
by an experienced radiologist, considering systematically single /multifocal bone
lesion, bone marrow, joint effusion, soft tissues, adenopathies, parenchymal and vessels
looking for PDC. We considered as a Potential Diagnostic Clue each alteration of the
examined district that can potentially guide the diagnosis. Each alteration found
is a PDC. We retrospectively evaluated patients’ clinical history and final diagnosis
and we classified the PDCs identified during both first evaluation and re-evaluation
as: Not useful (the identified PDC did not guide the diagnosis and is not coherent
with the final diagnosis), consistent (the identified PDC is congruent with the patient’s
final diagnosis) or diagnostic (the identification of the considered PDC strongly
orient the final diagnosis).
Results: We collected 102 patients who underwent WBMRI; 24 (23%) of them presenting
FUO, 27 (26%) presenting recurrent fever and 51 (51%) presenting persistent low grade
fever . The mean age of onset symptoms was 7 years and seven months (range: 2 weeks
old- 17 years and 6 months). The mean age of execution of WBMRI was 9 years (range:
5 months old- 19 years and one month). After the whole diagnostic work-out a final
diagnosis was achieved in 42 patients (41%).PDCs were identified at the first evaluation
in 76/102 cases (74.5%).In 22 cases (21.5%) the identified PDCs were consistent with
the diagnosis, whereas in 7 cases (7%) the identified PDCs were considered diagnostic.
Globally we can consider that at first evaluation PDCs were somehow contributory to
the diagnosis in 29 cases (28.5%; 6 JIA, 7 systemic infections, 5 monogenic inflammatory
diseases, 4 ALPS, 2 Goldbloom’s Syndrome,2 Vasculitis,1 eosinophilic fasciitis, 1
hystiocytosis, 1 neuroblastoma). Blind re-evaluation of WBMRI allowed the identification
of additional PDCs in 52 patients (12 of them previously negative) . In 10 cases the
PDC found after re-evaluation were consistent with the final diagnosis (2 JIA, one
infectious disease, one neuroblastoma, 3 ALPS, 1 monogenic inflammatory disease, 1Takayasu
arteritis, 1 Goldbloom’s syndrome).
Conclusion: WBMRI can be a powerful diagnostic tool in patients with FUO. A predefined
checklist increase sensitivity of WBMRI in the identification of PDC.
Disclosure of Interest
None Declared
PT2A03 A biomarker profile including S100A12 as diagnostic tool for the differential
diagnosis of sJIA-associated MAS vs. primary or secondary HLH
Christoph Kessel1, Ndate Fall2, Alexei Grom2, Wilco de Jager3, Sebastiaan Vastert4,
Raffaele Strippoli5, Claudia Bracaglia6, Erik Sundberg7, Anna Horne8, Stephan Ehl9,
Sandra Ammann9, Kai Lehmberg10, Fabrizio De Benedetti6, Helmut Wittkowski1, Katharina
Kessel1, KarinBeutel11, Dirk Foell1, Dirk Holzinger12
1Pediatric Rheumatology and Immunology, University Children’s Hospital, Muenster,
Germany; 2Division of Rheumatology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, United States; 3Laboratory of Translational Immunolgy, Utrecht Medical
Center; 4Pediatric Rheumatology and Immunology, University Medical Center Utrecht,
Utrecht, Netherlands; 5Cellular Biotechnology and Hematology, Sapienza University
of Rome; 6UO Reumatologia, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy; 7Paediatric
Rheumatology Unit; 8Childhood Cancer Research Unit, Karolinska University Hospital
Solna, Stockholm, Sweden; 9Center for Chronic Immunodeficiency, University Hospital
Freiburg, Freiburg; 10Pediatric Hematology and Oncology, University Medical Center
Hamburg Eppendorf, Hamburg; 11Pediatric Hematology and Oncology, Children’s Hospital,
TU Munich, Munich; 12Pediatric Hematology-Oncology, University of Duisburg-Essen,
Essen, Germany
Correspondence: Dirk Holzinger
Introduction: Macrophage activation syndrome (MAS) is a severe complication of autoimmune
and autoinflammatory disease and is strongly associated with systemic juvenile idiopathic
arthritis (sJIA).
Objectives: While the granulocytic protein S100A12 is highly overexpressed in sJIA,
and the assessment of S100A12 serum levels helps to distinguish sJIA from other febrile
illnesses, the presence of elevated levels of IFNγ, IFNγ-induced chemokines and IL-18
have recently been suggested to play a pivotal role during particularly MAS episodes.
Clinically, however, MAS is strikingly similar to hemophagocytic lymphohistiocytosis
(HLH) and the initial differentiation between sJIA-associated MAS and primary or secondary
HLH can be challenging. In this study we set out to define a serum marker profile
to support the initial diagnosis of sJIA-MAS and differentiate this from primary or
secondary HLH.
Methods: A multiplexed bead array panel for simultaneous detection of 53 cytokines
and chemokines was built based upon their suggested relevance in MAS or HLH according
to respective literature. Serum samples from patients with active primary HLH (pHLH)
(n=10), secondary HLH (sHLH) (n=12), clinically active or inactive sJIA-MAS (both
n=11) as well as healthy controls (n=10) were subjected to this bead array assay as
well as quantification of S100A12 levels by ELISA. Based on the data obtained from
this discovery cohort we extracted a subset of analytes, which was validated using
commercially available bead array reagents in an independent cohort.
Results: Following analysis of the discovery cohort, out of 54 serum analytes 14 markers
were identified that significantly distinguished sJIA-MAS from HLH. These mostly distinguished
between pHLH and MAS, while S100A12, IL-18 as well as the MIG/IL-18-ratio also separated
between MAS and sHLH. In ROC-analyses six out of these 14 analytes separated MAS from
HLH with AUC > 0.9. S100A12 (AUC=0.99), sFASL (0.98) and IL-18 (0.97) were the top-three
performing markers in these analyses. The 14plex panel including S100A12 was validated
in an independent cohort resulting in IL-18 (AUC=0.83), S100A12 (0.75) and sFASL (0.7)
as the top-three performing markers in separating sJIA-MAS from HLH.
Conclusion: IL-18, S100A12 and sFASL serum levels are useful to differentiate between
sJIA-associated MAS and HLH. This can be a helpful diagnostic tool to discriminate
sJIA-associated MAS during early onset of the disease from primary or secondary HLH.
Disclosure of Interest
None Declared
PT2A04 Early treatment with anakinra in systemic juvenile idiopathic arthritis
Manuela Pardeo, Claudia Bracaglia, Anna Tulone, Antonella Insalaco, Giulia Marucci,
Rebecca Nicolai, Virginia Messia, Emanuela Sacco, Fabrizio De Benedetti
Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Manuela Pardeo
Introduction: Systemic juvenile idiopathic arthritis (sJIA) accounts for 10-20% of
all patients with JIA. The prominent systemic clinical features, the marked elevation
of inflammatory markers and the absence of autoantibodies make this disease different
from other JIA forms. sJIA should be considered as a polygenic autoinflammatory disease.
Interleukin 1 (IL-1) has been shown to be a major mediator of the inflammatory cascade
that underlies sJIA. Treatment with anakinra has been reported to be effective in
a sizable portion of patients with sJIA.
Objectives: To assess clinical response rate and disease course in sJIA patients treated
with anakinra.To evaluated whether the response to anakinra was related to baseline
variables.
Methods: We reviewed 56 (28 F) consecutive patients with sJIA treated with anakinra
for at least 6 months in our institution. The diagnosis of sJIA was established according
to the International League of Associations for Rheumatology (ILAR) classification
criteria. We analyzed the effect of anakinra on fever, rash, number of active joints,
erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white blood cells
count, platelets count and ferritin levels. Clinically inactive disease (CID) was
defined according to Wallace criteria. Clinical and laboratory data were obtained
using a standard data collection form.
Results: The median age at the disease onset was 5.7 (IQR 2.9-10.2) years. The median
time from onset to received anakinra was 1.9 (IQR 0.7-9.7) months. At baseline 52/56
(93%) of patients had fever and median number of active joints was 2 (IQR 1-4). After
6 months of treatment 39 patients (69.6%) met criteria for inactive disease. Among
56 patients 17 (30.3%) received anakinra in monotherapy and 39 (69.6%) received anakinra
with glucocorticoids. There were no statistically significant differences between
the two groups for demographic, clinical and laboratory features.13/17 (76.4%) patients
treated with anakinra alone and 26/39 (66.6%) patients treated with anakinra and glucocorticoids
met criteria for CID off glucocorticoids at 6 months (p=0.54). Among the 56 patients,
29 (51.7%) received anakinra within 2 months from disease onset. There were no statistically
significant differences for demographic, clinical and laboratory features among patients
who started anakinra in the first 2 months from disease onset compared to those that
started anakinra after 2 months. At 6 months after beginning of anakinra treatment,
27/29 patients (93.1%) who started anakinra within 2 months from disease onset and
12/27 (44.4%) who started anakinra after 2 months from disease onset reached clinical
inactive disease off glucocorticoids (p=0.0001). Patients who started anakinra after
the first 2 months from disease onset have a significantly higher risk of non-response
(OR=8.06, 95% CI: 2.03-32.0).
Conclusion: According with several observations, anakinra is effective in a significant
proportion of patients with sJIA. A possible approach to introduce IL-1 inhibitor,
with or without concomitant glucocorticoids, early in the disease course taking advantage
of a “window of opportunity” has been suggested. Our observation confirms that earlier
treatment with anakinra is associated with a better short-term outcome. Moreover,
our results show that beginning of treatment after two months from disease onset is
correlated with a high risk of non-response.
Disclosure of Interest
M. Pardeo: None Declared, C. Bracaglia: None Declared, A. Tulone: None Declared, A.
Insalaco: None Declared, G. Marucci: None Declared, R. Nicolai: None Declared, V.
Messia: None Declared, E. Sacco: None Declared, F. De Benedetti Grant / Research Support
from: Novartis, Novimmune, Hoffmann- La Roche, SOBI, AbbVie, Pfizer
PT2A05 Antibodies to collagen V and K-Α 1 tubulin in a patient with systemic juvenile
idiopathic arthritis associated lung disease
Elena Tronconi1, Thalachallour Mohanakumar2, Lara Danziger-Isakov3, Grant Schulert1,
Alexei Grom1
1Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati;
2Norton Thoracic Institute Research Laboratory, St. Joseph’s Hospital and Medical
Center, Phoenix; 3Division of Infectious Diseases, Department of Pediatrics, Cincinnati
Children’s Hospital Medical Center, Cincinnati, United States
Correspondence: Elena Tronconi
Introduction: Lung transplantation is still characterized by high morbidity and mortality.
Bronchiolitis obliterans syndrome (BOS), the clinical correlate of chronic rejection,
highly impacts long-term outcomes. It has been shown that recipients can develop antibodies
to self-antigens (sAgs) like collagen V (ColV) and K-α 1 tubulin (Kα1t), and this
correlates with the development of BOS. ColV and Kα1t are expressed by small airway
epithelial cells. The interstitial remodeling that occurs with transplantation seems
to enhance ColV and Kα1t exposure. Systemic juvenile idiopathic arthritis (sJIA) is
a form of juvenile arthritis characterized by various degree of arthritis and prominent
systemic features. In few cases it can be associated with lung involvement, a life-threatening
complication, whose exact pathogenetic mechanism is still poorly understood.
Objectives: We decided to explore the possible role of antibodies to lung sAgs in
a single patient affected by sJIA complicated by several episodes of macrophage activation
syndrome (MAS), interstitial lung disease and pulmonary alveolar proteinosis.
Methods: We retrospectively analyzed serum samples collected during clinical follow-up
from August 2015 to February 2018. We considered positive values more than 218 ng/ml
for Kα1t and 160 ng/ml for colV according to the study by Hachem et al. The results
were matched with clinical symptoms and laboratory parameters as white blood cell
counts (WBC), hemoglobin (Hb), platelets (PLT), C reactive protein (CRP) and ferritin.
Furthermore, we reviewed the ongoing treatment at the time of sample collection.
Results: In our patient ColV antibodies fluctuated over time, 7/20 samples were positive.
The correlation analysis between ColV and WBC, Hb, PLT, CRP and ferritin did not show
statistical significance. However, the review of clinical charts showed that at the
time of 6 out of the 7 positive samples there was fever, worsening of respiratory
symptom like persistent cough, increase respiratory rate or exertional tachypnea,
mild flare of sJIA or MAS. Twelve of the 13 negative samples were collected when the
patient was in stable clinical conditions, only 1 sample was collected during an episode
of early MAS. The trend of Kα1t antibodies did not match completely with ColV. Considering
the previously reported normality range, we did not find any positive result. Therapy
was a combination of steroid, cyclosporin, anakinra, canakinumab, interleukin 18-binding
protein, intravenous immunoglobulins (IVIG). All the treatments, the dosage of steroid
and cyclosporin as well as timing of IVIG were tailored on clinical conditions and
laboratory test so it is difficult to define a clear association with ColV antibodies
values.
Conclusion: The pathogenic mechanism of sJIA-associated lung diseases is still poorly
understood. This preliminary retrospective study showed a good correlation between
antibodies to ColV and clinical disease activity, in particular with MAS and worsening
of respiratory symptoms. The lack of correlation with laboratory markers can be explain
by the prompt modification of treatment according to the clinical condition of the
patient and the retrospective nature of the study. Similar to what happens in BOS
after transplantation, we hypothesize that during a flare of sJIA or an episode of
MAS the inflammation and cellular damage expose sAgs, normally hidden, to the circulation,
worsening and amplifying the immune response. This preliminary evidence of increased
pulmonary sAgs in sJIA with lung involvement represents a possible paradigm shift
in the pathophysiology of the disease although we need more evidence prospectively
collected in a larger population.
Disclosure of Interest
None Declared
PT2A06 Recurrent fever, recurrent pyoderma gangrenosum-like and bacterial infections
due to a novel homozygous WDR1 mutation in a child treated with allogeneic hematopoietic
stem cell transplantation
Estibaliz Iglesias1, Monica Roldan2, Alexandru Vlagea3, Manuel Solís-Moruno4, Juan
Manuel Mosquera1, Violeta Bitterman1, Joan Calzada-Hernández1, Laia Alsina5, Angela
Deyà-Martinez5, Rocío Lara3, Maria Carmen Anton3, Susana Plaza3, Helios Martínez-Banaclocha6,
María Trabazo7, Georgina Morón7, Manel Juan3, Jordi Yagüe3, Ferran Casals8, Isabel
Badell7, Claudia Fortuny9, Asunción Vicente10, Jordi Anton1, Pablo Pelegrin6, Juan
I. Aróstegui3, Anna Mensa-Vilaro3
1Pediatric Rheumatology; 2Confocal Microscopy Unit, Hospital Sant Joan de Déu, Esplugues;
3Immunology, Hospital Clinic; 4Experimental and Health Sciences, Pompeu Fabra University,
Barcelona; 5Clinical Immunology Unit, Hospital Sant Joan de Déu, Esplugues; 6Instituto
Murciano de Investigación Biosanitaria IMIB-Arrixaca, Murcia; 7Pediatric BMT Unit,
Hospital de Sant Pau; 8Genomics, Pompeu Fabra University, Barcelona; 9Pediatrics;
10Pediatric Dermatology , Hospital Sant Joan de Déu, Esplugues, Spain
Correspondence: Anna Mensa-Vilaro
Introduction: Immunodeficiency is increasingly recognized as a relevant feature in
certain novel monogenic autoinflammatory diseases including the often fatal deficiency
of actin-interacting protein 1 (AIP1) caused by biallelic loss-of-function WDR1 mutations.
Objectives: To characterize the clinical and immunological features, genetic and molecular
mechanisms and treatment outcome, underlying a child combining immunodeficiency and
sterile inflammation.
Methods: Whole-exome sequencing (WES) was performed in the family to identify the
genetic defect. Immunological evaluations and functional assays were performed to
demonstrate the pathogenicity of the candidate variant.
Results: The patient is a 10-year-old girl born of consanguineous Pakistani parents.
She was followed since the age of 5 for recurrent fever, recurrent pyoderma gangrenosum-like,
upper respiratory and ocular bacterial infections, one episode of non-bacterial osteomyelitis,
anemia, mild-to-moderate thrombocytopenia, neutrophilia, and increase acute-phase
reactants. WES detected the novel, homozygous p.(Lys411Asn) WDR1 variant, classified
as likely pathogenic according to ACMG guidelines. Immunological investigations revealed
moderate B cell lymphopenia with normal immunoglobulin levels, and normal numbers
of T and NK cells. Phalloidin staining of patient’s neutrophils showed increased levels
of F-actin compared with healthy subjects. Neutrophil respiratory burst was normal
with fMLP stimuli, but repeatedly impaired for phagocytosis of opsonized E. coli.
Confocal and electronic microscopy reveals aberrant morphology of neutrophils, with
nuclear herniations, low cytoplasmatic granule content, and defects in chemotaxis
and chemokinetics. Inflammasome-related experiments with patient’s monocytes showed
lower levels of both ASC specks formation and active caspase-1 compared with healthy
subjects. Finally, she has undergone HLA-identical unrelated hematopoietic stem cell
transplantation (HSCT) and she is clinically well with a follow-up time of 50 days.
Conclusion: Our results strongly support deficiency of AIP1 as the cause of the disease
observed in this patient. Allogeneic HSCT might be a curative option for this severe
and rare disease.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Guided poster tour 2B
PT2B01 Adenosine deaminase 2 deficiency: correction of the immune defects by gene
therapy
Immacolata Brigida1, Matteo Zoccolillo1,2, Raisa Jofra Hernandez1, Lucia Sergi Sergi1,
Giulia Milardi1,3, Federica Barzaghi2,4, Luigi Naldini1,3, Maria Pia Cicalese1,3,4,
Alessandro Aiuti1,3,4, Alessandra Mortellaro1
1San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific
Institute, Milan; 2Tor Vergata University, Department of Systems Medicine, Rome; 3Vita-Salute
San Raffaele University; 4Pediatric Immunohematology and Bone Marrow Transplantation
Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
Correspondence: Alessandra Mortellaro
Introduction: Adenosine deaminase 2 deficiency (DADA2) is caused by loss-of-function
mutations in the ADA2 gene. Clinical features include vasculitis, ischemic strokes,
intracranial hemorrhages, hematological abnormalities and immunodeficiency mainly
affecting B cells. Anti-TNF therapy reduced the ischemic events, controlled vasculitis
and partly restored the B-cell function. Allogeneic hematopoietic stem progenitor
cells (HSPCs) transplantation attempted in some patients restored ADA2 activity and
improved the inflammatory and hematological manifestations in transplanted DADA2 patients.
However, the morbidity and mortality of the allogeneic HSPC transplantation remained
high and unacceptable in less severe cases.
Objectives: Based on the observation that HSPC transplantation may be curative, we
hypothesized that strategies based on genetic correction and engraftment of autologous
HSPCs could provide a complete cure for DADA2.
Methods: CD34+ HSPCs isolated from healthy donors and DADA2 patients were transduced
with a lentiviral vector (LV) encoding ADA2. HSPCs engraftment and differentiation
were assessed in vitro and in vivo in humanized NSGW41 mice.
Results: Transduction of CD34+ HSPCs isolated from healthy donors and DADA2 patients
with the ADA2-LV efficiently restored ADA2 expression in vitro without significant
toxicity. Immunological reconstitution of ADA2-transduced CD34+ HSPCs was successfully
achieved in vivo in humanized NSGW41 mice. LV-derived ADA2 expression boosted immune
reconstitution of myeloid and B cells in vivo.
Conclusion: LV-mediated gene transfer restored ADA2 expression and enhanced myeloid
and B-cell reconstitution. Future studies will be required to explore the safety and
efficacy of HSPC gene therapy approach for DADA2.
Disclosure of Interest
None Declared
PT2B02 Analysis of the efficacy of treatment on 45 patients with deficiency of adenosine
deaminase 2
Amanda K. Ombrello1, Deborah L. Stone1, Karyl Barron2, Patrycja M. Hoffmann1, Cornelia
Cudrici3, Anne Jones1, Tina Romeo1, Dimana Dimitrova4, Amit Dotan5, Donna Wall5, Monica
Thakar6, Jennifer Kanakry4, Daniel Kastner1
1NHGRI; 2NIAID; 3NHLBI; 4NCI, NIH, Bethesda, United States; 5Hospital for Sick Children,
Toronto, Canada; 6Fred Hutchinson Cancer Research Center, Seattle, United States
Correspondence: Amanda K. Ombrello
Introduction: Since its initial description in 2014, the deficiency of adenosine deaminase
2 (DADA2) has undergone massive phenotypic expansion. The implementation of anti-TNF
agents has resulted in a significant reduction in occurrence of lacunar strokes but
variable effects on the other disease manifestations. Hematopoietic stem cell transplantation
(hSCT) is another potential curative treatment but, as numbers of patients transplanted
rise, specific DADA2 complications have emerged.
Objectives: To analyze the efficacy of treatment modalities used in DADA2 patients
in a single center, 45 patient cohort.
Methods: Patients with confirmed biallelic mutations in ADA2 were enrolled and a comprehensive
multi-system evaluation was undertaken to establish the extent of disease. From June
2013 forward, all patients with DADA2 were offered treatment with anti-TNF agents.
Patients were followed longitudinally on an annual basis. At each visit the patients
were followed by a core group of consultants with a battery of laboratory, radiologic,
and pathological analyses completed. Patients with significant evidence of bone marrow
involvement (pure red cell aplasia [PRCA], immune mediated neutropenia, trilineage
bone marrow failure) were referred for hSCT.
Results: Anti-TNF Analysis: In total, 42/45 were initiated on anti-TNF agents. At
the time of analysis 38/45 continued treatment (4 underwent hSCT and 3 declined treatment).
15/38 were on adalimumab, 20/38 were on etanercept, 2/38 were on golimumab and 1 was
on infliximab. Prior to anti-TNF initiation, there were 66 cumulative strokes and
post-anti-TNF initiation, there were 0 strokes. There was a statistically significant
decrease in inflammatory burden (ESR, CRP) post-anti-TNF initiation. Pre-treatment
transient elastography was abnormal in 11/34 with 6/11 normalizing post-treatment.
The inflammatory skin manifestations such as erythema nodosum and vasculitic nodules
improved on treatment. There was visible improvement of livedo racemosa but little
response to peripheral vascular disease/Raynaud’s phenomenon with 1 patient undergoing
3 partial digit amputations despite treatment. The patient with PRCA remained transfusion
dependent. Immune mediated neutropenia was present in 10/38 pre-anti-TNF and persisted
in 6/10 post-treatment. Trilineage bone marrow failure developed in 1 patient on anti-TNF.
hSCT Analysis: At the time of analysis 4/45 had undergone hSCT (2 for immune mediated
neutropenia, 1 for combined PRCA/immune mediated neutropenia, 1 for trilineage bone
marrow failure).All had been on anti-TNF agents leading up to hSCT and 1 developed
trilineage bone marrow failure after 4 years of anti-TNF treatment. All received reduced
intensity conditioning with varying regimens. One patient was transplanted successfully
and is doing well 1 year post-transplant. Two additional patients with immune mediated
neutropenia experienced graft failure due to host CD8+T lymphocyte attack requiring
second transplant. Patient 4 remains hospitalized after decreasing chimerism and reemergent
neutropenia necessitated donor lymphocyte infusion. Three additional patients await
hSCT.
Conclusion: The inflammatory and neurologic manifestations of disease have a robust
response to anti-TNF; hepatic and hematologic manifestations have a variable response
and vascular manifestations have little response. hSCT can be curative but delayed
engraftment/graft failure is a potential complication in patients with neutropenia.
Disclosure of Interest
None Declared
PT2B03 Long-term retention rate of anakinra in adult onset Still’s disease and predictive
factors for treatment response
Antonio Vitale1, Giulio Cavalli2, Serena Colafrancesco3, Roberta Priori3, Guido Valesini3,
Lorenza Maria Argolini4, Elena Baldissera2, Elena Bartoloni5, Daniele Cammelli6, Giovanni
Canestrari7, Jurgen Sota1, Elena Cavallaro8, Maria Grazia Massaro9, Piero Ruscitti10,
Paola Cipriani10, Ginevra De Marchi8, Salvatore De Vita8, Giacomo Emmi6, Gianfranco
Ferraccioli7, Micol Frassi11, Roberto Gerli5, Elisa Gremese7, Florenzo Iannone12,
Giovanni Lapadula12, Giuseppe Lopalco12, Raffaele Manna9, Alessandro Mathieu13, Carlomaurizio
Montecucco14, Marta Mosca15, Ilaria Piazza16, Matteo Piga13, Irene Pontikaki4, Micol
Romano4, Silvia Rossi14, Maurizio Rossini16, Elena Silvestri6, Chiara Stagnaro15,
Rosaria Talarico15, Angela Tincani11, Ombretta Viapiana16, Gianfranco Vitiello6, Paola
Galozzi17, Paolo Sfriso17, Carla Gaggiano18, Donato Rigante19, Lorenzo Dagna2, Roberto
Giacomelli10, Luca Cantarini1 and “Working Group” of Systemic Autoinflammatory Diseases
of SIR (Italian Society of Rheumatology)
1Research Center of Systemic Autoinflammatory Diseases and Behçet’s Disease Clinic
Surgery and Neurosciences, Department of Medical Sciences, Surgery and Neurosciences,
University of Siena, Siena; 2Unit of Immunology, Rheumatology, Allergy and Rare Diseases
(UnIRAR), IRCCS San Raffaele Scientific Institute, Milan; 3Department of Internal
Medicine and Medical Specialties, Sapienza University of Rome, Rome; 4Division of
Rheumatology, ASST Gaetano Pini, Milan; 5Rheumatology Unit, Department of Medicine,
University of Perugia, Perugia; 6Department of Experimental and Clinical Medicine,
University of Firenze, Firenze; 7Institute of Rheumatology and Affine Sciences, Division
of Rheumatology, Catholic University of the Sacred Heart, Rome; 8Department of Medical
and Biological Sciences, Rheumatology Clinic, University of Udine, Udine; 9Periodic
Fever Research Center, Institute of Internal Medicine, Catholic University of the
Sacred Heart, Fondazione Policlinico A. Gemelli, Rome; 10Department of Biotechnological
and Applied Clinical Science, Division of Rheumatology, University of L’Aquila, L'Aquila;
11Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical
and Experimental Sciences, University of Brescia, Brescia; 12Rheumatology Unit,Department
of Emergency and Organ Transplantation, University of Bari, Bari; 13Rheumatology Unit,
Department of Medical Sciences, University and AOU of Cagliari, Cagliari; 14Department
of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia;
15Rheumatology Unit, Department of Clinical and Experimental Medicine, University
of Pisa, Pisa; 16Rheumatology Unit, Department of Medicine, University of Verona,
Verona; 17Department of Medicine DIMED, Rheumatology Unit, University of Padua, Padua;
18Clinical Pediatrics, Department of Molecular Medicine and Development, University
of Siena, Siena; 19Institute of Pediatrics, Università Cattolica Sacro Cuore, Fondazione
Policlinico Universitario A. Gemelli I.R.C.C.S., Rome, Italy
Correspondence: Antonio Vitale
Introduction: Anakinra (ANA) is an effective treatment choice in patients with adult
onset Still’s disease (AOSD). Variables affecting treatment survival include loss
of efficacy or adverse events, but also the decision to discontinue treatment after
long-term clinical remission.
Objectives: Aims of this study were: i) to assess the drug retention rate (DRR) of
ANA during a long-term follow-up looking for any difference related to the line of
biologic treatment, the concomitant use of conventional disease modifying anti-rheumatic
drugs (cDMARDs) and the different type of AOSD (systemic versus chronic articular);
ii) to identify predictive factors of lack of efficacy, loss of efficacy and ANA withdrawal
owing to long-term remission.
Methods: AOSD patients classified according with Yamaguchi criteria and treated with
ANA were retrospectively enrolled in 18 Italian tertiary Centers. Demographic, laboratory,
clinical and therapeutic data related to the start of ANA (baseline), the 3-month
assessment and the last follow-up visit while on ANA treatment were retrospectively
collected and statistically analyzed.
Results: One hundred and forty-one AOSD patients (48 males, 93 females) treated with
ANA for a mean period of 35.96±36.05 months were enrolled. The overall DRR of ANA
was 44.6% and 30.5% at the 60- and 120-month assessments, respectively, with no significant
differences between: i) biologic naïve patients and those previously treated with
other biologics (log-rank p=0.97); ii) monotherapy and concomitant use of cDMARDs
(log-rank p=0.45); iii) systemic and chronic articular types of AOSD (log-rank p=0.67).
No variables collected at baseline could predict primary inefficacy, while the number
of swollen joints at baseline was significantly associated with secondary inefficacy
(p=0.01, OR=1.194, C.I. 1.043-1.367). The typical AOSD skin rash was negatively related
with ANA withdrawal owing to long-term remission (p=0.03, OR=0.224, C.I. 0.058-0.863).
Conclusion: Long-term DRR of ANA has been found excellent and is not affected by different
lines of biologic treatment, concomitant use of cDMARDs, or type of AOSD. The risk
of losing ANA efficacy increases along with the number of swollen joints at the start
of therapy, while the typical skin rash is a negative predictor of ANA withdrawal
related to sustained remission.
Disclosure of Interest
None Declared
PT2B04 The anti-inflammatory cytokine interleukin 37 is an endogenous inhibitor of
trained immunity
Giulio Cavalli1,2, Mark Gresnigt3, Travis Nemkov4, Rob Arts2, Angelo D'Alessandro4,
Silvia Giugliano5, Elan Eisenmensser4, Lorenzo Dagna1, Leo Joosten2, Mihai Netea2,
Charles Dinarello2,6
1Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UniRAR), Vita-Salute
San Raffaele University, Milan, Italy; 2Department of Medicine, Radboud university
Medical Centre, Nijmegen, Netherlands; 3Microbial Pathogenicity Mechanisms, Leibniz
Institute for Natural Product Research and Infection Biology, Jena, Germany; 4Department
of Biochemistry and Molecular Genetics, University of Colorado Denver, Aurora, CO,
United States; 5Mucosal Immunology and Microbiota Unit, Humanitas University, Rozzano,
Italy; 6Department of Medicine, University of Colorado Denver, Aurora, CO, United
States
Correspondence: Giulio Cavalli
Introduction: Trained immunity (TI) is a de-facto innate immune memory program induced
in monocytes/macrophages by exposure to pathogens or vaccines, which evolved as a
protective mechanism against infections. TI is characterized by rewiring of functional,
epigenetic and metabolic programs of innate immune cells such as monocytes and macrophages,
which sustain enhanced production of pro-inflammatory cytokines. Since aberrant activation
of TI is implicated in inflammatory diseases, tight regulatory mechanisms are likely
in place, but the mechanisms responsible for this modulation remain elusive.
Objectives: Scope of this study was to evaluated the role of IL-37, an anti-inflammatory
cytokine that curbs inflammation as well as modulates metabolic pathways, as an endogenous
regulator of trained immunity.
Methods: The effects of recombinant IL-37 were evaluated in a mouse model of TI induced
by the administration of beta-glucan in vivo (survival to a lethal inoculum of infectious
agents, production of inflammatory cytokines, recruitment of inflammatory cells at
the sites of infection). Subsequently, the effects of IL-37 were evaluated ex vivo
on splenic and bone marrow monocytes (production of inflammatory cytokines, metabolomic
analysis of the activation status of the main pathways of cellular energy metabolism).
Finally, we evaluated the association between IL-37 gene polymorphisms and the induction
of TI in monocytes of healthy donorswith in vitro functional studies.
Results: The exogenous administration of IL-37 abrogates the pro-inflammatory effects
of TI, significantly reducing the production of pro-inflammatory cytokines and the
survival of experimental animals subjected to a disseminated infection model. The
inhibitory effects of IL-37 on TI are also associated with reduced recruitment of
neutrophils at sites of inflammation. IL-37 and TI programs have differential and
opposite effects on the modulation of cellular energy metabolism of monocytes. In
humans, polymorphisms in the IL-37 gene are associated with reduced activation of
TI programs and reduced production of inflammatory cytokines by healthy donor monocytes.
Conclusion: In conclusion, IL-37 emerges as an endogenous regulator of TI, which makes
this cytokine a potential therapeutic target in immune-mediated pathologies.
Disclosure of Interest
None Declared
PT2B05 Interleukin 18 gene expression by human monocytes is controlled by type I interferon
Emely Verweyen1, Dirk Holzinger2, Helmut Wittkowski1, Peter Pickkers3, Dirk Foell1,
Christoph Kessel1
1Pediatric Rheumatology and Immunology, University Children's Hospital, Muenster;
2Child and Adolescent Medicine, University Hospital, Essen, Germany; 3Intensive Care
Medicine, Radboud University Medical Center, Nijmegen, Netherlands
Correspondence: Christoph Kessel
Introduction: Interleukin (IL) 18 is a member of the IL-1 cytokine family and has
a pivotal role in natural killer and T cellular interferon (IFN) γ production but
its precise function in inflammatory diseases as well as regulatory mechanisms underlying
IL-18 expression still remain poorly understood.
Objectives: Both IL-1β and IL-18 are particularly associated with the autoinflammatory
diseases familial mediterranean fever (FMF) or systemic juvenile idiopathic arthritis
(sJIA) and IL-18 is thought to drive autoinflammation or infection associated macrophage
activation syndrome (MAS). Apart from gathering evidence for the pathophysiological
implications of IL-1β and IL-18, several studies have investigated the genetic control
of IL-1β expression, highlighting a role for NF-κB in IL-1β transcription. Albeit
there are some studies that investigated IL-18 expression by either murine or human
cells, it still remains poorly understood whether and how this is regulated.
Methods: Cytokine expression in plasma of healthy individuals subjected to lipopolysacharide
(LPS) re-challenge experiments was quantified. LPS-stimulated primary human monocytes
isolated from healthy donors were analyzed for cytokine expression on gene and protein
level over time as well as following various drug or recombinant cytokine treatments.
Results: In plasma of healthy individuals subjected to LPS re-challenge experiments
we initially observed that, in contrast to TNFα, IL-6 or IL-1β, the IL-18 levels were
unaffected by LPS-tolerance. Similarly, in endotoxin desensitization experiments on
primary human monocytes, IL-18 gene expression was resistent to endotoxin tolerance
and appeared to rather benefit from endotoxin re-challenge. When studying time kinetics
of cytokine gene expression, we found that IL-1 and IL-18 followed identical secretion
but completely divergent gene expression patterns, thus providing an explanation for
observations on IL18 expression in LPS re-challenge experiments. When studying triggers
for the observed attenuated gene expression kinetics of IL-18, we found that both
IL-18 gene and protein expression upon LPS-stimulation of primary human monocytes
was not affected by other prominent inflammatory cytokines but was sensitive to interference
with JAK/STAT-signaling and could be modulated by type I interferon priming of cells
or STAT1 gain-of-function. While by itself type I interferon did not induce IL-18
expression, IFNβ-neutralization during LPS-stimulation blunted IL18 transcription.
Further, microtubule-destabilizing drugs, such as colchicine, completely abrogated
monocytic IL18 expression, which could be reversed by addition of type I interferons.
Conclusion: Our data suggest monocytic IL-18 expression to require cooperate toll-like
receptor and type I interferon signaling, which has implications for IL-18 expression
during viral infections and its overexpression in autoinflammation and MAS.
Disclosure of Interest
None Declared
PT2B06 Glycogen synthase kinase 3B regulates TLR3-mediated antiviral response
Ryeojin Ko, Soo Young Lee
Department of Life Science and the Research Center for Cellular Homeostasis, Ewha
Womans University, Seoul, Korea, Republic Of
Correspondence: Ryeojin Ko
Introduction: Toll-like receptor 3 (TLR3) plays a critical role in the antiviral immune
response. The protein tyrosine kinase BTK has been reported to regulate signal pathways
for TLR3-mediated antiviral gene expression. However, the regulation of BTK activity
in TLR3 signaling remains unclear.
Objectives: Here we investigate the molecular mechanisms underlying GSK3b regulation
of BTK in TLR3-mediated antiviral gene expression.
Methods: To determine whether GSK3b regulates TLR3-mediated antiviral response, we
establish the GSK3b knockdown stable macrophage cell lines.
Results: We demonstrate that GSK3b positively regulates TLR3 signaling via BTK activation.
After poly I:C stimulation, GSK3b interacts with BTK in a time-dependent manner. Furthermore,
suppression of GSK3b expression or its kinase activity significantly reduces the poly
I:C-induced BTK activation and antiviral gene expression such as type I interferon
(IFN) and IFN stimulated gene (ISG).
Conclusion: Together, our results suggest that GSK3b is critical for antiviral response
by regulating TLR3 signaling and is a potential molecular therapeutic target in autoimmune
disease.
Disclosure of Interest
None Declared
PT2B07 Anticytokine therapy is successful inprevention and treatment OFBCG-associated
inflammatory syndrome (IS) after hematopoietic stem cell transplantation (HSCT) in
patients with severe combined immunodeficiencies (SCID)
Alexandra Laberko1, Irina Shipitsina2, Svetlana Rodigina2, Sergei Blagov2, Daria Yukhacheva1,
Elena Deripapa1, Anna Kozlova1, Yulia Rodina1, Larisa Shelikhova2, Dmitrii Balashov2,
Anna Shcherbina1
1Immunology; 2Hematopoietic Stem Cell Transplantation, National Medical Research Center
of Hematology, Oncology and Immunology Named After D. Rogachev, Moscow, Moscow, Russian
Federation
Correspondence: Anna Shcherbina
Introduction: Immune recovery IS is a well-known complication in patients with HIV-driven
acquired immunodeficiency syndrome after initiation of antiretroviral therapy.It is
caused by cytokine storm due to recovering CD4+ lymphocyte activation in response
to persistingpathogens. We observed similar phenomena in patients with SCID after
allogenic HSCT.
Objectives: To report BCG-related IS in a group of SCID patients.
Methods: 22 SCID patients, vaccinated with BCG, received allogenic haploidentical
HSCT with TCRab/CD19 graft depletion in our Center between 2012 and 2018. Seven patients
had symptoms of BCGitis before HSCT, at the moment of HSCT BCGitis was controlled
by antimycobacterial drugs in all of them.
Post-transplant immunosuppressive therapy before November 2016 ( 11 patients) included
tacrolimus, in 2 cases in combination with short course of methotrexate. From November
2016 11 patients received graft versus host disease and cytokine release syndrome
prophylaxis with tocilizumab 8mg/kg days -1 , +14, + 28, abatacept 10mg/kg days -1,
+5, +14, +28.All patients have been receiving from 2 to 4 antimycobacterial drugs
for BCGitis prophylaxis at HSCT and in posttransplant period until full immune recovery.
Results: 5\22 patients developed early BCG-related IS (4/11 prior to tocilizumab introduction,
and only 1/11 – with tocilizumab). Three of them presented at days +4, +6 and +12
after HSCT with sustained fever, focal BCGitis exacerbation and one additionally developed
macrophage activation syndrome (MAS). All received therapy with steroids and IL-1
inhibitors, in one of them IS symptoms were controlled, but eventually all three died
shortly after. One patient without signs of BCGitis before HSCT at day +38 developed
IS with symptoms of systemic BCG infection and MAS. He was successfully treated with
combination of etoposide and IL-6 receptor inhibitors – tocilizumab 10mg/kg. In one
patient local BCGitis resolved without treatment. In most cases of early IS significant
elevation of TCRgd cell level was observed.
Six patients (5/6 with tocilizumab prophylaxis ) had immune recovery associated IS
2,5 - 5,5 months after HSCT (M 4,4 months), accompanied by CD3+ lymphocytes increase
in peripheral blood. Symptoms included focal BCGitis in all 6 (5 of them had no BCGitis
before HSCT), fever in 3, lymphadenopathy in 3, MAS in 1. In four patients monotherapy
of anakinra 7-12mg/kg/day was used with full response within 2-4 weeks. They were
later switched to canakinumab 5mg/kg every 4 weeks for the next 1-3 months. In one
patient IS was controlled by 2 infusions of tocilizumab 10mg/kg every 4 weeks. The
patient who developed MAS received anakinra 10mg/kg in combination with steroids with
full resolution of symptoms.
Conclusion: BCG vaccinated SCID patients are at high risk of BCG-related early IS
after HSCT. Anticytokine therapy with IL6 receptor inhibitor is an effective option
for prevention of early BCG-related IS. IL1 inhibitors lead to full resolution of
BCG-related immune recovery IS.Evidence-based protocols for IS prevention and treatment
are needed.
Disclosure of Interest
None Declared
PT2B08 Allogeneic haematopoietic stem cell transplantation (HSCT) outcome in immunedysregulation
and rheumatologic patients: a single center 19 years experience
Sara Signa1,2, Andrew Gennery1, Sophie Hambleton1, Terence Flood1, Andrew Cant1, Mario
Abinun1, Mary Slatter1
1Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust
and Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle upon
Tyne University, Newcastle upon Tyne, United Kingdom; 2University of Genoa and Center
for Autoinflammatory Diseases and Immunodeficiencies-Clinics of Pediatrics and Rheumatology
, G.Gaslini Institute, Genoa, Italy
Correspondence: Sara Signa
Introduction: Haematopoietic stem cell transplantation (HSCT) is a potential treatment
for severe and conventional therapy-resistant immune dysregulation disorders (autoinflammatory
diseases ,complex autoimmune diseases, complex rheumatologic diseases).However, it
still remains the ‘last resort therapy”, particularly in pediatric age.
Objectives: To present the outcome of HSCT in 55 children with immune dysregulation
in a single center over a 19 year period of time.
Methods: We retrospectively collected cases of pediatric patients who underwent allogeneic
HSCTat Great North Children’s Hospital, Newcastle upon Tyne, UK between 01/1999 -06/2018
for immune dysregulation, rheumatologic and autoinflammatory disorders.Medical charts
were reviewed and the following data were extracted: patient demographics, diagnosis,
indication for HSCT, donor-recipient matching, conditioning regimen, and graft composition.
Post-transplantation data were collected on occurrence of GVHD, infections, and relapse
of initial (or occurrence of new, secondary, post-HSCT) immunedysregulation.
Results: We identified 55 patients who underwent allogeneic HSCT: 8 presented with
a defined Rheumatologic disease (5 children JIA, 3 with systemic lupus erythematosus),
7 patients with CTLA-4 deficiency, 6 with STAT 3 gain-of-function mutation disease,6
with IPEX syndrome, 7 with autoinflammatory disorders, 3 children with ALPS, 5 with
autoimmune enteropathy, 2 with STAT1 gain-of-function disease, 7 with complex autoimmuny
features, and two each with RAS associated autoimmune lymphoproliferative disorder
(RALD) and FADD deficiency. 41 patients presented with a monogenic disease, although
only 21 were diagnosed pre- HSCT.Mean age of symptom onset was 3.5 years (range: birth-15.34
years). Mean age at HSCT was 8.5 years (range: 0.25-19.34 years). Patients underwent
HSCT from 10/10 or 12/12 HLA matched unrelated donors (n 29), 9/10 HLA mismatched
unrelated donor (n 5), matched sibling donor (n 14), 9/10 HLA mismatched related donor
(n 3) or haploidentical TCR alpha/beta-CD19+ depleted parental donor (n 4). Most patients
received reduced toxicity conditioning with fludarabine 3, treosulfan, alemtuzumab(n
27). Peripheral blood was the stem cell source in most cases (n 32). Most received
cyclosporine (CsA) and mycophenolate mofetil (MMF) as GVHD prophylaxis (n 37). One
did not engraft, needing a rapid second HSCT procedure. 39 patients showed evidence
of viral replication (61%) , sometimes from multiple pathogens. Acute GVHD was usually
mild and confined to skin (grade I/II, n=27, 49%).Severe acute GVHD occurred in 6
patients (grade III-IV GVHD -10%; 3 died) and two patients experienced extensive chronic
GVHD, both deceased.With a median follow-up of 6 .67years (range, 2 months-18 years),
43 of 55 patients were alive and most are either cured and completely healthy (n=21)
or significantly improved but with pre-existing end-organ damage (n=11). 19 patients
experienced new autoimmune phenomena post-transplant, mostly involving thyroid or
hematologic-related.Among the 12 deceased patients, one died from non-transplant related diabetic
ketoacidosis, whereas five patients died of GVHD-related causes, five due to infectious
causes and one due to extreme induction toxicity, giving a transplant related mortality
(TRM) of 20%. Mean age of death was 11 years (range: 0.67-21 years).
Conclusion: Allogeneic HSCT can be an effective therapeutic option for severe refractory
immune dysregulation in childhood, potentially curative. Appropriate and timely patient
selection is fundamental to minimise HSCT-related complications.
Disclosure of Interest
S. Signa Grant / Research Support from: Research Support from: EFIS-Immunology Letters
(IL) Short-Term Fellowship, A. Gennery: None Declared, S. Hambleton: None Declared,
T. Flood: None Declared, A. Cant: None Declared, M. Abinun: None Declared, M. Slatter:
None Declared
PT2B09 Global profiling and molecular characterization of the autoantibody repertoire
in APECED
JohnM. Lindner1, Alexander Krämer1, Xavier Leber1, Valerie Caballero1, Frank Kolbinger1,
Michail S. Lionakis2, Steven Holland2, Elisabetta Traggiai1
1Novartis Institutes for BioMedical Research, Basel, Switzerland; 2National Institutes
of Health, Bethesda, United States
Correspondence: Elisabetta Traggiai
Introduction: Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED,
also called APS-1), is a phenotypically pleiotropic disease caused by the breakdown
of central T-cell tolerance due to mutation of the autoimmune regulator (AIRE) gene.
The presence of autoreactive antibodies (Ab) in APECED has implications for T cell-mediated
governance of B-cell tolerance. In particular, soluble factors such as cytokines and
antimicrobial peptides are frequent autoantigens in APECED. To fully characterize
the humoral response against these and other targets, we tested donor sera for reactivity
against more than 3000 secreted proteins using customized protein microarrays.
Results: Applying stringent evaluation methods, we identified more than 50 reactivities
enriched among 26 APECED patients relative to 19 healthy donors. We subsequently validated
several targets by ELISA, then screened patient IgG memory B cells for Ab of desired
specificities using recently developed high-throughput, multiplexed techniques for
culture, screening, and cloning. Of particular relevance is the production of Ab against
interleukin (IL)-17, given the relationship between TH17-mediated fungal control and
chronic candidiasis as a common clinical feature of APECED. To understand the composition
and functionality of these Ab, we cloned 15 antigen-specific IgG molecules from 3
APECED patients, and found clear patient-specific skewing toward IL-17A or IL-17F,
with some Ab showing cross-reactivity. Furthermore, several also bound the heterodimeric
IL-17AF in addition to their respective homodimers, and one Ab specifically bound
only the heterodimer, the latter one a specificity which has not yet been described.
All Ab showed extensive somatic hypermutation, had sub-nanomolar affinities, and functionally
block the interaction between IL-17 and its receptor.
Conclusion: These features indicate a clear history of interaction with antigen-specific
T helper cells, and suggest that autoantibodies in APECED can disrupt immune control,
offering insights into the therapeutic control both of APECED and other human diseases.
Disclosure of Interest
None Declared
Monogenic autoinflammatory diseases (clinical)
P2001 In vitro NLRP3 inflammasome activation assay assists diagnosis of genetically
negative CAPS patients and guides anti-IL1 therapy
Leonardo O. Mendonca1,2,3, Myrthes T. Barros2, Tereza Robazzi4, Pedro F. Giavina-Bianchi2,
Francesco Caroli5, Alice Grossi5, Jorge Kalil2, Fabio F. Morato Castro2, Isabella
Ceccherini5, Marco Gattorno6, Alessandra Pontillo3
1International Center for Autoinflammatory Diseases and Primary Immunodeficienceis,
Istituto Giannina Gaslini, Genoa, Italy; 2Autoinflammatory Unit, University of São
Paulo, School of Medicine; 3Immunogenetics Laboratory, Biomedical Science Institute,
University of São Paulo, Sao Paulo; 4Pediatric Rheumatology Unit, School of Medicine
of Bahia, Federal University of Bahia, Salvador, Brazil; 5UOC Medical Genetics; 6Center
for Autoinflammatory Diseases and Primary Immunodeficienceis, Istituto Giannina Gaslini,
Genoa, Italy
Correspondence: Leonardo O. Mendonca
Introduction: Constitutive activation of NLRP3 inflammasome and the consequent elevate
production of inflammatory cytokine IL-1ß are the pathogenic mechanisms involved in
CAPS syndromes. However due to the heterogeneity of clinical presentation and to the
missing of genetic proving in 40% of patients, both diagnosis and therapeutic choice
are often tricky.
Cryopirin/NLRP3-associated periodic syndromes (CAPS) is a group of rare autoinflammatory
diseases characterized by early onset urticarial rash and periodic fever, positive
acute reactants markers (CRP, SAA), arthritis and neurologic involvement, including
ocular disorders and progressive deafness. The constitutive activation of NLRP3 inflammasome
and the consequent elevate production of inflammatory cytokine IL-1ß are the pathogenic
mechanisms involved in CAPS. Gain-of-function mutations in NLRP3 were detected in
about 60% of patients. Early diagnosis and quick start of anti-IL-1 treatment are
very important to prevent severe complications, however due to the heterogeneity of
clinical presentation and to the missing of genetic proving in 40% of patients, both
diagnosis and therapeutic choice are often trickThe constitutive activation of NLRP3
inflammasome and the consequent elevate production of inflammatory cytokine IL-1ß
are the pathogenic mechanisms involved in a group of rare autoinflammatory diseases
grouped as Cryopirin Associated Periodic Syndromes. Gain-of-function mutations in
NLRP3 were detected in about 60% of patients. Early diagnosis and quick start of anti-IL-1
treatment are very important to prevent severe complications, however due to the heterogeneity
of clinical presentation and to the missing of genetic proving in 40% of patients,
both diagnosis and therapeutic choice are often trickyThe constitutive activation
of NLRP3 inflammasome and the consequent elevate production of inflammatory cytokine
IL-1ß are the pathogenic mechanisms involved in a group of rare autoinflammatory diseases
grouped as Cryopirin Associated Periodic Syndromes. Gain-of-function mutations in
NLRP3 were detected in about 60% of patients. Early diagnosis and quick start of anti-IL-1
treatment are very important to prevent severe complications, however due to the heterogeneity
of clinical presentation and to the missing of genetic proving in 40% of patients,
both diagnosis and therapeutic choice are often tricky.
Objectives:
Demonstrate the usefulness of an in vitro test for NLRP3 inflammasome activation as
supportive method for CAPS diagnosis and therapeutic choice.
Methods: Five patients (P1-P5) with a suspect of CAPS were included in a pilot study
between 2016 and 2018. All patients were genetically sequenced using gene panels for
mutations in candidate genes (NLRP3, NLPR12 and NLRC4). Monocytes were stimulated
with LPS and ATP. IL-1ß concentration was measured in serum and culture supernatants
by ELISA.
Results: All patients presented clinical features compatible with a CAPS. Candidate
genes screening revealed a pathogenic mutation in NLRP12 (exon 3; c.C910T; p. H304Y)
in P1 and a variant of uncertain significance (VUS) in NLRP3 (exon 4; c.A2176G; p.S726G)
in P2. The other 3 patients were genetically negative. Monocytes isolated from P2,
P3 and P4 produced high level of IL-1ß when challenged with LPS, and ATP did not amplify
cytokine production, suggesting a defect in NLRP3 inflammasome. P1 and P5 produced
normal levels of IL-1ß. According with NLRP3-IA test results, P3 and P4 were successfully
treated with anti-IL1. P2 presented also an IgM monoclonal gammopathy, therefore receiving
a final diagnosis of Schnitzler Syndrome (SS); colchicine ameliorated his clinical
presentation. P5 (genetically negative and NLRP3-IA test negative) was successfully
treated with corticosteroids.
Conclusion: These results demonstrate the convenience of the NLRP3-IA test in the
examination of suggestive CAPS and SS patients, especially for those with negative
genetic test, to (1) confirm the diagnosis and to (2) guide the therapeutic choice.
Disclosure of Interest
None Declared
P2002 Vaccination safety and coverage in a single cohort of autoinflammatory syndromes
in Italy
Leonardo O. Mendonca, Enrica Toniolo, Stefano Volpi, Roberta Caorsi, Marta Bustaffa,
Matteo D'Alessandro, Sara Signa, Marco Gattorno
International Center for Autoinflammatory Diseases and Primary Immunodeficienceis,
Istituto Giannina Gaslini, Genoa, Italy
Correspondence: Leonardo O. Mendonca
Introduction: Vaccine-preventable diseases are emerging after anti-vaccine movements
appear. In AID, vaccine triggered-disease is a well known phenomena for Hyper-IgD/Mevalonate-Kinase
Deficiency (MKD). However, recent publications stressed out doubts in physicians and
families, regarding severe flares after pneumococcus vaccine in CAPS or that PFAPA
patients does not achieve sufficient and protective levels of antibodies.
Objectives: This work aims to evaluate the vaccination coverage of Italian Vaccination
Schedule and the prevalence of adverse reactions or disease induced flare to vaccine
in a single cohort of AID in Italy.
Methods: An anamnestic questionnaire was applied to outpatients, followed at AID Unit,
Istituto Giannina Gaslini from august 2017 to august 2018. Data acquired was revised
for quality of information. Data of triggers in Autoinflammatory disease from EUROFEVER
registry was obtained for statistical reference.
Results: Triggers in AID Eurofever Registry: In august 2018 a total of 3783 patients
were enrolled in EUROFEVER registry and 50,43%, 1908 were female. The average of age
symptoms started was 7.04 years (standard deviation of 9,48 years, minimal of 0 and
maximum of 75,92 years).The distribution among the periodic hereditary fevers were:
28,75% were FMF (n=1081); 17,66% were PFAPA (n=666); 7,85% (n=297) were CAPS; 7,16%
were TRAPS (n=271) and 5,39% were MKD (n=204). Vaccine triggered disease was most
common in MKD with 70%. PFAPA, TRAPS and UND presented with similar prevalence of
reactions, around 20%. CAPS had 12,34% of vaccine reactions identified. FMF and inflammatory
bone disorders carried 6% and 3%, respectively. Excluding other causes of reactions,
and isolating just vaccine as cause, MKD still remains the top of the rank (7,14%).
Just PFAPA and UND had more than 1% and CAPS, TRAPS, FMF and inflammatory bone disorders
had all less than 1%. IGG cohort: 150 questionnaires were distributed with 70% rate
of response. Quality of data was 100% for coverage and adverse reactions. Data of
105 patients could be obtained distributed as PFAPA (n=26); CAPS (n=5); TRAPS (n=6);
FMF (n=14); MKD (n=8); Inflammatory Bone Disorders (CRMO and PAPA, n=4) and Undefined
Inflammatory Diseases, UND, (n=41). Rate of converage was lower than 90% for Hib3
(83,11%) , all measles containing vaccine MMR/MMRV (88,9%) and for Rota C (1,85%).
For DTP3, Hep3, PCV3 and IPV the rate of coverage was higher than 90% for all vaccines.
A total of 13 severe/serious reactions was observed following: 5 after DTPA+IPV (1
PFPAPA; 2 TRAPS, 1 MKD and 1 UND); 2 after Hep B (TRAPS); 1 after Hib (PFAPA); 1 after
P10/13 (PFAPA); 4 after MPR (1 PFAPA, 1 TRAPS, 1 MKD and 1 UND) and 1 afterHepatitis
C (1 PFAPA). The general rate of severe reaction per shot was 7,7 for every 1000 shots
and no severe infection, death, persistent or significant disability or life-threatening
condition was observed. Just one patient, MKD, with severe/serious flare required
hospitalization due to disease activity following pneumocoocal vaccine.
Conclusion: Vaccination in AID is a distinct and a potential public health problem.
Specific recommendations for vaccination in AID are extremely necessary as well as
further investigations for immunologic protection.
Disclosure of Interest
None Declared
P2003 Peripheral T regulatory lymphocytes and apoptosis expression in a large group
of autoimmune, multifactorial and autoinflammatory diseases reveals specific clinical
manifestations
Leonardo O. Mendonca1, Marta Bustaffa1, Caterina Matucci-Cerinic1, Ignazia Prigione1,
Stefano Volpi1, Roberta Caorsi1, Sabrina Chiesa1, Francesca Schena1, Alice Grossi2,
Paola Terranova3, Isabella Ceccherini2, Maurizio Miano3, Marco Gattorno1
1International Center for Autoinflammatory Diseases and Primary Immunodeficienceis;
2UOC Medical Genetics; 3Pediatric Hematology Unit, Istituto Giannina Gaslini, Genoa,
Italy
Correspondence: Leonardo O. Mendonca
Introduction: The application of the semantical immunological division into innate
and adaptive immunity to systemic inflammatory syndromes segregates autoinflammatory
from autoimmune diseases. Nonetheless a large number of conditions falls down into
undefined systemic inflammatory syndromes and some share clinical characteristics
with immunedysregulation syndromes such as Autoimmune Lymphoproliferative Syndromes
(ALPS) characterized by activation of apoptosis pathway.
Objectives: Characterize clinically, immunological, molecular and therapeutically
a group of patients with high expression of apoptosis pathway. Describe the main diferences
expressions of regulatory T cells in a large group of autoinflammatory, autoimune
and multifactorial diseases.
Methods: Retrospective review of all patients submitted, from 2015 to 2018, to flow
citometry, for specific ALPS markers and markers of lymphocyte apoptosis: CD3+TCRαβ+CD4-CD8-(αβ-DNTCs),
CD19+CD27+(Memory B), TCR αβ+ B220+, CD3CD25+/CD3HLA-DR+ RATIO. Furthermore NK cells,
NKT-like cells (CD3+CD16+CD56+), B cells TCRγδ+, Treg, Tnaive and Tmemory cells ,
sFAS ligand, interleukin 18, interleukin 10, FAS-apoptosis were also studied. A similar
flow cytometry composed of healthy Italian controls was used as reference. All clinical
and laboratory results were statistically analyzed.
Results: A total 2089 “ALPS-flow” was realized between 2015-2018. Data that could
not be accessed or repeated was ruled out. Finally, 562 flow cytometry was selected
and revised. Results divided by age resulted in (number ;female ratio ; average age
flow was performed): 1-12 months (9; 55,5%; 0,78); 1-5 years (174; 43,67%; 3,13);
5-10 years (150; 43,3%; 7,25) and > 10 (220 ; 62,33%; 19,5) and no difference between
healthy controls were observed. High levels (>1,8) Double negative T cells (CD4-CD8-(αβ-DNTCs)
were present in 38 patients carrying the diagnosis of ALPS/ALPS-like, 14 patients
with PFAPA, 30 patients with undefined syndromes and in 9 patients with classical
autoinflamamtory diseases. 13 patients fulfilled the four flow criteria for apoptosis
(1 ALPS, 1 PFAPA, 1 AID, 6 UIS, 1 autoimmune and 1 SJIA). Clinical and immunological
comparison was done between those who had complete response to sirolimus or micofenolate.
28 patients were genetically sequenced for large genetic pannels.
Conclusion: The “alps flow” is an useful instrument to guide clinical evaluation in
undefined inflammatory syndromes and can guide specific therapy. Further evaluations
are necessary to understand the immunological observation of apoptosis activation
in this group of patients.
Disclosure of Interest
None Declared
P2004 Association of gene polymorphism with autoinflammatory syndromes in patients
with palindromic rheumatism and intermittent hydrathrosis
Takako Miyamae, Yumi Tani, Takayuki Kishi, Manabu Kawamoto, Yasushi Kawaguchi, Atsuo
Taniguchi, Hisashi Yamanaka
Institute of Rheumatology, Tokyo Women's Medical University, Tokyo, Japan
Correspondence: Takako Miyamae
Introduction: Palindromic rheumatism (PR) is defined as articular and para- articular
inflammation that lasts from a few hours to several days, which resolves spontaneously
and is associated with increase in inflammatory markers during active disease. It
is characterized by recurrent joint manifestations without residual joint destruction.
Intermittent hydrarthrosis (IH) is a chronic condition of unknown cause characterized
by recurring, temporary episodes of fluid accumulation in the knee. The cause is unknown
but allergic and auto-inflammatory mechanisms have been proposed. More recently, specific
association with the Mediterranean fever gene, MEFV, has been proposed. So, with some
individuals carrying gene mutations (MEFV and also TRAPS-related genes), the native
immune system seems to plays a role in the development of IH.
Objectives: We evaluated polymorphisms of the genes responsible for AID and clinical
characteristics in patients diagnosed as PR with IH.
Methods: Among patients who visited Institute of Rheumatology, Tokyo Women’s Medical
University, those who fulfills thediagnostic criteria of PR by Gonzal-Lopez L, et
al. and manifested IH were enrolled in this study. Polymorphisms of AID genes, clinical
manifestations, findings of blood examinations and joint images, treatment responses,
and outcome were evaluated retrospectively. Genomic DNA was isolated from the patients’
peripheral blood and a polymerase chain reaction (PCR) was used to amplify the indicated
exons of 12 genes: MEFV (exons 1-10), TNFRSF1A (exons 2-4), MVK (exons 9-11), NLRP3
(exon 3-6), NOD2 (exon 4), LI1RN (exons 2-4), IL36RN (exons 2-5), PSMB8 (exons 2,
3, and 5), NALP12 (exons 3 and 9), PSTPIP1 (exons 10 and 11), TNFAIP3, and NLRC4.
After cleaning the PCR products, cycle sequencing was carried out using the Big Dye®
Terminator v3.1 kit and analyzed with an ABI 3130xl Prism Genetic Analyzer. Genetic
polymorphisms within the above-mentioned genes were examined.
Results: Out of six patients (2 males and 4 females, median age: 47.1 years, median
age at disease onset: 20 years, median disease duration:12 years), all manifested
intermittent knee hydrathrosis lasting for several days with 1-4 weeks of attack intervals.
Rheumatoid factor and anti-cyclic citrullinated peptides antibody were not detected
in anyone. Knee joint X-ray showed no abnormality in all cases whereas increased synovial
fluid and synovium tissue proliferation with positive vascularity by ultrasonography.
Polymorphisms of AID genes were identified in all 7 cases as following; MEFV (n=4,
all non-exon10), CIAS1(n=1) and TNFRSFIA (n=1). Regarding efficacy of medical treatments,
although csDMARDs were not effective in all cases, colchicine applied to 4 with MEFV
polymorphism was effective in all the four cases. TNF inhibitors was effective in
one of two. During observation, no patients developed rheumatoid arthritis and one
patient was complicated with Bechet’s disease.
Conclusion: Association of polymorphisms of the genes responsible for auto-inflammatory
diseases should be considered in cases manifesting PR, especially IH, though systemic
manifestations were not noted. Colchicine is promising medication in these conditions.
Disclosure of Interest
None Declared
P2005 Report of 65 patients with SAID in Argentina
Ileana Moreira, Analía G. Seminario, Agostina Llarens, Lina R. Riaño Cardozo, Lorena
Regairaz, Liliana Bezrodnik
Immunología, Centro de Inmunología Clínica Dra. Bezrodnik, Buenos Aires, Argentina
Correspondence: Ileana Moreira
Introduction: Systemic auto-inflammatory diseases (SAID) can be defined as a group
of immunodeficiencies marks by excessive inflammation that is predominantly mediated
by increase response to known or unknown triggers by cells and molecules of the innate
immune system. Most patients have recurrent systemic inflammation episodes with fever,
acute phase reactants elevated and several clinical manifestations, with healthy intervals.
SAIDs have, in most cases, a genetic background, with highly penetrant mutations of
single genes, but some cases are polygenic with strong environmental influence that
can modulate the phenotype.
Objectives: Report 65 Argentinian patients with different SAID.
Methods: Retrospective analysis of medical records of 65 patients with SAID.
Results: The patients have: Family mediterranean fever (FMF):22 patients (p), Hiper
IgD Syndorme (HIDS): 1p. Familial Cold Autoinflammatory Syndrome (CAPS): 1p. Chronic
atypical neutrophilic dermatitis with lipodystrophy (CANDLE) like: 1p. Syndrome of
periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA syndrome):
30p and 10p are unclassified.
Most of them are female and only 5/63 has a relative affected.
The median age of the first symptom was 2 yo (0-16 yo) and the median age at first
immunology consult was 10 yo (0.1-48y).
The most frequent clinical manifestation was periodic fever and skin compromise. Other
symptoms include: abdominal pain, arthralgia, aphthas, adenomegalies, pharyngitis,
headache and chronic diarrhea.
During the fever episodes most of them had neutrophilia and elevated CRP and ESR.
Four patients have humoral compromise (2 with FMF and the ones with CAPS and Candle
like).
Among the FMF, five patients have homozygous pathogenic variants and three have heterozygous
compound variants. There are 14 patients with heterozygous variants, but all of them
have periodic fever with several associated symptoms and also all of them present
good response to oral colchicines treatment.
The CAPS patient has a heterozygous variant in NLRP12 and he is doing well with IVIG
and oral budesonide. The patient with Candle-like syndrome has a poor response to
steroids, anti-TNF and anti IL-1β. She has a homozygous variant in SAMD9L. After diagnosis,
she received a full matched non related donor HSCT with full engraftment.
Among the patients with PFAPA syndrome, most of them have good response to oral steroids
during crisis and half of them required also daily colchicine. All of them improve
around 6 yo without new episodes.
None of patients have currently amyloidosis.
Conclusion: The symptoms between the different diseases can be similar, with predominant
skin involvement, in addition to fever. All patients with heterozygous variants in
MEFV gen were symptomatic and improved with the treatment. Only in 1 patient (SAMDL9)
needed biological treatment, all the others had have good responses to colchicine
or steroid treatment. There is a significant difference between the age of onset of
the symptoms and the age of the first visit to the immunologist. We believe that the
diagnosis is important because of potential implications for therapy, monitoring for
the development of secondary amyloidosis, and the need for genetic counseling. Diffusion
of SAID between pediatricians and clinicians would improve the age of diagnosis.
Disclosure of Interest
None Declared
P2006 Multisystemic inflammatory disease due to DNASE2 mutations: from physiopathology
to new therapeutic approaches
Valentina Moressa1, Alessandra Tesser2, Andrea Trombetta1, Sergio Ghirardo1, Marco
Bobbo1, Elisa Piscianz1, Flavio Faletra2, Stefano Volpi3, Alberto Tommasini2, Serena
Pastore2, Andrea Taddio2
1University of Trieste, Italy; 2IRCCS Burlo Garofolo, Trieste, Italy, Trieste; 3IRCCS
Istituto G. Gaslini, Genova, Italy
Correspondence: Valentina Moressa
Introduction: We recently described the case of a boy with a novel interferonopathy
due to DNase2 deficiency. He presented at birth a TORCH-like picture with hepatitis
and cytopenias, self-healing in the following months. In his early years, he presented
unexplained fever episodes, growth retardation, and poly-articular arthritis. In the
subsequent years he developed lipodystrophy, skin rash and lupus pernio. The disease
was refractory to several antirheumatic drugs and steroids. At the age of 15 years,
DNase2 deficiency was diagnosed by exome analysis (1). Functional data showed that
the disease is due to cGAS-dependent interferon inflammation, paving the way for improved
treatments based on the inhibition of the hyperactive pathway.
Objectives: To describe how the diagnosis impacted on medical choices and overall
clinical history of a patient.
Methods: Review of clinical sheets and analysis of interferon signature over the 4
years after genetic diagnosis.
Results: At the time of the genetic diagnosis, the patient complained of failure to
thrive, severe poly-articular arthritis with impairment in walking ability, almost
requiring a wheelchair assistance, and severe headache (NRS 9-10) requiring daily
administration of major analgesics like tramadol. Treatment included: prednisone,
Ramipril, lansoprazole, calcium, celecoxib, tramadole and abatacept.
After the diagnosis, a treatment with hydroxychloroquine and mepacrine was started,
based on proofs of an inhibitory action of these drugs on cGAS (2). With such therapy,
he was able to reduce the dosage of steroids and to improve motor capacity. To obtain
a more complete control of the disease, ruxolitinib (JAK1/2 inhibitor) was added at
the dosage of 10 mg, resulting in a rapid improvement of the headache and of the articular
range of motion. In the subsequent six month, the lipodystrophy also showed some improvement,
allowing further steroids tapering. However, he developed fatigue, tachycardia and
peripheral cyanosis. Cardiologic assessment detected pulmonary arterial hypertension
(PAH) and thus the boy started treatment with sildenafil, iloprost, and ambisentan.
Considering a possible adverse effect of ruxolitinib, as supported by a single case
report (3), we interrupted all immunosuppressive therapies except for steroid boluses,
but without any improvement. Moreover, he developed progressive cytopenia and increased
interferon signature. Therefore he started again ruxolitinib at an higher dose, together
with antimalarials, obtaining a marked drop of pulmonary pressure and an improvement
in interferon signature, as described in published cases ofPAH (4). In few months
he got well again, being able to taper steroids. Recently, ruxolitinib was switched
to baricitinib, without any evident change in clinical efficacy.
Conclusion: The overall clinical improvement and the possibility of reducing the corticosteroid
dosage suggest that treatment of our patient can be considered a precision, tailored
therapy.
Nevertheless, due to the novelty and the rarity of such cases, hard is to disentangle
between manifestations of the disease and the effects of treatments that are tailored
to each patient without a consistent previous experience, as it is evident for orphan
disease.
1. Rodero MP, et al. Nat Commun. 2017 Dec 19;8(1):2176.
2. An J, et al. The Journal of Immunology, 194(9), 4089–4093.
3. Low AT, et al. Haematologica, 100(6), e244–e245.
4. Sanchez GAM, et al. J Clin Invest. 2018 Jul 2;128(7):3041-3052.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2007 Pregnancy and other gynecological aspects in mevalonate kinase deficiency
Catharina Mulders-Manders, Anna Simon
Radboud University Medical Center, Nijmegen, Netherlands
Correspondence: Catharina Mulders-Manders
Introduction: Mevalonate kinase deficiency (MKD) is one of the classic monogenic autoinflammatory
diseases. Only two pregnancies in MKD patients, have been reported, both with favorable
outcome. Little is known on the influence of MKD on pregnancy or other gynecological
aspects.
Objectives: To gain further insight in pregnancy, lactation and gynaecological aspect
in MKD.
Methods: All adult female MKD patients from the Radboud university medical center,
a Dutch expertise center on MKD, were asked to fill out an online questionnaire regarding
pregnancy, lactation, menses and anticonceptive use, and their influence on frequency,
duration and symptoms of MKD attacks.
Results:
Pregnancy and lactation
Of twenty adult female MKD patients, eleven responded to the questionnaire (55.0%).
Median age was 28 years (range 21-55 years). Two patients were treated with anakinra
(18.2%) and six with canakinumab (54.5%).
Four participants indicated that they had ever wanted to become pregnant, and all
of them conceived spontaneously. One patient reported one pregnancy, and the other
three all reported two pregnancies. Median age at first pregnancy was 27 years (range
24-30 years). During all pregnancies, patients remained attack-free without treatment.
One of the four patients reported an MKD attack following delivery, and more frequent
attacks in the first three months thereafter.
During pregnancy, one patient was treated because of pre-eclampsia during the first,
and hypertension during her second pregnancy. Five other pregnancies were uncomplicated.
All pregnancies resulted in birth of a healthy living child without congenital abnormalities.
One patient reported two periods of lactation in two children: one week in the first
and 23 weeks in her second child. During lactation attack frequency was unchanged,
but attacks were shorter.
Other gynaecological aspects
Four of the eleven patients reported more frequent MKD attacks after menarche. Two
reported increased attack severity. In four patients, attacks were triggered by menstruation
and during menstruation, two patients experienced longer attack duration. During the
use of hormonal anticonceptive drugs, one out of eight patients experienced more frequent
attacks, while four reported a decrease in frequency. Two patients reported shorter
attack duration, while the other six did not notice any change in duration.
Two patients were in menopause, one of whom experienced more frequent attacks after
menopause. One patient reported a shorter attack duration, while the duration increased
in the other patient.
Five patients had ever experienced vaginal or vulvar ulcers.
Conclusion: During seven pregnancies in female MKD patients, no MKD attacks occured.
In one pregnancy delivery triggered an MKD attack, and during the only episode of
lactation, MKD attacks were shorter than usual. All seven children were born healthy.
As our cohort size was small, it would be interesting to confirm these positive findings
in a larger number of patients.
Disclosure of Interest
None Declared
P2008 Early onset sarcoidosis associated with NOD2 mutation: familial cases report
Roberta Naddei1, Francesca Orlando1,2, Carolina Porfito1, Teresa Lastella1, Marinabiondina
Amico1, Maria Alessio1
1Pediatric Rheumatology Unit, Mother and Child Department, University of Naples Federico
II; 2Department of Pediatrics, Santobono-Pausilipon Children’s Hospital, Naples, Italy
Correspondence: Roberta Naddei
Introduction: Early onset sarcoidosis is characterized by a triad of polyarthritis,
uveitis and rash. The familial cases, manifesting the classic clinical triad and an
autosomal transmission pattern, have been termed Blau syndrome (BS). The mutation
involved the NOD2 gene.
Objectives: To describe clinical features of a family with a history of uveitis, early
onset arthritis and skin rash.
Methods: Case report.
Results: The propositus (patient 1) is a 7-year-old female referred to our Unit at
the age of 2 years. The family history revealed a mother with rheumatoid arthritis
and visual loss due to panuveitis. The clinical history disclosed that at the age
of 12 and 15 months the patient had two episodes of diffused rash spontaneously resolved
in two weeks. From the age of 18 months recurrent hip pain, defined as transient synovitis
of the hip, was reported. It was treated successfully with non-steroideal antinflammatory
drugs (NSAID) but pain would reappear once stopped the treatment. Clinical evaluation
showed polyarticular symmetrical arthritis of wrists, elbows, knees, proximal interphalangeal
joints. Polyarticular Juvenile Idiopathic Arthritis (JIA) diagnosis was made and treatment
with NSAID and Methotrexate was started without significant improvement; therefore,
Etanercept was added and NSAID stopped. Screening of uveitis was performed every six
months. Persisting arthritis of right wrist after 7 months of therapy, ultrasound
was performed showing tenosynovitis. Therefore, she underwent intra-articular injection
of long-acting glucocorticoids with partial response. At the age of 4 years, she presented
papuloerythematous rash, mainly on the trunk, infiltrated and confluent in plaques;
skin biopsy was performed resulting consistent with granulomatous disease sarcoid-like.
Suspecting BS, molecular analysis was done. At the age of 5 years, she presented scotoma
and visual loss; the ocular assessment found bilateral anterior uveitis and posterior
bilateral synechiae. She started systemic glucocorticoid therapy and shifted from
Etanercept to Adalimumab with improvement of both ocular and articular disease. The
molecular analysis of NOD2 showed missense mutation p.R334W (c.1000C<T) consistent
with BS. Currently, the articular and cutaneous manifestations are controlled by the
combined therapy with Adalimumab and Methotrexate; the ocular disease evolved into irido-lenticular synechiae,
some mutton-fat keratic precipitates, band keropathy. She started topical treatment with improvement.
Her brother (patient 2, age 3 years) at the age of 34 months, developed boggy tenosynovitis
and face papuloerythematous rash; inflammatory cellular deposits at anterior segment
were disclosed at ophthalmic evaluation. Therefore, treatment with Adalimumab and
Methotrexate was started.
The molecular analysis of NOD2 gene in patient 2, in a youngest asymptomatic brother
and in the mother is ongoing.
Conclusion: Patient 1 presented typical clinical manifestations of pediatric sarcoidosis,
confirmed by skin biopsy. R334W is the most common mutation reported in the international
Blau registry. The presence of typical clinical manifestations, NOD2 mutation and
family history led to the diagnosis of Blau Syndrome. Clinical surveillance and molecular
analysis is essential in first-degree relatives of patients with Blau Syndrome in
order to recognize clinical manifestations precociously and start appropriate therapy.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2009 Extending the clinical spectrum of Blau syndrome, a case report with liver cirrhosis
Mohammed Nashawi1, Heiko Brennenstuhl1, Barbara Bangol2, Thomas Lutz1
1Center for Pediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg;
2Genetic Department, Center for Human Genetics and Laboratory Diagnostics, Martinsried,
Germany
Correspondence: Mohammed Nashawi
Introduction: Blau Syndrome is a rare auto-inflammatory disease with variants in NOD2
and an important differential diagnosis for periodic fever syndrome. Patients typically
present in the first year of life with fever and a triad (skin manifestation, arthritis
and uveitis). The patients could develop pan-uveitis, cardiac manifestation or even
renal diseases.
Objectives: Our objective is to expand the differential diagnosis of periodic fever
syndrome by characterizing a patient with atypical clinical features of Blau Syndrome
harboring the most common known genetic variant.
Methods: We used standard laboratory assessment of inflammatory markers, MRI and liver
biopsy. To confirm the diagnosis we used next generation sequencing to identify NOD2
variants.
Results: A 2-year-old male child presented to the hospital with recurrent fevers and
decompensating heart failure due to arterial hypertension. He could not walk because
of swelling in both ankles and additionally had swelling of the wrists. The past and
the family history were unremarkable. On clinical examination, his weight and length
were below the 3rd percentile. Skin examination showed erythematous exanthema on the
trunk. There were also hepatosplenomegaly and a cardiac murmur present. At that time,
he had been treated for heart failure and hypertension. After his medical condition
was stable, further work-up had been done to look for the cause of his symptoms. CRP
was massively increased. Infections and malignancy were excluded. There were no signs
of immunodeficiency and no signs of uveitis. With the presented symptoms and signs
the child was finally diagnosed with systemic juvenile idiopathic arthritis. Initially,
he was started on Prednisolone 2 mg/kg/d. He started to get better. Methotrexate (MTX)
had been also introduced and titrated until 15 mg s.c. once weekly. His symptoms improved
under therapy, but he was still not in remission, with recurrent fevers, arthritis
and high inflammatory markers. In this condition he was transferred to our center.
Here, we started the treatment according to the following table:
However, there was no full remission, so whole body MRI was performed, which showed
signs of liver cirrhosis, which was not explained by the disease and medications.
Liver biopsy showed liver fibrosis with signs of inflammation and granulation formation.
We did a molecular genetic analysis (fever panel) which showed a heterozygous mutation
in NOD2 gene (c.1001G>A; p.Arg334Gln, Exon 4), which causes Blau Syndrome. Currently,
he is responding well to the therapy with Adalimumab.
Conclusion: Here, we report a case of Blau Syndrome with liver cirrhosis extending
the phenotypic spectrum of this rare disease. In our case the patient presented with heart
failure, hypertension, arthritis, skin rash and also hepatomegaly. Episodic fever
was noted. Our patient did not develop uveitis, under the treatment with MTX and the
other medications which are all effective against uveitis. The recommended therapy
for Blau Syndrome is to use steroid daily in addition to immunosuppressants. Different
types of immunosuppressants have been used with a controversial effect, but TNF-alpha
inhibitors have been shown to be most effective in treating patients with or without
uveitis. Our patient showed partial response under the therapy with MTX, IL-1β antagonist
and IL-6 antagonist. For the first time, under treatment with TNF-alpha inhibitor
(specifically Adalimumab), he is in full clinical and laboratory remission.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P2009).
See text for description
09/2012
01/2013
10/2015
10/2016
09/2017
Steroid
x
x
x
x
x
MTX
x
x
x
x
x
Canakinomab
x
x
Tocilizumab
x
Etanercept
x
Adalimumab
x
P2010 Diagnosis and management of hereditary recurrent fevers: 20-year experience
at a single Italian referral centre
Laura Obici1, Grazia Bossi2, Roberto Caporali3, Roberta Mussinelli1, Simona Casarini1,
Sara Monti3, Isabella Ceccherini4, Francesco Caroli4, Antonio Vergori2, Eleonora Di
Buduo1, Claudia Sforzini1, Marco Gattorno5, Giampaolo Merlini1
1Amyloidosis Research and Treatment Centre; 2Pediatrics Unit; 3Rheumatology Unit,
Fondazione IRCCS Policlinico San Matteo, Pavia; 4Medical Genetics Unit; 5Pediatric
Rheumatology Unit, IRCCS Giannina Gaslini Institute, Genova, Italy
Correspondence: Laura Obici
Introduction: Disease awareness, diagnostic tools and therapeutic options for hereditary
periodic fevers (HRF) have significantly improved in recent years but whether patients’
diagnostic pathway and outcome have consistently ameliorated remains to be elucidated.
Objectives: To investigate presentation, genotypes, clinical characteristics, natural
history and response to treatment in patients with HRF referred to our centre between
1998 and 2018.
Methods: We conducted a retrospective study of all patients diagnosed with HRF according
to genetics and/or clinical Eurofever classification criteria. All patients underwent
genetic analysis and full clinical evaluation including investigation for possible
amyloid disease.
Results: 213 patients (FMF 166, TRAPS 33, CAPS 5, MKD 9) were included, 10% of them
are of non-Caucasian ancestry and 41% had a positive family history. Overall 61 genotypes
were identified, with 3 novel gene variants, not reported to date. 87% of FMF patients
had ³ 1 clearly pathogenic variant, the most common being p.Met694Val. 79% of TRAPS
patients had a clearly pathogenic mutation, affecting a cysteine residue in 15 cases.
Median age at disease onset was 12 years (range 0.5-51). Median age at diagnosis was
34 years (2-78). 79 % of patients presented in adult age, of which 35 (31 FMF and
4 TRAPS) reported symptom onset after the age of 20 (median 30, range 21-51). Median
time from disease onset to diagnosis in patients referred in adult age was 25 years
(0.5-61). Fever was the most common reported symptoms (in 96% of patients), followed
by abdominal flares. Median number of inflammatory attacks was 8 in FMF (1-24). A
chronic disease course was seen in 50% of TRAPS patients. AA amyloidosis was diagnosed
in 22 patients (10.3%). Median age at AA onset was 40 years (range 12-77) with a median
time from HRF onset to appearance of renal amyloidosis of 33.5 (8-56). In 19 cases
(86%) the diagnosis of HRF was established after AA amyloidosis presentation. Regarding
diagnostic delay, presenting features and rate of AA amyloidosis, no significant differences
was observed throughout different time periods (1998-2004; 2005-2011; 2012-2018).
In patients with FMF, complete response to colchicine is observed in 88%, with a median
dose of 1 mg/day (range 0.5-2); partial response and/or limited tolerability was reported
in 29 patients (22.7%). 7 pts were shifted to anti-IL1 agents, including two kidney
transplanted patients due to AA amyloidosis, with complete response and good safety
profile
Conclusion: Diagnostic delay hasn't significantly reduced over time in spite of increasing
awareness and optimized diagnostic tools. A substantial proportion of patients is
still recognized in adult age and therefore remain at high risk ofdeveloping long-term
renal complications.
Disclosure of Interest
None Declared
P2011 RNF213 gene variants in patients with Takayasu arteritis or vasculopathy
Ebun Omoyinmi1, Annette Keylock1, Dara McCreary1, Sarka Fingerhutova2, Pavla Dolezalova2,
Seza Ozen3, Sylvia Kamphuis4, Cheryl Hemingway5, Despina Eleftheriou1, Paul Brogan1
1Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute
of Child Health, London, United Kingdom; 2Paediatric Rheumatology and Autoinflammatory
Diseases Unit, General University Hospital, praha, Czech Republic; 3Department of
Paediatric Rheumatology, Hacettepe University, Ankara, Turkey; 4Department of Paediatric
Rheumatology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam,
Netherlands; 5Paediatric neuroradiology department, Great Ormond Street Hospital for
Children NHS foundation Trust, London, United Kingdom
Correspondence: Ebun Omoyinmi
Introduction:
RNF213 (Ring Finger Protein 213) was first identified as a major susceptibility gene
for moyamoya arteriopathy, which is a progressive steno-occlusive disease of the cerebral
arteries and the development of abnormal basal collateral vessels. Several other studies
have since reported an association of RNF213 variants with various vasculopathies,
pulmonary hypertension, coronary artery disease and stroke. In vivo experiments demonstrated
abnormal development of brain vessels in rnf213 knockdown zebrafish, while suppression
of both arteriogenesis and angiogenesis were observed in knockout mice.Consequently,
RNF213 may not be just a susceptibility gene for moyamoya, but could also play a role
in systemic vasculopathy, and be an important mimic of Takayasu arteritis (TA) of
the young.
Objectives: To review the phenotype of vasculopathy/vasculitis in a cohort of patients
referred for genetic testing where rare or novel variants in RNF213 were identified.
Methods:
RNF213 variants were screened as part of a next-generation sequencing screening strategy
for patients with suspected vasculitis or autoinflammation. Variants that were either
novel or less than 1% in public genetic databases were considered as candidate for
the purposes of this study.
Results: We identified 54/272 patients with at least one novel or rare RNF213 variant.
Fifteen/54 had vasculopathy or suspected vasculitis without clearly defined aetiology
(Table). Amongst these cases, there were two children with TA, and a third case with
familial moyamoya arteriopathy with 3 affected family members. The first case was
a Turkish girl, with a novel heterozygous RNF213 mutation p.L5003V; predicted to be
damaging, who presented with hypertension at the age of 4 years, with vascular phenotype
suggestive of TA, without cerebral involvement. The second TA case was a Dutch girl
presenting with systemic inflammation and occlusive vasculopathy of multiple arterial
beds, including renal and brain. She has 2 heterozygous variants in RNF213: p.P1721L
and p.K4732E. The p.P1721L variant has previously been reported in cohort of patients
with moyamoya arteriopathy, and is predicted to be damaging. The third case was a
child from a family investigated for suspected familial moyamoya arteriopathy affecting
3 family members. The proband had a heterozygousp.D4013N RNF213 missense mutation,
previously reported in association with moyamoya. He had typical occlusive cerebral
arteriopathy and collateral vessel formation. This mutation segregated with the same
phenotype in the affected father and sister. Vasculopathies observed in the other
cases are summarised in the Table.
Conclusion: These observations could support a role for mutations in RNF213 as the
cause of a monogenic but heterogeneous vasculopathy mimicking vasculitis such as TA,
or stenotic vasculopathy associated with moyamoya arteriopathy.
Disclosure of Interest
None Declared
Table 1 (abstract P2011).
RNF213 variants in patients with Takayasu arteritis or vasculopathy
Patient ID
RNF213 variants
Clinical phenotype
1
p.E803G
Behcet's disease/vasculitis
2-3
p.D1386N
Case 2; Severe congenital heart disease
Case 3; Small vessel vasculitis with evolving autoimmunity
4
p.T1705K
lupus –like disease with progressive leukoencephalopathy, presumed small vessel brain
disease
5
p.P1721L
Bilateral multifocal cerebral vasculopathy
6
p.P2905L
Stroke with right side focal lesion
7
p.T4155P
Ischaemic stroke
8
p.E4865K
Severe vasculopathy with multi-organ involvement including kidneys
9
p.T1705K
p.I3318V
Left sided hemiplegia and progressive motor function deterioration with perivascular
inflammation in brain biopsy
10
p.K4732E
p.L4901F
Transient ischaemic attack (TIA)
P2012 Clinical and molecular features of 3 children with neonatal onset multisystem
inflammatory disease: an experience from a setting where there is lack of access to
anti-IL1 agents
Vignesh Pandiarajan1, Deepti Suri2, Sagar Bhattad1, Anju Gupta1, Amit Rawat1, Raphaela
Goldbach-Mansky3, Marco Gattorno4, Surjit Singh1
1Allergy Immunology Unit, Pediatrics; 2Postgraduate Institute of Medical Education
and Research, Chandigarh, India; 3Translational Autoinflammatory Diseases Section,
National Institute of Allergy and Infectious Diseases (NIAID), National Institutes
of Health (NIH), Bethesda, United States; 4UO Pediatria II, Istituto G. Gaslini, Genoa,
Italy
Correspondence: Vignesh Pandiarajan
Introduction: Neonatal-onset multisystem inflammatory disease (NOMID) is characterized
by sterile inflammation of multiple organs due to molecular defect in NLRP3. Clinical
manifestations usually start from early infancy and include fever, urticaria-like
rash, arthropathy, and aseptic meningitis. Development of targeted therapies against
interleukin-1 (IL1) has revolutionized the management of this clinical condition.
Objectives: To describe 3 cases of NOMID from a tertiary care centre in North India.
Methods: Case records of the patients followed up in our Pediatric Rheumatology Clinic
were reviewed. Children with clinical features suggestive of of NOMID and proven molecular
defect in NLRP3 were included after informed consent from the parents.
The first child (P1) was symptomatic since early infancy in form of recurrent episodes
of fever and urticaria-like rash. She developed frontal bossing and progressive arthropathy
of knees over years, and the diagnosis was established at age of 13 years. Second
child (P2) had swelling of knees and recurrent urticaria-like rash over trunk since
early infancy. He developed sensorineural hearing loss, progressive enlargement of
knees and contractures of both hips and knees. He developed renal amyloidosis and
obstructive hydrocephalus at the age of 11 years. Radiograph of knees showed metaphyseal
cupping, epiphyseal enlargement with sclerosis and prominent patella. Third child
(P3) developed nephrotic syndrome at the age of 6.5 years. She received multiple immunosuppressive
medications for her treatment- cyclophosphamide, tacrolimus, and mycophenolate mofetil.
Renal biopsy done at the age of 10 years revealed AA amyloidosis. She had occasional
urticarial rash in early infancy which went unnoticed. All three children had persistent
neutrophilic leukocytosis, thrombocytosis, elevation in erythrocyte sedimentation
rate (ESR), and C-reactive protein (CRP).
Results: Thalidomide (3 mg/kg) produced significant reduction in inflammatory burden
of the first child (P1). She is now 16 years old and doing well. The second child
(P2) was started on thalidomide since 4 years of age, however, no response was noted.
Second (P2) and third child (P3) succumbed to renal failure secondary to amyloidosis,
at the age of 13 and 11 years, respectively. Molecular defects identified in NLRP3
in children P1, P2, and P3 were p.Asp305His, p.Thr349Ile, and p.Ala352Val, respectively.
Conclusion: Delay in diagnosis, lack of awareness, and lack of access to anti-IL1
agents contributed to significant morbidity and mortality in our patients. Thalidomide
can be tried to reduce the inflammatory burden in patients with NOMID in settings
where there is no access to anti-IL1 agents
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2013 Long-term outcomes and treatment efficacy in patients with TNF receptor-associated
autoinflammatory syndrome (TRAPS): a series of 290 cases from the Eurofever/EUROTRAPS
international registry
Riccardo Papa1, Thirusha Lane2, Taryn Youngstein2, Tamer Rezk2, Charalampia Papadopoulou3,
Nicolino Ruperto1, Paul A. Brogan3, Philip N. Hawkins2, Patricia Woo3, Marco Gattorno1,
Helen J. Lachmann2
1Paediatric Rheumatology Clinic, IRCCS Giannina Gaslini Institute, GENOVA, Italy;
2National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University
College London; 3Department of Infection, Inflammation and Rheumatology, UCL Great
Ormond Street Institute of Child Health, London, United Kingdom
Correspondence: Riccardo Papa
Introduction: Tumour necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS)
is one of the best known monogenic auto-inflammatory disorder resulting from an autosomal
dominant variation in the TNF super family receptor 1A (TNFRSF1A) gene.
Objectives: To define best treatment approach in patients with TRAPS and effect on
long-term outcomes.
Methods: We reviewed all data on patients with TNFRSF1A variants enrolled in the Eurofever/EUROTRAPS
international registry.
Results: Data on 290 patients were available. Patients with R92Q, P46L or intronic
variants (49%) displayed milder disease than 147 patients with mutations affecting
other coding regions, with less frequent abdominal pain and skin rashes (P<0.01),
higher efficacy rate of colchicine as maintenance treatment, and none developed AA
amyloidosis. Almost 90% of patients with exon mutations required maintenance therapy.
Anti-interleukin (IL) 1β drugs were the most frequently used (47 patients), with the
highest efficacy rate (>90% complete response), while Etanercept was less effectively
used and discontinued in 72% of patients. No patients on anti-IL1β treatment developed
amyloidosis and 10 patients with amyloidosis have been successfully treated with anti
IL-1 agents with preservation of native renal function in 7 and excellent long-term
transplant function in 2. Nine women had a history of failure to conceive and seven
had successful pregnancies without fertility treatment following complete disease
control with anti-IL1β drugs. Long term safety profiles for anti IL-1 agents were
excellent even in the presence of comorbidity.
Conclusion: Anti-IL1β drugs are the best maintenance treatment in TRAPS with potential
to reverse the most serious disease complications of AA amyloidosis and infertility.
The diagnosis of TRAPS should be considered very carefully in patients carrying R92Q,
P46L or intronic TNFRSF1A variants.
Disclosure of Interest
None Declared
P2014 A child with Majeed syndrome from India
Pallavi Pimpale Chavan, Raju P. Khubchandani
Pediatric Rheumatology Clinic,Department of Pediatrics, Jaslok Hospital and Research
Centre, Mumbai, India
Correspondence: Pallavi Pimpale Chavan
Introduction: Majeed syndrome is a very rare autosomal recessive, autoinflammatory
disorder characterized by a triad of chronic recurrent multifocal osteomyelitis, congenital
dyserythropoietic anemia and neutrophilic dermatosis caused by LPIN2 gene mutation.
14 mutation positive cases identified till 2017 have been reported from the Middle
East.
Objectives: We describe our brief experience with the second family with a child afflicted
with Majeed syndrome from India.
Methods: A 4 year old male child born of a consanguineous marriage, presented with
recurrent irregular episodes of fever with irritability and failure to thrive since
5 months of age. At 9 months of age parents noticed, small skin ‘boils’ over the trunk
and limbs, which recurred every 15-20 days along with the fever and stayed for 4-5
days. At 18 months, parents noticed that he refused to bear weight and walk and would
cry on handling.
Gradually the episodes of painful small skin boils, limb pains which the parents could
not localize and fever increased in frequency and after multiple pediatric, orthopaedic
consults he was referred to us by a pediatric neurologist who had been referred the
case to rule out Fabry disease. The pediatric neurologist had asked for whole exome
sequencing and referred the case to us for clinical evaluation sensing a musculoskeletal
rather than neurological disease.
Results: On examination the weight (10 kg) and height (83 cm) were below 3rd centile.
He had pallor, painful swelling over the left tibia, motor delay with hamstring tightness
and mild bilateral knee contractures. Language and social milestones were normal.
There were no skin lesions at the time of evaluation and systemic examination was
normal.
Review of his past investigations revealed a persistent, microcytic hypochromic anemia
(Hemoglobin 8.3-10.6 gm/dl) with raised erythrocyte sedimentation rate (54-105 mm/hr),
C-reactive protein (37-98 mg/l) and platelets (4.3-8.9 x103 cu mm).
His genetic mutation for LPIN 2 returned positive with homozygous missense variation
in exon 17 of the LPIN2 gene resulting in amino acid substitution of cysteine to arginine
at codon 736 (p.Arg736Cys;ENST00000261596). Meanwhile a bone scintigraphy done, showed
increased vascularity and osseous activity in proximal shaft of left tibia with mild
osseous activity at D9 and D10 vertebrae. A bone marrow examination was not performed
as a conclusive mutation diagnosis was obtained.
He showed a dramatic response to Ibuprofen with abatement of fever, no skin boils
and improvement of general mood and playfulness. With a view to attempt to omit NSAIDs,
intravenous Pamidronate was commenced. He has received four doses of Pamidronate (cumulative
dose 12 mg/kg) over one year and has gained weight (11.5kg) and height (96cm), remained
afebrile with full physical activity and no new skin lesions.
Conclusion: Paucity of awareness amongst the medical community about these rare illnesses
are responsible for diagnostic delays and complex referral pathways. With the high
rates of consanguinity in several parts of our country we believe that we are seeing
just the tip of the iceberg of monogenic autoinflammatory diseases. Due to non availability
of Interleukin-1 inhibitors in India, which are highly effective at controlling osseous
and systemic inflammation in Majeed syndrome , we have limited treatment options to
offer to our patient. We have offered educational resources and genetic counselling
to the family.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2015 Spondyloenchondrodysplasia – a case from India
Pallavi Pimpale Chavan1, M Moreews2, Shashi Ranade3, A Belot2, Raju P. Khubchandani1
1Section of Pediatric Rheumatology, Jaslok Hospital and Research Centre, Mumbai, India;
2Pediatric Rheumatology Clinic, National Referee centre RAISE (Rhumatism and AutoImmunity
in children) & CIRI, INSERM U1111, Lyon, France, 3Consultant Paediatrician, Ranade
Hospital, Karad, India
Correspondence: Pallavi Pimpale Chavan
Introduction: Spondyloenchondrodysplasia (SPENCD) is a very rare genetic immuno-osseous
dysplasia characterized by skeletal anomalies (short stature, platyspondyly) and enchondromas
in the long bones or pelvis. SPENCD may have a heterogeneous clinical spectrum with
neurological involvement or autoimmune manifestations, such as systemic lupus erythematosus
(SLE).
Objectives: We describe a child from India with SPENCD, who presented with features
of SLE , skeletal dysplasia and enchondromas
Methods: A 9 year old male born of second degree consanguineous marriage presented
with fever , oral ulcers, leg pain with morning stiffness since 1 month. He was worked
up by his primary paediatrician for pyrexia of unknown origin and a summary of laboratory
tests performed included, hemogram with hemoglobin 8.7 gm/dl, white cell count 5900
/cu mm platelet 1.85 x 103 cu mm, erythrocyte sedimentation rate 100 mm/hr, antinuclear
antibody 4+.Suspecting connective tissue disease child was referred to us for further
evaluation.
Results: On further enquiry, there was past history of multiple medical visits for
poor growth since infancy and a bony swelling of the right forearm leading to incomplete
supination for which he was operated at age 5 years. No details were available. His
milestones were appropriate for age with normal scholastic performance.His weight
(16.9 kg) and height (113cm) were below the 3rd centile. On examination, he had pallor,
facial rash, mucositis of the palate, generalised lymphadenopathy, triangular facies,
prominent anteverted ears, prominent conjunctival blood vessels, supernumerary teeth,
right elbow swelling, paucity of body hair On systemic examination abdomen was soft
with hepatosplenomegaly and other systems were normal.
On further investigation his dsDNA was 4+ , Direct Coombs test was positive, C3 -
19.1 mg/dl C4 - 3.36 mg/dl, urinalysis was normal, Anti Ro and lupus anticoagulant
were negative and APLA IgG was positive and APLA IgM negative. The diagnosis of SLE
was confirmed.
Considering, consanguineous marriage, short stature and right elbow swelling with
other subtle dysmorphisms described above, a syndromic form of lupus was suspected
and a skeletal Xray analysis showed extensive areas of metaphyseal abnormalities with
epiphyseal remodelling changes and platyspondyly. Hence a clinical diagnosis of Spondyloenchrondrodysplasia
(SPENCD) was considered. Sanger sequencing of ACP5 encoding the protein TRAP revealed
homozygous non sense mutation (c.849T>A, p.(Tyr283stop) confirming the diagnosis of
SPENCD.He was further investigated for diseases associated with SPENCD, which revealed
normal thyroid function, IGF – 1, immunoglobulin levels and 2DECHO.
He was started on hydroxychloroquine (5mg/kg/day), oral prednisolone (0.6mg/kg/day),
low dose aspirin, supplements and was advised sun protection. On follow up after a
year, he is continued on hydroxychloroquine (5mg/kg/day), oral prednisolone (0.25mg/kg/day),
low dose aspirin and supplements. He has gained weight (20.6 kg), height (114 cm),
is afebrile with no arthritis, mucositis or rash.
Conclusion: SPENCD is an immunosseous dysplasia and a very rare cause of monogenic
lupus. This, is the second case of SPENCD reported from India. The entity should be
suspected in children with SLE with a consanguineous background who have short stature
and bony abnormalities. We expand the phenotype here with additional dysmorphic features
comprising supernumerary teeth, triangular facies, prominent anteverted ears and prominent
conjunctival blood vessels not described before to the best of our knowledge.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2016 Clinical profile of seven children with hereditary complement deficiency from
a center in Mumbai, India
Prajakta Ranade1, Y.J. Crow2, Pallavi Pimpale Chavan3, L Seabra4, G Rice5, Raju P.
Khubchandani3
1Paediatrics, St John's Medical College Hospital, Mumbai, India; 2Centre for Genomic
And Experimental Medicine, Institute of Genetics and Molecular Medicine, Edinburg,
United Kingdom; 3Section of Pediatric Rheumatology, Jaslok Hospital and Research Centre,
Mumbai, India; 4Neurogenetics and Neuroinflammation, Laboratory of Neurogenetics and
Neuroinflammation, Paris, France; 5Division of Evolution and Genomic Science, Manchester
Academic Health Science Centre, Manchester, United Kingdom
Correspondence: Pallavi Pimpale Chavan
Introduction: While systemic lupus erythematosus (SLE) is classically considered as
a multifactorial polygenic disease, hereditary monogenic forms are well recognized.
Deficiencies in the early components of the classical pathway strongly predispose
to the development of SLE, of which C1q deficiency is the commonest. Children with
C1q deficiency are estimated to develop SLE in 93% of cases. We report our experience
with this entity.
Objectives: To describe the clinical and laboratory profile and follow up of a cohort
of seven children with hereditary complement deficiency.
Methods: We reviewed our data on seven children with hereditary complement deficiency
and obtained a genetic diagnosis in 5 of these 7 patients using next-generation sequencing.
Informed consent was taken from the parents and the data was tabulated in the study
proforma.
Serial no/Sex
CSM
Onset (m)/time to diagnosis (m)
Clinical
Positive antibody profile
C3/C4/CH50
Genetics
Treatment
Follow up (m)/Outcome
1/F
N
10/7
Rash, mucositis,
neuroregression
ANA
Ds DNA Anti Ro
175/23/42.1
Homozygous for a
c.606delA /
p.Gly204Alafs*78
variant in C1QA
HCQ Sx AZT
28/Improved
2/F
Y
24/24
Rash, mucositis, arthritis, renal disease, herpes zoster
ANA
Anti Ro
203/73/54
Homozygous for a
c.622C>T /
p.Q208* STOP
variant in C1QA
HCQ,Sx,AZT,MMF
Death (at 12 years of age)
3/M
Y
21/12
Rash, mucositis, delayed development,
hyperreflexia
ANA
Ds DNA Anti Ro
ACLA IgG
158/47.7/43
Homozygous for a
c.622C>T /
p.Q208* STOP
variant in C1QA
HCQ,Sx,AZT
16/Improved
4/M
Y
12/24
Rash, mucositis,
hyperreflexia, seizures
ANA
Anti Ro
117/39/18.6
Homozygous for a
c.171delT /
p.Gly58Alafs*224
variant in C1QA
HCQ,Sx,AZT,MMF
41/Improved
5/F
Y
27/4
Rash, mucositis,
neuroregression,
hemiparesis, cerebral
atrophy,
hyperreflexia,
hypothyroidism
ANA
Anti Ro ACLA IgM
Anti TPO
179/42.8/NA
Homozygous for a
c.79C>T /
p.Arg27* variant in
C1QA
HCQ,Sx,Cyc,AZT
31/Improved
6/M
Y
40/0.5
Rash’ mucositis
ANA ACLA IgM
114/NA/NA
Afflicted sibling of Sr no 2 Not tested
HCQ,Sx
22/Improved
7/F
Y
48/36
Rash, mucositis,
arthritis, proteinuria,
infections
(varicella, scabies,
impetigo),
hypothyroidism
ANA
30/NA/35.7
Demise before testing
HCQ,
Sx,
Cyc
MMF
Death (at 12 years of age)
Abbreviations: F: Female, M: Male, CSM: Consanguinity, Y: Yes, N: No, m: months, Sx:
Steroids, AZT: Azathioprine, Cyc:Cyclophosphamide, MMF: Mycophenolate
Results:
Conclusion: Based on our study and others reported, hereditary complement deficiency
(notably C1Q deficiency) is the commonest form of monogenic lupus in our part of the
world. Afflicted children present most commonly with rash and mucositis below 5 years
of age and there is a significant delay in diagnosis due to lack of physician awareness.
Neurologic features are frequently seen while renal manifestations are not. Neuroregression
responds to immunosuppressive therapy with children improving on their mental, motor
and speech milestones. Except in one patient major life-threatening infections have
not been a challenge despite high infection rates in the community coupled with immunosuppression.
Disclosure of Interest
None Declared
P2017 Preliminary results of the Latin-American cohort of auto-inflammatory syndromes
Daniela G. P. Piotto1, Clovis A. Silva2, Katia Kozu2, Ana Luiza Cunha3, Flavia Patricia
Santos4, Ana Laura Tolin5, Sheila K. Oliveira6, Simone Appenzeller7, Claudia S. Magalhães8,
Marcia Bandeira9, Flavio Sztajnbok10, Carlos NobreRabelo Jr11, Carmen Laurade Cunto12,
Cristina De Battagliotti13, Blanca Bica14, P Munittis15, Liliana Bezrodnik16, Marta
F. Rodrigues17, Tereza C. Robazzi18, Erica N. Matos19, Ricardo Russo20, Maria Teresa
Terreri1
1Division of Rheumatology, Department of Pediatrics, Universidade Federal de Sao Paulo;
2Division of Rheumatology, Department of Pediatrics, Faculdade de Medicina da Universidade
de São Paulo (FMUSP), São Paulo; 3Division of Rheumatology, Department of Pediatrics,
Hospital Infantil João Paulo II, Belo Horizonte; 4Division of Rheumatology, Department
of Pediatrics, Universidade Federal de Minas Gerais, São Paulo, Brazil; 5Division
of Rheumatology and Unit of Pediatric Rheumatology - Department of Pediatrics, Hospital
Notti, Mendoza, Argentina; 6Division of Rheumatology, Department of Pediatrics, Federal
University of Rio de Janeiro, Rio de Janeiro; 7Rheumatology Department, Faculty of
Medical Sciences, UNICAMP, Campinas; 8Division of Rheumatology, Department of Pediatrics,
Universidade Estadual de São Paulo - Faculdade de Medicina de Botucatu, Botucatu;
9Division of Rheumatology, Department of Pediatrics, Hospital Pequeno Principe, Curitiba;
10Division of Rheumatology, Department of Pediatrics, Hospital Universitário Pedro
Ernesto, Rio de Janeiro; 11Division of Rheumatology and Unit of Pediatric Rheumatology
- Department of Pediatrics, Universidade Federal de Fortaleza, Fortaleza, Brazil;
12Division of Rheumatology, Department of Pediatrics, Hospital Italiano, Buenos Aires;
13Division of Rheumatology, Department of Pediatrics, Hospital de niños Dr Orlando
Alassia, Santa Fe, Argentina; 14Division of Rheumatology, Department of Pediatrics,
Hospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de Janeiro,
Rio de Janeiro, Brazil; 15Division of Rheumatology and Unit of Pediatric Rheumatology
- Department of Pediatrics, Hospital El Cruce, F. Varela; 16Servicio Inmunología HNRG.,
Hospital de Niños, Buenos Aires, Argentina; 17Division of Rheumatology and Unit of
Pediatric Rheumatology - Department of Pediatrics, Universidade Federal do Rio de
Janeiro, Rio de Janeiro; 18Division of Rheumatology and Unit of Pediatric Rheumatology
- Department of Pediatrics,Universidade Federal da Bahia, Bahia; 19Division of Rheumatology,
Department of Pediatrics,Hospital Universitário da Faculdade de Medicina da Universidade
Federal de Mato Grosso do Sul, Mato Grosso do Sul, Brazil; 20Division of Rheumatology,
Department of Pediatrics, Hospital Garrahan, Buenos Aires, Argentina
Correspondence: Daniela G. P. Piotto
Introduction: Auto-inflammatory syndromes (AIS) are rare and with large spectrum of
clinical, genetical and laboratorial findings, which vary according to ethnic and
geographical factors.
Objectives: There is no report evaluating AIS solely in Latin–American (LA) cohorts.
Therefore, the objective of this study is to characterize AIS in a LA population.
Methods: Fourteen countries from all over Latin America were invited to participate
in this observational and descriptive study collecting data on clinical, laboratory,
genetic characteristics and treatment response of polygenic and monogenic AIS. Inclusion
criteria were patients with clinical and/or genetic diagnosis of AIS. Data were prospectively
collected in a web-based data bank.
Results: At the time of this report, 162 patients from Brazil (78.8%) and Argentina
(21.2%) had been included: 52% males, 75% Caucasians; median age at symptoms onset
was 2.1 years, median age at diagnosis of 6.9 years, and median disease duration was
8.5 years. The main AIS diagnosis were: PFAPA (28%), CNO (18%), FMF (16%), PGA (10%),
CAPS (9%), HIDS (7%), TRAPS (5%) and PAPA (3%).The diagnosis was made clinically in
62% of patients (either they were PFAPA or CNO patients or presented a negative genetic
test); 33% of patients were diagnosed by both clinical features and genetic tests
and 5% of patients had no clinical but only a positive genetic test that was performed
due to family history. Clinical features were consistent with the genetic abnormalities
found. Genetic testing had been done in different laboratories using either Sanger
sequencing and/or NGS. One of both acute phase reactants (either ESR or CRP) elevation
occurred in 91% patients. The most frequently used medication were corticosteroids
(66%, partial response in more than a half of patients) and colchicine (29.6%, total
or partial response in half of patients). Regarding biological agents, etanercept
was used in 11.1% with a partial response in most patients. IL1 blockers were prescribed
in 11.1% but with a total response in the majority who used them. Of note, 51% of
patients achieved remission, but 46% were still active at the time of evaluation,
2% had deceased, MAS was observed in 1% and none of them had amyloidosis.
Conclusion: A Latin-American registry of AIS included patients especially from South
America. A clear limitation in access to genetic diagnosis was noted. Recognizing
the barriers to the awareness about expansion of this group is a priority to better
understand these complex diseases, especially in Central America. Some features like
absence of amyloidosis and medications used in treatment differentiate our cohort
from American and European ones.
Disclosure of Interest
None Declared
P2018 Chronic nonbacterial osteomyelitis: report of six cases
Daniela G. P. Piotto1, André Aihara2, Artur Fernandes2, Gabriela Balbi1, Claudio Len1,
Maria Teresa Terreri1
1Division of Rheumatology and Unit of Pediatric Rheumatology - Department of Pediatrics;
2Department of Imaging Diagnosis, Universidade Federal de Sao Paulo, São Paulo, Brazil
Correspondence: Daniela G. P. Piotto
Introduction: Chronic nonbacterial osteomyelitis (CNO), also known as chronic recurrent
multifocal osteomyelitis (CRMO), is a rare autoinflammatory bone disorder that causes
multifocal aseptic lytic lesions in bone biopsy and is characterized by periodic exacerbations
and remissions, mostly affecting children and adolescents.
Objectives: To report and describe clinical features, laboratory and treatment of
six cases of CNO.
Methods: Retrospective descriptive review of six children and adolescents with CNO
treated at a specialized center, between 2010 and 2018.
Results: Four (66%) out of 6 patients were girls with mean age of 15.5 years (range
11-20.4) and mean follow-up time of 5.1 years (range 1.5-10.2). Mean age of first
symptoms was 10.3 years (range 0.7–15.3) and mean age at diagnosis was 12.8 years
(range 9.5-16). The most affected sites were metaphysis and diaphysis of long bones.
Median number of initial bony lesions was 2.8 (range 1-7) at onset and 3.5 (range
1-8) during the follow up. Two (33.3%) patients had recurrence in clavicle, one (16.6%)
in temporomandibular joint and two in mandible. One (16.6%) patient presented with
fever and dyserythropoietic anemia, receiving diagnosis of Majeed syndrome.Five (83.3%)
patients presented with arthralgia and bone pain, and two (33.3%) of them had acute
migratory polyarthritis. All patients had increased acute phase reactants and radiographic
and magnetic resonance imaging alterations.All patients received NSAIDs therapy (indomethacin)
with clinical remission in half of the cases.Three (50%) patients received bisphosphonates
(alendronate), and one took methotrexate associated with alendronate. All patients
had good clinical response and two achieved clinical remission.
Conclusion: The awareness of characteristic features of CNO is important for an early
diagnosis and can help avoiding unnecessary diagnostic procedures and prolonged antibiotic
therapy.
Disclosure of Interest
None Declared
P2019 Familial Mediterranean fever: strong evidence for a functional effect of E148Q
when combined with M694V
Elon Pras1, Ori Eyal1, Yael Shinar2, Mordechai Pras3
1Institute of Human Genetics; 2FMF Clinic; 3Heller Institute of Medical Science, Sheba
Medical Center, Ramat Gan, Israel
Correspondence: Elon Pras
Introduction: The role of E148Q in the pathogenesis of familial Mediterranean fever
(FMF) is controversial. The penetrance of the M69V/M694V genotype in adult FMF patients
is close to 100%. Disease penetrance in patients with the M694V/E148Q and M694V/null
(single M694V mutation) genotypes is unknown. A difference in the penetrance of the
latter two may indicate functionality for E148Q.
Objectives: To assess the penetrance of the M694V/E148Q and M694V/null genotypes in
FMF
Methods: The study was performed on North African Jewish (NAJ) population in which
FMF is highly prevalent and mutation frequencies are well known. Combined carrier
rates for M694V and E148Q were calculated from three previous studies. The expected
frequencies of the M69V/M694V, M694V/E148Q and M694V/null genotypes were calculated.
We constructed a cohort of 107 consecutive patients with definite FMF, all of NAJ
decent who came for genetic analysis. The ratio between the calculated frequencies
of the 3 genotypes and the actual frequency obtained from the patient cohort was used
to determine the penetrance of M694V/E148Q and M694V/null.
Results: In the patient cohort we found 75 patients with the M694V/M694V genotype,
15 with the M694V/E148Q an 16 with M694V/null. Pooled allele frequencies from 443
NAJ controls were 0.066 and 0.047 for M694V and E148Q, respectively.Considering 100%
penetrance for adult FMF patients homozygous for M694V, calculations show a penetrance
of 0.1405 and 0.00756 for M694V/E148Q and M694V/null, respectively.
Conclusion: The penetrance of M694V/E148Q is more than 18 times higher than M694V/null
indicating an active role for E148Q when combined with M694V.
Disclosure of Interest
None Declared
P2020 Treatment of type 1 interferonopathy with Ciclosporin A and baricitinib in a
5 year old boy with heterozygous PSMB-8 mutation
Christoph Rietschel1, Eduardo Salamano1, Min Ae Lee-Kirsch2, Kay Latta3
1Pediatric Rheumatology, Clementine Kinderhospital, Frankfurt/Main; 2Molecular Pediatrics,
Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden;
3General Pediatrics, Clementine Kinderhospital, Frankfurt/Main, Germany
Correspondence: Christoph Rietschel
Introduction: Type 1 Interferonopathy is a challenging autoinflammatory disease that
can mimic different systemic diseases such as systemic Juvenile Idiopathic Arthritis.
It shows a considerable clinical heterogeneity with neurological, cutaneous, arthritic
and other symptoms and is commonly transmitted in an autosomal recessive manner. Different
mutations have been discovered in recent years. Exceptionally, only one mutation can
be found. The activation pattern of genes involved in the interferon pathway, the
interferon signature, is the diagnostic hallmarkof the disease and provides an important
tool for monitoring disease activity.
Objectives: We present this interesting case to show the clinical spectrum, diagnostic
workup, possible complications and the chosen treatment modalities in this particular
disease.
Methods: Our patient, born 03/2013, with an uneventful previous history, developed
first symptoms in 09/2016. He showed persistent fever and a transient rash. From the
beginning he suffered from strong, unexplained abdominal pain. His CRP values and
leukocytes were only moderately elevated. He was first treated in another hospital
for infection, but did not respond to broad spectrum antibiotics. He was transferred
for further rheumtologic evaluation. Initial blood testing yielded only slightly elevated
CrP levels but high ferritine >2000ug/l. Bone marrow aspiration showed strong granulopoiesis,
no malignant infiltration or MAS. Ultrasound revealed hepatosplenomegaly, moderate
serositis and cervical lymphadenopathy. Due to ongoing doubt on the diagnosis of SJIA
a second bone marrow aspirate, lymph node and skin biopsy were performed, which were
nonspecific. In the course of the disease the general condition deteriorated,CrP levels
rose to >200mg/l and ferritine to >12.000ug/l. Liver enzymes were elevated, no cytopenia
was seen. We assumed that our patient was at constant risk of full-blown MAS.
Results: Treatment with Anakinra was started at 2mg/kg/d and raised to 4mg/kg/d but
was not effective. High dose methylprednisolonetherapy showed good clinical and laboratory
response. On tapering of corticosteroids (CS) however, a rapid relapse resulted and
the patient was put on tocilizumab 12mg/kg/2w and ultimately canakinumab 4mg/kg/4w,
both of which were not effective. Ciclosporin A (CSA) 5mg/kg/d was added 01/17 due
to incomplete control of inflammation and persistent risk of MAS. Further laboratory
evaluation was obtained. IL-18 levels were above the detectable level of 20.000pg/ml.
Panel diagnostic for autoinflammatory diseases showed a heterozygous mutation of unknown
relevance in the PSMB-8 gene, a gene hosting several known mutations responsible for
interferonopathies. Interferon signature in our patient showed a very high score,
ultimately leading to the hypothesis of type 1 interfonopathy. We started a treatment
with baricitinib (BAR) 05/17 and continued CSA and CS. The patient showed a rapid
response, BAR was continuously raised to a dose of 4x2mg/day with complete remission.
CS were tapered carefully and stopped 08/17. Ultimately CSA was tapered and stopped
09/17. Six weeks after discontinuation of CSA while on monotherapy with BAR 4x2mg/kg,
a moderate clinical relapse occured, the interferon signature showing an extremely
high score. Thus CSA was restarted and a course of CS was necessary to induce remission.
Since 01/17 our patient is off CS and shows a complete remision with excellent tolerance
of the tretment with BAR+CSA.
Conclusion: Treatment with Janus kinase inhibitor BAR was a breakthrough in the treatment
of our patient, however, a combination with CSA was necessary to preserve complete
remission.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2021 Protein prenylation is defective in mevalonate kinase deficiency and is an accurate
biomarker in peripheral blood mononuclear cells
Michael Rogers1, Julie Jurczyluk1, Oliver Skinner1, Anna Simon2, Sam Mehr3, Pravin
Hissaria4, Rob Arts5, David Coman6, Marcia Munoz1
1Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, Sydney,
Australia; 2Department of Internal Medicine, Radboud University Medical Center, Nijmegen,
Netherlands; 3Department of Allergy/Immunology, Royal Children's Hospital, Melbourne;
4Department of Clinical Immunology, Royal Adelaide Hospital, Adelaide, Australia;
5Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands;
6Department of Metabolic Medicine, Queensland Children's Hospital, Brisbane, Australia
Correspondence: Michael Rogers
Introduction: Mevalonate kinase deficiency (MKD, which includes HIDS and mevalonic
aciduria) is caused by recessive, hypomorphic mutations in the MVK gene encoding mevalonate
kinase, a crucial enzyme of the mevalonate pathway. This biochemical pathway is required
for the synthesis of isoprenoid lipids that are essential for the post-translational
prenylation of proteins, particularly small GTPases such as Rab proteins and Rap1A.
Blockade of the mevalonate pathway prevents the synthesis of isoprenoid lipids and
results in the cytosolic accumulation of small GTPase proteins in their unprenylated
form. It has long been assumed that mutations in MVK lead to defective protein prenylation
in patients with MKD, but direct evidence for the accumulation of unprenylated proteins
in patients’ cells has been lacking.
Objectives: To address the question whether protein prenylation is defective in MKD
patients’ peripheral blood mononuclear cells (PBMCs), we optimized an in vitro prenylation
assay that is capable of detecting very low levels of unprenylated Rab proteins in
cell lysates and compared it to a western blot approach that specifically recognises
the unprenylated form of Rap1A.
Methods: We analysed freshly-isolated PBMCs from nine individuals with genetically-confirmed
MKD and compared these with PBMCs from parents who were heterozygous for MVK mutations,
as well as PBMCs from unaffected controls and 2 individuals each with genetically-confirmed
FMF, CAPS or TRAPS.
Results: Using the in vitro prenylation assay we observed a very clear accumulation
of unprenylated Rab proteins in freshly-isolated PBMCs from eight MKD patients with
different compound heterozygous mutations in MVK. In a patient homozygous for the
V377I mutation the defect in Rab prenylation was milder but still detectable. Unprenylated
Rap1A was also identifiable by western blotting in the MKD patients that had the greatest
defect in Rab prenylation, but this western blot approach was considerably less sensitive
than the in vitro prenylation assay. Importantly, the defect in Rab and Rap1A prenylation
was absent in individuals with FMF, CAPS or TRAPS, and absent in individuals with
heterozygous mutations in MVK or healthy volunteers.
Conclusion: These findings demonstrate that protein prenylation is indeed defective
in individuals with MKD. Furthermore, the accumulation of unprenylated Rab proteins
in PBMCs is a sensitive and specific biomarker of MKD that distinguishes this autoinflammatory
disease from FMF, CAPS and TRAPS and could therefore be used to aid diagnosis.
Disclosure of Interest
None Declared
P2022 Encephalopathy in early-onset sarcoidosis: is it neurosarcoidosis or autoimmune
encephalitis?
Nihal Sahin1, Sumeyra O. Cicek1, Aysenur P. Kisaarslan1, Zubeyde Gündüz2, Muammer
H. Poyrazoglu1, Ruhan Düşünsel1
1Pediatric Rheumatology, Erciyes University Faculty of Medicine; 2Pediatric Rheumatology,
Acibadem Hospital, Kayseri, Turkey
Correspondence: Nihal Sahin
Introduction: Early onset sarcoidosis (EOS) / Blau Syndrome is NOD2 gene–associated
chronic autoinflammatory disease characterized by the classic triad of skin rash,
chronic symmetric arthritis, and recurrent uveitis. Pathologic investigation of organs
reveals granulomatous inflammation. This disease involves many organ systems, however,
neurologic involvement is rare. Cranial nerve palsy and papilledema were reported
in the literature.To our knowledge, our patient is the first case with encephalitis
in (EOS).
Objectives: We present a patient with encephalopathy in early-onset sarcoidosis.
Methods: Case report
The informed consent form for the publication was obtained from patient and her parents.
Results: A 12-year-old girl was diagnosed with juvenile idiopathic arthritis at the
3 years of age. While she was on methotrexate (MTX) and etanercept treatment, at 7
years of age, liver and kidney biopsy was performed due to high levels of transaminase
and impairment of renal function tests. Granulomatous interstitial nephritis and granulomatous
inflammation of the liver were detected in the biopsies, drug-induced sarcoidosis
was considered in our patient, and ETA was stopped. MTX and systemic steroid were
continued. Boggy synovitis and, camptodactyly were appeared on follow up. We reevaluated
all clinical signs, and NOD2 gene analysis was performed 3 years later. M513T heterozygous
mutation was detected. There was consanguinity, but no family history Thus, we diagnosed
EOS. In the last three years, the disease activations included arthritis, interstitial
lung disease, interstitial nephritis, and bilateral panuveitis. The treatment was
systemic steroids on attack periods, MTX, and infliximab (INF). Lastly, she was admitted
to our clinic with a headache and vomiting in June 2018. These complaints were there
for two weeks and were increasing especially in the morning. She was on Methotrexate
(15 mg/w sc), prednisolone (10 mg/d) and infliximab (200 mg/mt) A high fever, high
blood pressure, lethargy, diplopia, and bilateral papilledema were detected on PE.
Laboratory examination revealed leukocytosis, increased ESR and CRP and pyuria. E.
coli was detected in the urine culture. Brain MRI and MRI angiography were normal.
The patient underwent repeat lumbar punctures and opening pressures were 23 cm/H2O
and 38 cm/H2O, respectively. Study of cerebrospinal fluid (CSF) revealed pleocytosis
(120 leukocyte /mm3 and), the protein level of 0.35 g/l, normal chloride, and glucose
level. CSF cultures were negative. Serology of viruses and Mycobacterium tuberculosis
were negative. Electroencephalography (EEG) showed delta brush waves compatible with
encephalitis. The pediatric neurology department considered autoimmune encephalitis.
CSF limbic encephalitis antibody panel that included NMDA, AMPA1, AMPA2, CASPR2, LGI1,
GABA B antibodies was performed. ANA, ANA subgroups were negative. After the urinary
tract infection treatment, the fever was resolved. Intravenous immunoglobulin was
given at a dose of 400 mg/kg/d for 5 days. But lethargy, diplopia, and papilledema
were not resolved. Then the patient was treated with pulse intravenous methylprednisolone
(1 g/kg/day for 5 days). After this treatment, his neurological findings improved
rapidly. Infliximab, methotrexate, prednisolone (40 mg/d) were continued. At the last
visit, neurological and ophthalmologic examinations were normal.
Conclusion: Early onset sarcoidosis is an autoinflammatory disease. Autoimmunity is
not expected in EOS. Delta brush waves seen in EEG are frequently were detected in
autoimmune encephalitis. We could not distinguish that this case is autoimmune encephalitis
or neurological involvement of EOS. We wanted to present this interesting case to
contribute to the literature.
Disclosure of Interest
None Declared
P2023 Risk factors of colchicine resistance in pediatric patients with familial Mediterranean
fever: a single center experience
Nihal Sahin1, Aysenur P. Kisaarslan1, Sumeyra O. Cicek1, Zubeyde Gunduz2, Muammer
H. Poyrazoglu1, Ruhan Düşünsel1
1Pediatric Rheumatology, Erciyes University Faculty of Medicine; 2Pediatric Rheumatology,
Acibadem Hospital, Kayseri, Turkey
Correspondence: Nihal Sahin
Introduction: Colchicine treatment high effectively prevents familial Mediterranean
fever (FMF) attacks and secondary amyloidosis but, colchicine resistance was reported
in 5 to 10% of patients receiving the highest dose tolerated. There are no validated
criteria that could define colchicine resistance FMF.
Objectives: This study was aimed to determine the risk factors of colchicine resistance
in pediatric FMF patients.
Methods: Two cohorts of pediatric Turkish patients followed in our pediatric rheumatology
center were involved in the study. Familial Mediterranean fever was diagnosed by Turkish
pediatric criteria. Group1 was determined as FMF, group2 was determined as colchicine-resistant
FMF(CR-FMF).
Results: There were 50 patients in group 1 and 33 patients in group 2. An age, gender,
consanguinity, family history of FMF, amyloidosis, and chronic renal failure, weight
SDS, height SDS were not different between two groups(p>0,05). Presence of fever,
peritonitis, pleuritis, arthritis, prolonged febrile myalgia, erysipelas like rash,
headache, constipation, dysmenorrhea in attack periods and hepatosplenomegaly were
not different between two groups (p>0,05). The myalgia and diarrhea in attacks period,
chronic arthritis, and homozygous Exon 10 mutation were detected high in CR-FMF group
p<0,05). In CR-FMF, the age of presence of symptoms, and age of diagnosis were detected
lower than FMF groups(p<0,05). The colchicine compliance was same rate between the
two groups. The number of attacks, international severity scoring system for familial
Mediterranean fever (ISSF) scores, PRAS scores, CRP, ESR were more high in CR-FMF
after at least 6 months colchicine treatments. All of the parameters were evaluated
with multivariate logistic regression analysis. The presence of diarrhea, ISSF and
PRAS scores were detected independent risk factors (OR 136,950, 95% CI: 1,128-16537,589,
p=0,045; OR 8,313, 95%CI: 1,267-54,552, p=0,027; OR 3,170, 95%CI: 1,072-9,372, p=0,037,
respectively).
Conclusion: This study will develop a formula to predict colchicine resistance. Early
diagnosis of chronic inflammation and treatment can be kept from FMF complications.
Disclosure of Interest
None Declared
P2024 Distinctive features of familial Mediterranean fever with juvenile spondyloarthritis
patients from familial Mediterranean fever and juvenile spondyloarthritis patients
Ayşenur Paç Kısaarslan1, Nihal Şahin1, Sümeyra Özdemir Çiçek1, Zübeyde Gündüz2, Muammer
H. Poyrazoğlu1, Ruhan Düşünsel1
1Pediatric Rheumatology, Erciyes University Faculty of Medicine; 2Pediatric Rheumatology,
Acıbadem Hastanesi, Kayseri, Turkey
Correspondence: Nihal Şahin
Introduction: Musculoskeletal involvement of familial Mediterranean fever(FMF) extends
from acute arthritis to juvenile spondyloarthritis(jSpA).
Objectives: Our aim was to identify distinctive features of FMF with jSpA patients
from FMF and jSpA patients.
Methods: Three cohorts of pediatric Turkish patients followed in our pediatric rheumatology
center were involved in the study. Familial Mediterranean fever was diagnosed by Turkish
pediatric criteria. Juvenile spondyloarthritis was diagnosed by ILAR criteria. These
two groups did not have other inflammatory conditions and chronic diseases. FMF patients
who disclosed jSpA findings later andjSpA patients who disclosed FMF findings later
were determined as FMF+jSpA group. Findings of FMF+jSpA were compared with FMF and
jSpA groups.
Results: Thirty-two patients were in FMF+jSpA group, 50 patients were in FMF group,
and 54 patients were in jSpA group. Ages of patients were 16,6(10,9-21,3), 13,7(6,8-21,5),
and 14,0(7,0-16) in FMF+jSpA, FMF, and jSpA, respectively. Patients with FMF+jSpA
had less fever and peritonitis in attack periods than FMF patients(p<0,05). They had
more myalgia, cronic arthritis, high ESR levels on remission, and high disease activity
score( p<0,05). In FMF patients, FMF50 response was reached more than FMF+jSpA patients
after colchicine treatment(p<0,05). Two groups had the same rate of at least one Exon
10 mutationsin MEFV gene (87,4% to 88%, respectively). Other FMF attack findings,
proteinuria and amyloidosis were non significant differences in two groups(p>0,05).
Patients with FMF+ jSpA had less small joint involvement, sacroiliac tenderness, HLA-B27
positivity, jSpADA score than jSpA patients(p<0,05). Plantar faciitis and JADI-E score
were high in FMF+ jSpA group than jSpA (p<0,05). Other jSpA findings, uveitis and
sacroiliitis detected by MRI were same rate in two groups. Non steroidal antiinflammatory
drug usage was high in patients with FMF+ jSpA more than jSpA. Usage of steroid, DMARDs,
and biologic DMARDs(except for IL-1 antagonist) were at the same rate in two groups.
Conclusion: Articular involvement of familial Mediterranean fever especially in M694V
carriage may be associated with jSpA. Patients with FMF+ jSpA have more subclinical
inflammation. Because the disease damage index is high in this group, diagnose and
treatment should be made on time.
Disclosure of Interest
None Declared
P2025 Type 1 interferonopathy presenting with fever, fatigue, chronic urticaria, arthritis,
elevated liver enzymes and hyperferritinemia in a 13-year-old girl – an important
differential diagnosis to systemic juvenile idiopathic arthritis
Eduardo Salamano1, Min Ae Lee-Kirsch2, Christoph Rietschel1
1Rheumatology, Clementine Children Hospital, Frankfurt; 2Immunology, Universitätsklinikum
Carl Gustav Carus, Dresden, Germany
Correspondence: Eduardo Salamano
Introduction: Type 1 interferonopathies are a group of heterogenous diseases which
are characterized by a dysregulation of the type 1 interferon axis and as a result
an inadequate Type 1 interferon activation causing autoinflammation and autoimmunity.
While type 1 interferonopathies are genetic disorders the underlying mutation is not
always known. The variety of symptoms and the abundance of possible differential diagnosis
often lead to difficulties in recognizing the disease and thus delay an effective
therapy. Janus kinase inhibitors have been shown to yield promising results in the
treatment of these rare immunologic conditions.
Objectives: We report on a previously healthy 13-year-old german girl presenting with
recurrent and persistent fever, chronic itching urticaria-like rash and fatigue. Laboratory
results showed strongly elevated liver enzymes, LDH and ferritin with only mild signs
of inflammation. During the clinical course she developed joint pain with arthritis
of both wrists and leukopenia. After exhaustive diagnostic workup including bone marrow
biopsy steroid treatment was given and effective for fever and arthritis with normalization
of liver enzymes and ferritin while urticaria-like skin lesions and pruritus only
slowly improved. Due to steroid dependence IL-1-blockade with anakinra was started
but only partially effective.
Results: Results for HLA-B27, ANA, ENA, anti-dsDNA, ANCA, AMA, LKM1, immunoglobulin
A/G/M/E, ACE, Transglutaminase-AK-IgA/IgG, C1q, C2, C3, C4, CH50 were normal. S100-A8/A9
was only moderately elevated. Possible infectious causes were ruled out. A liver biopsy
was performed with the result of slight non-specific inflammation. Ultimately molecular
genetic panel diagnostic for known rare autoinflammatory conditions was performed
and showed no mutations.
With progression of symptoms and high steroid burden further treatment options were
evaluated. Due to the resemblance of some disease aspects with the clinical picture
of interferonopathies we ordered a type 1 interferon signature showing a very strong
activation. Type 1 interferonopathy was thus suspected and treatment with the Janus
kinase inhibitor baricitinib was initiated, which lead to an immediate improvement
of all symptoms and a regression of liver enzymes, ferritin and inflammatory markers.
A control of the type 1 interferon signature 4 weeks after start of the treatment
presented a normalization of the interferon activity confirming the suspected differential
Diagnosis of a Type-1-Interferonopathie. Two months into treatment the patient is
currently healthy and shows very good tolerance to the medication with no side effect
to this point.
Conclusion: Type 1 interferonopathies are autoinflammatory diseases with a very heterogenous
clinical manifestation. Symptoms can include every organic system, most common are
recurrent fever, cutaneous and neurological manifestations. They should be considered
as a differential diagnosis to systemic autoinflammatory diseases like systemic juvenile
arthritis. In this case we present a girl with possible type 1 interferonopathy with
no relevant medical antecedents or familial history of autoinflammation. While extensive
genetic testing in this girl yielded no known genetic cause of the disease, evaluation
of the type 1 interferon signature led to a specific treatment with a Janus kinase
inhibitor, which ultimately showed a rapid improvement with complete remission. Considering
the short duration of treatment to this point, the further disease course needs to
be monitored carefully.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2026 Cryopyrin-associated periodic syndromes in adults: diagnosis, therapy in clinical
practice
Svetlana Salugina, Evgeny Fedorov, Tatjana Dubinina, Svetlana Palshina
Nassonova Research Institute of Rheumatology, Moscow, Russian Federation
Correspondence: Svetlana Salugina
Introduction: Cryopyrin-associated periodic syndromes (CAPS) – a group of rare monogenic
hereditary autoinflammatory diseases (AIDs). CAPS is clinically characterized by fever,
urticarial skin rash, musculoskeletal features, eye manifestations, neurological symptoms,
hearing loss, acute phase markers. There is a high risk of amyloidosis, renal failure.
Age of onset may be different. The diagnosis is sometimes delayed for many years.
IL-1 inhibition (anakinra, canakinumab) is indicated for the whole spectrum of CAPS
(FCAS, MWS, CINCA/NOMID)
Objectives: To present clinical, laboratory and demographic characteristics and therapy
of patients with CAPS in the practice of an adult rheumatologist
Methods: The study included 11 inpatients or outpatients with CAPS, who were on examination
in Federal center of Rheumatology (10 women with MWS, 1 boy with CINCA/NOMID), aged
from 18 to 60 years. All conducted standard rheumatological examination, including
ESR, CRP.
Results: The age of the onset was 0-51 years, in 10 of 11 in childhood. Inflammatory
attacks in 7 pts started in the first year of life, 1 patient – in the age of 51 years.
Delay in diagnosis varied from 1 to 44 years, 1 - 6 years in 2 pts, 15-17 years in
4 pts, above30 years in 4 pts. The fever was in all pts, urticarial skin rash in 9
(81,8%), musculo-skeletal manifestations in 11 (mostly benign oligoarthritis, 4 –polyarthritis).
1 patient with polyarthritis had comorbid pathology - rheumatoid arthritis. Eye manifestations
(conjunctivitis, corneal dystrophy, uveitis) had 9 (81,8%), sensorineural hearing
loss – 6 (54,5%). 2 pts had abdominal pain, nausea, vomiting, 4 – headache. Duringthedisease
all pts had increased ESR, CRP. Among our pts there were 5 family cases. Mutations
in the NLRP3 gene in heterozygous state were revealed in all patients except one boy
with CINCA/NOMID. 6 pts before diagnosis received corticosteroids, treatment withIL-1
inhibitors was initiated in 7 pts (canakinumab -6, anakinra-1) with a complete or
partial response in all pts.
Conclusion: In the practice of an adult rheumatologist there are patients with recurrent
fevers and other manifestations of systemic inflammation, among which there may be
patients with CAPS. These patients need timely diagnosis and appointment of targeted
therapy. Most patients had childhood - onset. It is also very important to take into
account the presence of periodic fevers in the family history. The adult patients
have big problems with initiating or continuing treatment with IL-1 inhibitors
Disclosure of Interest
None Declared
P2027 Pulmonary screening of FMF patients during periodic follow-up: clinical and
pathogenetic considerations
Anna Sargsyan
Internal Medicine, YSMU, Yerevan, Armenia
Introduction: The most prominent pulmonary manifestations of FMF are chest attacks
due to pleuritis. It occurs in 45% of patients, sometimes as a sole manifestation
of disease. However, in Armenians pleuritis is more prevalent than arthritis- 84%
in 3 series of total 335 FMF patients1.
Objectives: To reveal the spectrum of possible pulmonary manifestations in FMF patients
and explore correlations with inflammatory biomarkers.
Methods: Pulmonary screening of a random group of 155 Armenian patients with FMF who
had pleuritic chest attacks. Pulmonary function test (PFT) by spirometry- FEV1(L),
FEV1%predicted, FVC(L), FVC% predicted, FEV1/FVC%; TTE for systolic pulmonary artery
pressure (sPAP), chest x-ray and HRCT-scan. C-reactive protein (CRP) by immunoturbidimetry,
SAA by ELISA, and capillary blood gases (PO2, PCO2, SpO2) were measured. All tests
were done in attack free period. Patients were followed prospectively for 5 years.
Results: Comparison of PFT volumes revealed statistically significant differences
in FMF-amyloidosis patient group vs FMF group (Mann-Whitney-U test, mean±SD):FEV1%pred
71.9±39 vs 71.8±13.3, p=0.046; FVC%pred 69.5±13.3 vs 74.4±10.7, p=0,033; FEV1/FVC%
77.39±9.5 vs 85.2±8.1,p<0.000. We observed 16 patients with pneumonia (lobar and interstitial),
in 5 patients pneumonia had recurrent or persistent course. Pulmonary hypertension
(sPAP>35mmHg) was diagnosed in 14 patients. 1 patient had plate atelectasis of right
lower lobe during chest attack, 2 patients bronchial asthma episodes, 2 bronchitis;
1 polyarteritis nodosa, 1Henoch-Schonlein purpura, 1 livedoid vasculopathy and 1Raynaud
disease.
Lab tests were as following in FMF-amyloidosis group vs FMF group (mean±SD):CRP 17.74±13.74mg/L
vs 11,88±13.79 and SAA 33±66.6mg/L vs 5.25±4,45 p<0,000; PO2 74±11.36mmHg, PCO2 35.3±4.5mmHg,
SpO2 90.1±10.26% vs PO2 83.6±8.95, PCO2 39.4±3.6, SpO2 94.6±3.38 p<0.000.
Conclusion: Clinically overt heart and lung diseases in FMF result from extrarenal
amyloid deposition2. Pulmonary hypertension due to amyloidosis is rare. Pulmonary
hemorrhage and infiltrates highly possible as FMF associates with vasculitis. Atelectasis
during chest attacks; ARDS due to pneumonia are described3.
We demonstrated that FMF patients with amyloidosis have hypoxia and it may have an
additive pathogenetic effect for pulmonary complications. We have shown for the first
time that patients without renal amyloidosis may develop pulmonary hypertension. These
findings raising an intriguing question about pathogenetic mechanisms. We assume that
the respiratory symptoms in FMF result from continuous low-grade inflammation. This
conclusion drawn from the significantly raised levels of inflammatory biomarkers,
CRP and SAA. The present study is the first to consider clinically relevant confounders.
Pleural adhesions were frequent radiologic findings (38%). We reveal impaired pulmonary
function and gas exchange in patients with amyloidosis. CRP but not SAA well correlates
with PO2, SpO2, and FEV1/FVC in FMF-amyloidosis group. Moreover, we reveal correlations
between CRP and PO2 in FMF patients group without amyloidosis. While pleural adhesions,
atelectasis and pulmonary infiltrates lead to restriction, obstruction causes hypoxia.
A physician, taking care of FMF patient with chest attack, can face various pulmonary
manifestations and should aware of their origin.
1 Ben-Chetrit E, Touitou I. FMF in the world. Arthritis Rheum 2009;61(10):1447-53
2 Lidar M et al. Thoracic and lung involvement in FMF. Clin Chest Med 2002;23:505-11
3 Arai Y et al. FMF mutations in a patient with recurrent episodes of ARDS. Clin Immunol
2013;147,58-60.
Disclosure of Interest
None Declared
Table 1 (abstract P2027).
Correlations (Spearman's) between PFT volumes, blood gases and CRP level
CRP
FMF-amyloidosis, n=75
FMF, n=80
FEV1
-0.063
-0.100
FVC
0.139
0.168
FEV1/FVC
-0,408**
-0.076
PO2
-0,301*
-0,329*
PCO2
-0,022
-0.037
SpO2
-0,317*
-0.131
*p<0.01, **p<0.001
P2028 Identification of novel loss-of-function mutations in two independent patients
with deficiency of adenosine deaminase 2
Oskar Schnappauf, Natalia Sampaio Moura, Qing Zhou, Natalie Deuitch, Daniel Kastner,
Ivona Aksentijevich
National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH),
Bethesda, United States
Correspondence: Oskar Schnappauf
Introduction: Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive
disorder that manifests with fever, rash, hypocellular bone marrow, early-onset vasculitis,
and propensity to ischemic and hemorrhagic stroke. Over 60 pathogenic mutations, mostly
missense variants, have been identified to date.
Objectives: The current study aimed to identify novel cryptic loss-of-function mutations
in the ADA2 gene in two unrelated families.
Methods: A variety of molecular and biochemical methods were used to identify novel
pathogenic variants in the ADA2 gene and to determine the effect of these variants
on the RNA and protein expression. The utilized methods include Sanger sequencing,
multiplex ligation-dependent probe amplification analysis (MLPA), quantitative RT-PCR
(qRT-PCR), long range PCR and long read sequencing, RNA sequencing, and ADA2 enzyme
activity assays.
Results: The first index patient is a 5-year-old female who was born to a consanguineous
Pakistani family and presented with features consistent with Diamond-Blackfan anemia
(DBA). Sequencing analysis did not identify pathogenic mutations in DBA-associated
genes and a chromosomal microarray did not detect duplications or deletions. Interestingly,
several regions of homozygosity were identified in the proband, one of which comprises
the ADA2 gene locus. Sanger sequencing of ADA2 did not identify a pathogenic variant
in the patient. Multiplex ligation-dependent probe amplification analysis (MLPA) identified
a homozygous duplication of a region comprising exon 7 of ADA2 in the proband, her
affected sister, her affected father, and a heterozygous duplication of this region
in the proband’s mother. Subsequent qRT-PCR experiments confirmed a complete loss
of RNA-expression in the individuals homozygous for the duplication. Reduced ADA2
enzyme activity corroborated the qRT-PCR findings. Long-range PCR and long-read sequencing
analysis were performed to localize the breakpoints of the duplication.
The second index patient is a 17-year-old female who presented with a history of ischemic
strokes, livedo rashes and vasculitis. She was found to be heterozygous for a known
pathogenic variant in ADA2 (c.1358A>G, p.Y453C). This variant was inherited from the
proband’s father and is also present in her three at the time unaffected siblings.
The ADA2 enzyme activity assay revealed that the proband and two of her siblings have
low to absent ADA2 enzyme activity. Her parents, as well as a fourth sibling, exhibited
ADA2 enzyme levels in the carrier range. Haplotype analyses revealed that the three
children with low ADA2 activity inherited the same allele from their mother while
the fourth sibling inherited the unaffected maternal allele. WGS of the mother and
the 3 affected children identified a novel canonical splice site variant (ADA2: c.-47+2T>C)
in an alternative ADA2 transcript (NM_001282225.1) present in all four individuals.
Sanger sequencing analysis confirmed the segregation of this variant with the disease.
This variant is absent from population databases and predicted to effect splicing.
RNA expression analysis showed that the affected individuals express only 50% of the
normal ADA2 mRNA and subsequent cDNA sequencing confirmed that only the allele carrying
the pathogenic c.1358A>G, p.Y453C variant is expressed.
Conclusion: The identification of two novel cryptic mutations in ADA2 that were not
detected by Sanger sequencing, suggests the incorporation of additional methods in
the diagnosis of DADA2. ADA2 enzyme activity testing should be utilized to identify
individuals with absent or almost absent enzyme activity even if Sanger sequencing
was negative. Subsequently, WGS and MLPA analyses can be applied to identify cryptic
single nucleotide variants and CNVs, respectively.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2029 Humoral immune compromise with autoinflammatory disease due to mutation in NLRP12
Analia G. Seminario, María S. Caldirola, Ileana Moreira, Lorena Regairaz, Liliana
Bezrodnik
Immunology, Centro de Inmunología Clínica Dra Bezrodnik, Buenos Aires, Argentina
Correspondence: Analia G. Seminario
Introduction: The hereditary periodic fevers, compromise a group of mendelian autoinflammatory
disorders characterized by recurrent episodes of fever and systemic inflammation,
sometimes complicated with amyloidosis
Objectives: Report a case of periodic fever syndrome due to NLRP12 mutation, with
humoral immune compromise.
Methods: Retrospective analysis of a clinical history of a patient with primary immunodeficiency
with humoral compromise and autoinflammatory syndrome
Results: Boy 8y.o. with recurrent severe fever episodes, since 1y.o. The crises were
like bacteremia with severe abdominal pain, arthralgia and rash with high levels of
CRP and ESR. In skin biopsy, it was observed neutrophilic vasculitis. He suffered
several bronchospasm sinusitis and acute otitis media. IgG and IgA low levels, not
response to pneumococcal antobodies and low post switched memory B cells. No improvement
with antibiotic prophylaxis. Due to its humoral immune defect, he started intravenous
gammaglobulin (IVIG) 800mg/kg/dose. He presented in the evolution coxsackie B type3
in stool, negative in CFS, needing high doses of weekly IVIG with good response and
no relapse until today. As our patient presented recurrent infections, with hypogammaglobulinemia
and autoinflammatory syndrome we studied ADA activity (NORMAL). Molecular studies
have been done, heterozygous mutation in NLRP12, was found. The infections improved
but severe episodes of abdominal pain and does not get better with colchicine treatment.Today
his treatment is IVIG, and oral budesonide. An endoscopy study to rule out amyloidosis
is pending.
Conclusion:We want to present a patient with humoral defect and autoinflammatory diseases,
due to NLRP12 mutations and demonstrate the crucial role of NLRP12 in inflammatory
signaling pathways.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2030 Genetic screening in patients with undifferentiated periodic fever syndrome
Ferhat Demir1, Ozlem Akgun Dogan2, Yasemin Kendir Demirkol2, Kubra Ermis Tekkus3,
Sezin Canbek3, Nuray Aktay Ayaz4, Levent Doganay3, Betul Sozeri1
1Pediatric Rheumatology; 2Pediatric Genetic; 3Genomic Laboratory (GLAB), Health Directorate
of Istanbul, University of Health Sciences, Istanbul, Umraniye Training and Research
Hospital; 4Pediatric Rheumatology, University of Health Sciences, Istanbul, Kanuni
Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
Correspondence: Betul Sozeri
Introduction: Autoinflammatory diseases (AID) are a group of hereditary diseases characterised
by inflammation periods accompanied with clinical findings such as fever, skin rash,
lymphadenopathy, abdominal pain, musculoskeletal symptoms, and with sign of inflammation
in the blood. Each disease has own typical clinical findings and they are associated
with mutations in specific genes such as in MEFV gene in familial Mediterranean fever
(FMF), MVK gene in hyperimmunglobulin D syndrome (HIDS), TNFRSF1A gene in tumor necrosis
factor-alpha receptor associated periodic fever syndrome (TRAPS) and NLRP3 gene in
cryopyrin associated periodic fever syndrome (CAPS) . Also in some patients with periodic
fever syndrome (PFS), clinical signs of these diseases can be seen but no mutation
can be detected in the related genes. There are also patients exhibit the incomplete
phenotype of a disease or overlap signs of more than one AID. The diagnosis of these
undifferentiated patients have difficult and may not be possible by a single target
gene analysis. Screening of the periodic fever syndrome (PFS) panel including various
AID genes may be beneficial to define the atypical cases. Molecular genetics has an
important role for lead to diagnosis in these patients.
Objectives: The aim of this study was to investigate the genotypic diagnosis in patients
with non-characteristic PFS findings for any AID.
Methods: This is a prospective study and conducted between June 2016 and December
2018. Next-generation sequencing (NGS) analysis was performed by using “Fever and
AutoInflammatory Syndrome panel: Panel by Sophia Genetics” including 8 genes (MEFV,
MVK, NLRP3, NLRP12, TNFRSF1A, TNFRSF11A, LPIN2 and PSTPIP1) in 30 patients with undifferentiated
PFS. Clinical features and genetic results were evaluated together and final diagnoses
were determined.
Results: Thirty patients included in the study did not have typical clinical features
for any of the eight monogenic diseases in the PFS panel. In the result of the genetic
screening; disease-causing mutation was found in MEFV gene in 12 patient, in NLRP3
gene in four patient, in NLRP12 gene in two patient and in MVK gene in one patient.
Also, genetic variants of uncertain significance (VUS) in different genes were shown
in five patient. No mutation was detected in remaining six patient. The final diagnosis
was made by both phenotypic and genotypic data. 12 patients were diagnosed with FMF,
four were FCAS, two were FCAS2, one was TRAPS and one was HIDS. Patients with negative
genetic screening or had mutation as VUS, were followed as undifferentiated PFS.
Conclusion: Autoinflammatory diseases may not always be appear with typical clinical
findings of related disease. In such patients, target gene sequencing and detection
of underlying disease can be challenging. Our study has shown that the NGS analysis
may help to determined the diagnosis in patients with non-characteristic PFS findings
for any AID.
Disclosure of Interest
None Declared
P2031 Deficiency of ADA2 from childhood to adult; the same mutation in a family
Betul Sozeri1, Gozde Ercan2, Ozlem Akgun Dogan3, Jale Yıldız4, Ferhat Demir1, Levent
Doğanay4
1Pediatric Rheumatology; 2Pediatrics; 3Pediatric Genetics; 4Genomic Laboratory (GLAB),
Health Directorate of Istanbul, University of Health Sciences, Istanbul, Umraniye
Training and Research Hospital, Istanbul, Turkey
Correspondence: Betul Sozeri
Introduction: The deficiency of adenosine deaminase 2 (DADA2) has recently been defined
as a monogenetic autosomal recessive autoinflammatory disease. It mainly characterized
by high fever, livedoid racemosa, early onset stroke, and mild immunodeficiency, clinically
polyarteritis nodosa (PAN) like symptoms. Wide spectrum of severity in phenotype as
well as in the age of onset has been reported in the literature. This phenotypic variability
is also found in our clinical practice even in patients with the same mutation.
Objectives: We present a case series of nine members of same family. p.Gly47Arg mutation
in CECR1 gene was detected in homozygous state in five patients who have moderate
to severe clinical findings, and in heterozygous state in four members with mild non-specific
symptoms in the family.
Methods: Genomic DNA was extracted from peripheral blood sample of the index case
and the next generation sequencing was performed on Illumina MiSeq (v1.9) platform
using the Periodic Fever Panel. Bioinformaticanalyses were performed by using SophiaDDM
software. A previously reported missensec.139G>A change in CECR1, which leads the
glysine to arginine substitution at position 139, was detected in homozygous state
in the index case. This variation were searched in the parents and siblings as well
as the symptomatic cousins, by Sanger sequencing. Five homozygos and four heterozygos
variations in CECR1 were detected.
Results: Fever, skin manifestations and neurological system involvement was observed
in the index case and three of which were homozygos mutations but in the one, none
of these was observed. A mild to severe involvement of neurological system and skin
manifestations was seen more severe in homozygous mutant patients with early onset
disease even resulted with necrosis. Gastrointestinal system involvement was only
observed in index case and the late-onset patient with homozygous mutation. Arthritis
was detected in three of patients with homozygous mutations. The age of onset of the
disease is quite different from each other, even in individuals with the same mutation.
In the light of these results, we suggest that early age of onset in the disease is
associated with serious clinical findings and poor outcome
Conclusion: With this report, we aimed to further delineate the phenotype and demonstrate
variability both in the clinical findings and in the age of onset in five patients
with the same mutation from the same family. As we know, there are any family cases
presented with DADA2 almost in all members have been reported yet.
Disclosure of Interest
None Declared
P2032 Autoinflammatory diseases in Ukraine
Yuriy Stepanovskyy1, Yaryna Boyko2
1Pediatric Infectious Diseases and Pediatric Immunology, Shupyk National Medical Academy
of Postgraduate Education, Kyiv; 2Rheumatology, Western Ukrainian Specialized Pediatric
Medical Centre, Lviv, Ukraine
Correspondence: Yuriy Stepanovskyy
Introduction: First case of monogenic autoinflammatory disease (CINCA/NOMID) was diagnosed
in Ukraine in 2001. Since, the number of patients with autoinflammatory diseases (AIDs)
was slowly growing up. More than 90% of patients were diagnosed and were under surveillance
in two centers: Kyiv city pediatric center of clinical immunology and Western Ukrainian
Specialized Pediatric Medical Centre.
Objectives: The purpose of this study is to describe current situation with AIDs in
Ukraine and its problems, and advances.
Methods: We reviewed the charts of patients with autoinflammatory diseases from 2
centers where they were followed up. Among them, 7 patients with monogenic AIDs (genetically
confirmed), 5 with strong clinical and laboratory phenotype of AIDs and 90 patients
with PFAPA-syndrome.
Results: We analyzed known patients with AIDs in Ukraine. Spectrum of patients is
presented it the Tab. 1. Delay with diagnosis of monogenic AIDs was 2 to 9 years,
and 1,5 years for PFAPA patients. The most common burdens on the way to diagnosis
were: very low awareness of physicians about AIDs, absence of accessible biologic
treatment and absence of genetic tests.Actually, all patient’s genetic tests were
done in foreign laboratories. In 2018 pediatric immunology community, initiated introduction
of IL-1 driven diseases with anakinra with government support.
Conclusion: Awareness about autoinflammatory disorders is still poor in Ukraine.Access
to treatment with anakinra in Ukraine opened new opportunities to moving forward in
the field of autoinflammatory diseases. Searching ways to facilitate access to genetic
diagnostic is always a question to be resolved.
Disclosure of Interest
None Declared
Table 1 (abstract P2032).
See text for description
Patient
Sex
Disease type
Genetic test
1, 2
F
FMF
confirmed & not done
3
M
HIDS
confirmed
4, 5, 6
F, F, M
CINCA/NOMID
confirmed
7
F
DADA2
confirmed
8
F
Cold-induced AID
not done
9
F
TRAPS-like phenotype
not done
10
F
AID, undefined
new mutation was found, under investigation at NIH
11
F
AID, undefined
WGS, mutations not found
12
F
NRLC4-MAS like illness
Panel sequencing for 15 genes including NLRC4-negative result
P2033 The spectrum of autoinflammatory syndromes at postgraduate institute of medical
education and research, Chandigarh, India
Deepti Suri1, Amit Rawat1, Anju Gupta1, P. Vignesh1, Ankur Jindal1, Sagar Bhattad1,
Marco Gattorno2, Adriana A de Jesus3, Raphaela Goldbach-Mansky3, Surjit Singh1
1Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Insitute of Medical
Education and Research, Chandigarh, India; 2Center for Autoinflammatory Diseases and
Immunodeficiencies, G. Gaslini Institute for Children, Genoa, Italy; 3Translational
Autoinflammatory Disease Section, NIAID, NIH, Bethesda, Maryland, United States
Correspondence: Deepti Suri
Introduction: This paper presents clinical and molecular data of patients with auto-inflammatory
diseases (AIDs) at Postgraduate Institute of Medical Education and Research, Chandigarh,
India.
Objectives: To highlight the clinical and molecular spectrum of AIDs at our centre.
Methods: A review of case records of patients with AIDs attending the Pediatric Immune
Deficiency in the last 7 years.
Results: A total of 35 children with AIDs were identified and their profile is summarized
in the Table. Among the periodic fevers group, Periodic Fever, Aphthous Stomatitis,
Pharyngitis and Adenitis (PFAPA) was diagnosed in 8 patients. Three patients had Cryopyrin-Associated
Periodic Syndrome (CAPS) while 2patients hadTumor Necrosis Factor Associated Periodic
Fever syndrome (TRAPS). A child novel PSTPIP 1 gene mutation with Pyogenic Arthritis,
Pyoderma gangrenosum, and Acne (PAPA) was diagnosed. Ten children werefound to have
chronic recurrent multifocal osteomyelitis. The first ever Indian child with Deficiency
of IL-1 Receptor Antagonist (DIRA) had presented with lytic bone lesions in early
infancy and has been reported. Another infant suspected to have DIRA responded to
glucocorticoid therapy with radiological improvement, however, molecular confirmation
is awaited.Eight children had Blau syndrome withNOD 2 gene mutations. There were considerable
delays in diagnosis and difficulties in treatment due to non-availability of anti-
IL-1 blocking drugs(Anakinra or Canakinumab) in India. Two children with NOMID/CAPS
died due to renal amyloidosis.
Conclusion: Delay in diagnosis and lack of availability of drugs for treatment of
AIDs are difficulties in managing patients in India.
Disclosure of Interest
None Declared
Table 1 (abstract P2033).
See text for description
Patient Profile
Diagnosis
Prominent clinical features
Age at Diagnosis(years)
Treatment
Outcome
NOMID
S,13 years F
NLRP3 C.913G>C, p.D305H
(de novo mutation)
Fever, rash in infancy, bony overgrowth, headache Amyloidosis, misdiagnosed as JIA,
13 years
Thalidomide
Doing well
Symptomatically better
NOMID
K,11years M
NLRP3 p.Thr349Ile
Parents negative (de novo mutation).
Mosaicism
Crippling arthritis, Bed bound, amyloidosis
11 years
Prednisolone
Died due to refractory renal failure secondary to amyloidosis
K,8 years F
CAPS
NLRP3 mutation
Diagnosed as steroid resistant nephrotic syndrome
8 years
Prednisolone
Died
TRAPS (n=2)
M,4 years, F
TNFRSF1A p. Cys43Tyr
Transmitted from father
Periodic fevers, subcutaneous swellings, rash, periorbital edema
Father symptomatic
4 years
Etanercept
Doing well on etanercept
KD,35 years, F
TNFRSF1A p.Pro301His
(Unreported VUS)
Fever, conjunctivitis, Pustular psoriasis with high Inflammatory markers
6 years
Prenisolone
cyclosporine
Partial control
Intermittent flares of skin and fever
DIRA (n=1)
B/O V, 2months, F1
IL1RN deletion, at chr2_hg19_113,865,011 and chr2_hg19_113,887,227 homozygous 22,216bp
deletion spans the first four exons of IL1RN
Parents carrier for same mutation (NM_173843)
Infant with multifocal osteitis, few pustules,
-
Anakinra*
Doing well
S, 1.5 months, M
Result awaited
Multifocal osteitis involving humerus, clavicle, ribs
1.5months
Prednisolone for 6 months
Doing well
PAPA (n=1)
M, 8 years F
PSTPIP1 gene
p.Thr 68Met
Pyoderma, abscess, colitis, fever
4 years
Prednisolone, Infliximab
Died
APLAID (n=1)
M, 3 years, F
PLCG2 exon 22 c.2393A>G p.Asn798Ser
Heterozygous
Joint swelling, rash and bloody diarrhoea
6 years
Prednisolone
Doing well
Intermittent skin flares
*Therapy courtesy compassionate use supply NIH
P2034 Patient with FMF presented by isolated myositis
Sema N. Taskin, Aysenur Kisaarslan, Sümeyra Ozdemir Çiçek, Nihal Sahin, Muammer Hakan
Poyrazoğlu, Ruhan Dusunsel
Pediatric Rheumatology, Erciyes University Medical Faculty, Kayseri, Turkey
Correspondence: Sema N. Taskin
Introduction: Familial Mediterranean fever (FMF) is a genetic disease characterized
by recurrent febrile episodes and mostly by the inflammation of serous membranes.
We presented our case whom presented with acute myositis and was diagnosed as FMF.
Results: A six year and 5 mounth old girl complained of severe pain in her right leg
and a gait while walking for a period of one week. It was learned from the history
that the right ankle swelled and hiperemic macular rash were determined on lateral
malleol area three years ago and the acute phase reactants were elevated at that time.There
was no consanguinity and family history of autoinflammatory diseases. Physical examination
of the patient revealed swelling, redness, thenderness, heat increase of on the calf
muscles and limitation of extension of the knee joint. White blood cells, C-reactive
protein (CRP), and eritrocyte sedimantation rate (ESR) were eleveated, muscle enzymes
were normal levels.In the USG, the right popliteal fossa fat tissue was prominent
and inflamed, and the neural structures were thick and edematous.Magnetic Resonance
imaging of the thighs and right leg posterolateral muscles was consistent with myositis.
After NSAID treatment, the clinic improved. However, the high CRP and ESR persisted
for six mounths. There was no mutation on TRAPS gene. When the M694V homozygous mutation
was detected in the FMF genetics of the patient, Familial Mediterranean Fever was
diagnosed and colchicine treatment was started. Other autoinflammatory diseases genes
could not studied. Acute phase reactans of the patient regressed after the treatment.
The patient experienced arthritis attack at once for two years follow up.
Conclusion: The patients who carried M694V homozygous mutations may presented nonclassical
findings of FMF.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2035 Interstitial lung disease in a newborn affected by mevalonic aciduria
Sofia Torreggiani1,2, Carlo Pietrasanta3,4, Francesca Minoia1, Giovanni Filocamo1,
Andrea Ronchi3, Stefano Volpi5, Roberta Caorsi5, Marco Gattorno5, Francesco Caroli6,
Alice Grossi6, Isabella Ceccherini6, Lorenza Pugni3, Fabio Mosca3,4
1Pediatria Media Intensità di Cura, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milan; 2University of Milan; 3NICU Fondazione IRCCS Ca’ Granda Ospedale
Maggiore Policlinico, Milan; 4University of Milan, Department of Clinical Sciences
and Community Health, Milan; 5Clinica Pediatrica e Reumatologia; 6UOC Genetica Medica,
Istituto Giannina Gaslini, Genova, Italy
Correspondence: Sofia Torreggiani
Introduction: Mevalonic aciduria (MA) is the most severe phenotype of mevalonate-kinase
deficiency (MKD), with a onset in early infancy and poor prognosis. MA diagnosis may
be challenging in the neonatal period given its rarity and its unspecific symptoms
that frequently recall those of other neonatal diseases. To our knowledge, interstial
lung involvement has never been described as onset feature in a newborn with MKD.
Objectives: We report the case of a newborn affected by MKD characterized by interstitial
lung disease.
Methods: The patient underwent laboratory and radiology evaluation as clinically indicated.
Direct Sanger sequencing was used to screen the 10 exons of the MVK gene.
Results: A female neonate born at term from consanguineous parents was referred to
our hospital at 16 days of life (DOL) for mild hypotonia and persistent raised inflammatory
markers despite antibiotic therapy. Infectious work-up was negative for both viral
and bacterial infections. Chest x-ray revealed bilateral perihilar peribronchial thickening.
Electroencephalography (EEG) reported moderate diffuse anomalies of background activity
without major abnormalities. On DOL 20 the first episode of fever was recorded. Due
to worsening tachypnea and persistent abnormal chest x-ray, a pulmonary CT scan was
performed and showed diffuse ground-glass bilateral infiltrates consistent with alveolar-interstitial
lung disease. On DOL 22 a palpable maculo-papular skin rash appeared on feet and hands,
vanishing spontaneously 24 hours later. Bone marrow examination and levels of perforins,
neuron-specific enolase and urinary catabolites of catecholamines were normal. A total
body MRI was normal except for a mild cerebellar hypoplasia and the known interstitial
lung disease. The patient kept presenting hypotonia, relapsing episodes of fever and
skin rashes, developed anemia requiring blood transfusions and failure to thrive became
evident. Type-I IFN signature was negative. A genetic test was requested, as well
as quantification of urinary levels of mevalonic acid, which were markedly above the
normal range. Direct Sanger sequencing allowed to detect a homozygous c.709A>T missense
mutation in the exon 8 of the MVK gene, coding for a protein substitution p.T237S
already classified as pathogenic in the INFEVERS database (http://fmf.igh.cnrs.fr/ISSAID/infevers/)
and therefore consistent with the diagnosis of MKD. Both parents and her sister were
found to be heterozygous carriers of the same mutation. On DOL 38 treatment with anakinra
was started, with prompt regression of fever and skin rash, decrease in inflammatory
markers, increase in reticulocytes count and weight gain. Hypotonia improved but persisted.
The patient was discharged from hospital on DOL 56 in good clinical conditions, with
acute phase reactants within the normal range and mild hypotonia. She is now 4 months
old, still on anakinra treatment without adverse events.
Conclusion: Autoinflammatory diseases in the neonatal period are a diagnostic challenge.
Clinical suspicion is crucial in order to perform specific laboratory and genetic
testing and start appropriate treatment. Interstitial lung involvement may be present
in MKD and, together with increased inflammatory markers, could be the first manifestation
of the disease.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2036 Familial Mediterranean fever related damage assessed by auto-inflammatory disease
damage index (ADDI) and associated factors with damage
Hakan Babaoglu1, Berkan Armagan2, Erdal Bodakci3, Timucin Kasifoglu3, Hasan Satis1,
Nuh Atas1, Alper Sari2, Gozde K. Yardimci2, Nazife S. Y. Bilge3, Reyhan B. Salman1,
Levent Kilic2, Mehmet A. Ozturk1, Seminur Haznedaroglu1, Berna Goker1, Umut Kalyoncu2,
Abdurrahman Tufan1
1Department of Internal Medicine, Division of Rheumatology, Gazi University Faculty
of Medicine; 2Department of Internal Medicine, Division of Rheumatology, Hacettepe
University Faculty of Medicine, Ankara; 3Department of Internal Medicine, Division
of Rheumatology, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
Correspondence: Abdurrahman Tufan
Introduction: Familial Mediterranean Fever (FMF) is the most frequent auto-inflammatory
disease caused by MEFV gene mutations. Although FMF is characterized by intermittent
inflammatory attacks some patients exert chronic persistent inflammation that can
result in damage of multiple organs. Available reports investigated only specific
components of damage such as amyloidosis. All possible organ targets of damage have
not been entirely evaluated before. Such as Disease severity index which is emerged
especially for FMF do not cover entire damage domains related to FMF. Recently, a
new scoring system (Auto-inflammatory disease damage index) was developed and validated
for autoinflammatory diseases.
Objectives: to investigate damage accrual caused by FMF and associated features with
damage.
Methods: All patients recruited from FMF in Central Anatolia (FiCA) cohort, which
is a duplication disabled, internal and externally controlled, cross-sectional, multicenter
accessible web-based cohort. This study is comprising 970 adult patients (mean age
35.3 ±12.1 years, 61.5% female). Demographic data, FMF disease characteristics, co-morbid
conditions, disease complications were meticulously questioned and laboratory features
and genotype data (if available) were recruited from patient files. FMF caused damage
was assessed by auto-inflammatory disease damage index (ADDI) which is recently validated.
Association between damage and demographic, disease and treatment characteristics
were analyzed.
Results: Proportions of FMF manifestations were fever 83.1%, peritonitis 91.5%, pleuritis
47.9%, arthritis 43.3% and skin rash 26.2%. Dominant attack types were fever in 6.2%,
serositis in 65.7%, musculoskeletal in 16.8% and all types of attacks were common
in rest of patients. MEFV mutations were available in 814 subjects and 75.9% of these
subjects were harboring M694V mutation (42.5% homozygous for M694V). Among all 63.1%
patients were well responded to colchicine and 8.8% were non-responders. Median ADDI
score was 1 (min 0-max 11). Most common FMF related damages were observed in musculoskeletal,
reproductive and kidney domains. Chronic musculoskeletal pain was present in 49%,
joint deformity in 2.9%, infertility in 6.6%, amenorrhea in 3.9%, proteinuria in 6.9%,
amyloidosis in 5.9% and renal failure in 3.7% of the patients. 411 (%42.3) of patients
had no damage accrual. M694V homozygous mutation, male gender and colchicine nonresponse
were found to be the independent predictors of damage.
Conclusion: M694V homozygous mutation, colchicine non-response and male gender are
predictors of damage and effective therapeutic interventions must be undertaken to
prevent from damage in these patients.
Disclosure of Interest
None Declared
P2037 Familial Mediterranean fever associated inflammatory disorders
Nuh Ataş1, Berkan Armagan2, Erdal Bodakci3, Timucin Kasifoglu3, Hasan Satis1, Alper
Sari2, Nazife S. Y. Bilge3, Hakan Babaoglu1, Gözde K. Yardımcı2, Reyhan B. Salman1,
Levent Kilic2, Mehmet A. Ozturk1, Seminur Haznedaroglu1, Berna Goker1, Umut Kalyoncu2,
Abdurrahman Tufan1
1Department of Internal Medicine, Division of Rheumatology, Gazi University Faculty
of Medicine; 2Department of Internal Medicine, Division of Rheumatology, Hacettepe
University Faculty of Medicine, Ankara; 3Department of Internal Medicine, Division
of Rheumatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
Correspondence: Abdurrahman Tufan
Introduction: Familial Mediterranean fever (FMF) is an autosomal recessive hereditary
autoinflammatory disease, characterized by recurrent self-limiting attacks of fever,
serositis, arthritis and erysipelas-like skin eruption. Beside these, a substantial
number of patients manifest with variety of inflammatory diseases probably due to
predisposing effects of disrupted immune pathways in FMF. There is no systematic study
investigating these conditions in FMF.
Objectives: The aim of this study is to determine prevalence of inflammatory conditions
observed in patients with FMF and to define new potential inflammatory disorders.
Methods: All patients recruited from FMF in Central Anatolia (FiCA) cohort, comprising
970 (mean age 35.3±12 years, 61.5% female) adult subjects. All patients fulfilled
Tel Hashomer criteria. Demographic data, FMF disease characteristics, co-morbid conditions,
disease complications were meticulously questioned and laboratory features and genotype
data (if available) were recruited from patient files. Data on inflammatory conditions
were derived from patient interviews and hospital records.
Results: Inflammatory diseases were detected in 205 (21.1%) patients. Most common
inflammatory disease was spondyloarthritis. Psoriasis, Henoch-Schönlein purpura, Behçet’s
and inflammatory bowel diseases were other remarkable relevant disorders. Contact
dermatitis and cryptogenic organizing pneumonia were two newly defined entities in
our cohort seem to be associated with FMF.
Conclusion: FMF is an inflammatory disease with short-lived/ self-limiting attacks.
However, our results suggest that FMF is more than our apprehension which can also
manifest with chronic conditions. In case of consistent symptoms, other potential
FMF associated inflammatory diseases must be considered. Elaboration of pathogenic
pathways linking these diseases to FMF warrant further investigations.
Disclosure of Interest
None Declared
P2038 Work productivity and activity impairment in familial Mediterranean fever patients
Erdem Suticen1, Nuh Atas2, Hakan Babaoglu2, Hasan Satis2, Reyhan B. Salman2, Ozkan
Varan2, Mehmet A. Ozturk2, Seminur Haznedaroglu2, Berna Goker2, Abdurrahman Tufan2
1Department of Internal Medicine; 2Department of Internal Medicine, Division of Rheumatology,
Gazi University Faculty of Medicine, Ankara, Turkey
Correspondence: Abdurrahman Tufan
Introduction: Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory
disease characterized with febrile attacks of serositis and arthritis. Although FMF
can be observed at any age, it commonly affects children and young adults who are
at most productive ages of the life. FMF has significant effects on work productivity
and working life of patients as their quality of life.
Objectives: The aim of this study is to investigate work productivity and impairment
in patients with FMF.
Methods: This study included 111 consecutive FMF patients who followed at the outpatient
rheumatology clinic of Gazi University Hospitals. Demographic characteristics, the
type of attacks, clinical and treatment features of FMF and work related data in last
three months were recorded. Work productivity and activity impairment (WPAI) questionnaire
was used for evaluation of the work productivity. Ten point visual analog scale was
used for the determination of patient reported global disease activity assesment.
Results: The mean age of patients were 32.72±8.65 years and 54.1% were males. The
proportion of FMF manifestations were peritonitis 87.4%, fever 83.8%, arthritis 75.7%,
pleuritis 62.4 % and skin rash 32.4%. Sixty-five (58%) patients were on paid jobs.
Absenteeism were evident in 12 of 65 subjects (18.4%). The median total lost days
due to disease in last three months was 1 (range, 0-30) day. The median ratio of absenteeism
was 22.4% (range, 2-100). The median presenteeism was 3 on a 0-10 point visual analog
scale (range, 0-10). Disase activity assessed by patient global assesment was correlated
with presenteeism (r=0.42, p<0.001) and absentteism (r=0.22, p=0.08).
Conclusion: Results of our study suggest that FMF is associated with work impairment
which is more frequently observed as presenteeism (work productivity). FMF disease
activity is remarkably associated with impairment in work productivity.
Disclosure of Interest
None Declared
P2039 Human phenotype ontology for systemic autoinflammatory disorders
Marielle Van Gijn1, Julia Pazmandi2,3, Paul Brogan4, Marco Gattorno5, Paul van Daele6,
Kaan Boztug2,3, Peter Robinson7, Matthias Haimel2,3, Anna Simon8
1Genetics, University Medical Center Utrecht, Utrecht, Netherlands; 2Ludwig Boltzmann
Institute for Rare and Undiagnosed Diseases; 3CeMM Research Center for Molecular Medicine
of the Austrian Academy of Sciences, Vienna, Austria; 4Infection Inflammation and
Rheumatology Section, University College London Great Ormond Street Institute of Child
Health, London, United Kingdom; 5Department of Pediatric Rheumatology, IRCCS G. Gaslini
Institute, Genoa, Italy; 6Deparment of Internal medicine and department of Immunology,
Erasmus MC, Rotterdam, Netherlands; 7The Jackson Laboratory for Genomic Medicine,
Farmington, CT, United States; 8Department of Internal Medicine, Radboudumc Expertise
Ccenter for Immunodeficiency and Autoinflammation, Radboud University Medical Center,
Nijmegen, Netherlands
Correspondence: Marielle Van Gijn
Introduction: Systemic autoinflammatory diseases (SAID) are highly heterogeneous monogenic
or multifactorial conditions whose onset is secondary to deregulation of mechanisms
controlling the immune innate response. Molecular analysis is able to provide a definitive
diagnosis in some patients with inherited SAID, but the results can be inconclusive.
Bioinformatics can facilitate matching of phenotypically similar patients to enable
gene discovery and the detection of new biomarkers. However, to allow efficient data
exchange between clinicians and laboratories standardized clinical descriptions are
necessary. Data structures such as the Human Phenotype Ontology (HPO) and disease
ontologies such as the OrphaNet Rare Disease Ontology (ORDO) aim to provide standardized
vocabularies of phenotypic abnormalities in human diseases, and can be used for this
purpose. However, there are still crucial gaps in HPO and ORDO for SAID.
Objectives: A directed re-evaluation and correction of SAID-specific HPO and ORDO
terms and ontology structures, as well as addition of new terms to enableuse of HPO
in clinical practice.
Methods: In a 2-day workshop geneticists, medical doctors and bioinformaticians started
to systematically re-evaluateSAID HPO and ORDO ontology terms, and re-annotate diseases.
To continue this process, a working group was formed that will use text-mining from
references from an international textbook on autoinflammation, and the Eurofever dataset
to further optimizeand re-evaluate SAID HPO.
Results: So far, we have collected changes regarding the classification of autoinflammatory
diseases to be submitted to ORDO. These include new disease terms such as “Autoinflammatory
diseases without immunodeficiency”; and “NLRP3-associated autoinflammatory disease”,
an umbrella term encompassing Muckle-Wells syndrome, CINCA, and Familial cold urticaria
syndrome. So far, we have revised six sub-branches of the HPO to include a more accurate
representation of autoinflammation-associated phenotypes, such as “increased inflammatory
response”, “abnormality of temperature” and “tissue ischemia”. Moreover, we have successfully
re-annotated 13 diseases entities with updated HPO terms.
Conclusion: Accurate metadata are increasingly needed to describe clinical information
not only in a genetic manner, but also phenotypically. With the continued systematic
re-evaluation of HPO for SAID, we expect to (i) standardize patient characterization
so that clinicians/researchers can characterize patients in a language-independent
manner; (ii) allow for efficient data exchange between clinicians, laboratories and
centers; (iii) facilitate matching phenotypically-similar patients to enable gene
discovery.
Disclosure of Interest
None Declared
P2040 Diagnosis and stratification of familial Mediterranean fever by a simple functional
assay
Hanne Van Gorp1, Linyang Huang1, Pedro Saavedra1, Tomoko Asaoka1, Andy Wullaert1,
Benson Ogunjimi2, Vito Sabato2, Joost Frenkel3, Fabrizio De Benedetti4, Joke Dehoorne1,
Filomeen Haerynck1, Giuseppe Calamita5, Piero Portincasa5, Mohamed Lamkanfi1
1Ghent University, Ghent; 2University of Antwerp, Antwerp, Belgium; 3University Medical
Center Utrecht, Utrecht, Netherlands; 4Bambino Gesù Children’s Hospital, Rome; 5University
of Bari, Bari, Italy
Correspondence: Andy Wullaert
Introduction: Familial Mediterranean Fever (FMF) is the most common monogenic autoinflammatory
disease (AID) worldwide. The disease is caused by mutations in the MEFV gene encoding
the inflammasome sensor Pyrin.
Objectives: Diagnosis of FMF is complicated by overlap in symptoms with other AIDs.
Around 340 MEFV variants have been reported without clear genotype-phenotype links,
thereby complicating interpretation of genetic testing. Therefore, we aimed to develop
a functional test to shed more light on the deleterious effect of specific MEFV variants
of the disease, and to aid in a more straightforward diagnosis.
Methods: In a prior study,1 we highlighted that in contrast to wild type Pyrin that
requires microtubules to activate the inflammasome signaling pathway, inflammasome
signaling by FMF-associated Pyrin variants is independent of microtubules. We used
this differential microtubule requirement as a functional assay for diagnosing and
stratifying FMF patients.
Results: Overall, our data nicely corroborate the recent consensus pathogenicity classification,
though also provide potential new insights for specific variants. The assay is highly
specific since related disorders (pyogenic arthritis, pyoderma gangrenosum, and acne
(PAPA) and mevalonate kinase deficiency (MKD)) involving Pyrin inflammasome signaling
are reliably segregated from FMF. The assay can be performed using purified peripheral
blood mononuclear cells (PBMC) as well as a small volume of whole blood, providing
a robust and versatile tool that paves the way for further research deciphering the
molecular pathophysiological mechanisms underlying FMF, and, most importantly, diagnosis
of FMF in the clinic.
Conclusion: To our knowledge, this microtubule dependency functional assay is the
first one allowing diagnosis of FMF that enables functional/immunological screening
of the disease among clinically overlapping auto-inflammatory patients and thus may
contribute to timely FMF diagnosis and commencement of therapy.
Reference
1Van Gorp, H. et al. Familial Mediterranean fever mutations lift the obligatory requirement
for microtubules in Pyrin inflammasome activation. Proc Natl Acad Sci U S A
113, 14384-14389, doi:10.1073/pnas.1613156113 (2016).
Disclosure of Interest
None Declared
P2041 Evaluation of coexisting diseases in children with familial Mediterranean fever
Mehmet Yildiz, Amra Adrovic, Emre Tasdemir, Khanim Baba-Zada, Muhammed Aydin, Oya
Koker, Sezgin Sahin, Kenan Barut, Ozgur Kasapcopur
Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul,
Turkey
Correspondence: Mehmet Yildiz
Introduction: Familial Mediterranean Fever (FMF) is most common periodic fever syndrome
in childhood. It is characterized by fever attacks, abdominal pain lasting between
6 - 72 hours, serositis and erysipelas like erythema. Since FMF is inherited in autosomal
recessive manner, it has higher frequency in populations that have higher rate of
consanguineous marriages. As it is a lifelong chronic disorder, it is important to
understand its clinical course for preventive medicine. Despite the higher incidence
of variety of disorders shown studies among adult FMF patient, there is not enough
data from pediatric populations.
Objectives: The objective of the study is to evaluate the comorbid disorders in a
large pediatric familial Mediterranean fever cohort.
Methods: Six hundred and eighty-six children with FMF were interviewed by the same
investigator between October 2018 and January 2019 in our pediatric rheumatology department.
Demographic features and MEFV gene mutations were recorded from patients’ charts.
Patients and/or their parents were asked about characteristics of their fever episodes,
presence of arthralgia, arthritis, abdominal pain, chest pain in the course of fever
attack and coexistence of any other disease confirmed by a physician.
Results: Female-male ratio of our cohort was 0,85. Mean age of the patients was 12,8
± 7,4 years. Mean age of patients at disease onset and at the time of diagnosis was
4,38 ± 3,46 years and 6,55 ± 3,67 years, respectively. Sixty-five and a half percent
of patients had family history of FMF. Consanguineous marriage rate was 29,8 %. Most
common MEFV mutations were: M694V homozygotes (18,8%), M694V heterozygotes (17,7%),
R202Q heterozygotes (13,1%), R202Q homozygotes (5,5%) and V726A heterozygotes (4,9%),
respectively. Resistance to colchicine treatment was present in 43 (6,2 %) patients.
Number of patients that underwent tonsillectomy were 9 (1,3 %) and number of patients
that had appendectomy was 11 (1,6 %). Detected coexisting diseases are listed in Table
1.
Conclusion: In this study, we have reported increased frequency of juvenile idiopathic
arthritis, asthma- reactive airway disease, Henoch Schonlein purpura, uveitis, inflammatory
bowel disease, PFAPA syndrome and acute rheumatic fever in a large pediatric FMF cohort.
Those findings consistent with data from literature. It is important to be alert about
these diseases that may develop in patients with FMF for preventing them from the
potential morbidities.
Disclosure of Interest
None Declared
Table 1 (abstract P2041).
Detected coexisting diseases in patients group
n(%)
Juvenile Idiopathic Arthritis
40(5,8)
-·Systemic
4 (0,5)
- Oligoarticular
17(2,4)
- Polyarticular
5(0,7)
- Enthesitis Related Arthritis
1(0,1)
- Juvenile Spondylitis
13(1,8)
Asthma/ Reactive Airway Disease
26(3,7)
Henoch Schonlein Purpura
18(2,6)
Uveitis
10(1,4)
Inflammatory bowel disease
9(1,3)
Periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis (PFAPA)
7(1)
Acute Rheumatic Fever
7(1)
Migraine
7(1)
Allergic Rhinitis
6(0,8)
P2042 Results of international Delphi survey on the investigation and management of
first-degree relatives of those with deficiency of ADA2
Taryn A.-B. Youngstein1, Eugene P. Chambers2, on behalf of DADA2 Foundation, Helen
J. Lachmann1, and DADA2 Delphi Study Participants
1National Amyloidosis Centre, National Amyloidosis Centre, UCL Division of Medicine,
London, London, United Kingdom; 2Vanderbilt University Medical Centre, Vanderbilt
University, Nashville, United States
Correspondence: Taryn A.-B. Youngstein
Introduction: DADA2 is thought to be a recessive disease that is phenotypically heterogenous
in its presentation, even within families with the same mutation.However, there have
been numerous reports of disease in true heterozygotes.
Objectives: As part of a broader E-Delphi study to establish consensus on the diagnosis,
investigations and management of those with DADA2, we explored current opinion and
practice with respect to first-degree relatives of those with DADA2.
Methods: A Delphi method over two rounds of consensus building was used. Invitation
email to participate in the study was sent to all published authors on DADA2 and physicians
and scientists known to the DADA2 Foundation, a patient advocacy group supporting
research into DADA2.Consensus was defined as > 80% agreement.
Results: 69 respondents contributed to Round 1 and 53 respondents in Round 2. 75%
of respondents were paediatricians, the rest adult physicians, a nurse specialist
and basic scientists.
88% of respondents would investigate asymptomatic first-degree relatives with genetic
testing.39% would refer formally for genetic counselling and 6% have counsellors in
their clinic consultations.
62.8% of respondents believe that true heterozygotes can have DADA2, and screen for
low ADA2 enzyme activity to make the diagnosis (66%).Treatment (anti-TNF) would only
be started in those who were symptomatic (defined by stroke (80%), digital gangrene
(64.6%), livedoid rash (49.2%) and cytopaenias (43.8%)). If asymptomatic, 65% would
follow-up carriers (heterozygote or homozygote), and 13.6% would only follow-up those
who also had low ADA2 activity.
74.5% screened for hypertension in carriers, 64.7% would treat borderline hypertension.89.7%
would not anti-coagulate asymptomatic carriers, 50.7% would not give anti-platelet
therapy.Statins would only be given if indicated by raised fasting lipids.50% perform
follow-up investigations such as testing inflammatory markers, 73.9% do not perform
any surveillance imaging (such as MRI Brain) in asymptomatic carriers. There was a
wide range of duration of follow-up visits, from monthly to annually, with 19.9% only
reviewing if symptoms evolved.
Conclusion: There is consensus, after two rounds, that first-degree relatives should
be screened for mutations in the ADA2 gene.Asymptomatic carrier status is recognised
with homozygotes and compound heterozygous.A majority also recognise a true heterozygote
disease state.The measurement of serum ADA2 activity levels is believed to be helpful
inrisk stratification but investigations and treatment are currently largely guided
by symptoms.
Measures are not in place to control traditional cardiovascular risk factors beyond
those employed in the general population.These data raise many questions and suggest
the need for an international case registry and a standardised approach to the investigation
of first-degree relatives.
Disclosure of Interest
None Declared
Non-monogenic SAIDs (clinical)
P2043 We need more tests for discrimination non-bacterial osteomyelitis form tuberculosis
in early stages
Mikhail Kostik1, Olga Kopchak2, Alexey Maletin3, Vyacheslav Zorin3, Alexander Mushkin3
1Saint-Petersburg State Pediatric Medical University, Saint-Petersburg; 2Kirov’s Regional
Children’s Hospital, Kirov; 3Science Research Institute of Phthisiopulmonology, Saint-Petersburg,
Russian Federation
Correspondence: Mikhail Kostik
Introduction: Non-bacterial osteomyelitis (NBО) and tuberculous osteitis (osteomyelitis,
TBO) are two primarily chronic inflammatory bone diseases with similar clinical and
radiological findings, but different in etiology, pathogenesis, treatment, and outcomes.
Objectives: The aim of the study is to determinate clinical and laboratory features
which could discriminate the NBO and TBO.
Methods: The following criteria for inclusion in the retrospective-prospective study:
i) patient’s age under 18 years old; ii) bone lesions, confirmed by any radiological
methods (X-ray films or CT or MRI); iii) inflammatory bone process confirmed by morphology
study; iv) bone lesions biopsy followed by bacteriological and morphology research.
In the cases of multifocal NBO, the biopsy had to be done at least from one bone focus;
v) positive cultural (MBT complex isolates) or molecular genetics (PCR) or GEEN-expert
studies from bone lesion site biopsy or operation material for TBO group. Exclusion
criteria: i) positive culture for non-MBT mycobacteriosis from bone lesion site biopsy
or operation material for TBO; ii) the negative cultural or PCR tests in the cases
of granulomatous osteomyelitis which could be suspected on TB or for patients who
had received at least two courses of antibacterial drugs. The study included 124 patients
- 91 with NBO and 33 with TBO. All patients underwent a routine blood test: WBC, platelets,
ESR, C-reactive protein (CRP) and hemoglobin levels. We compare our results with criteria
created by A. Jansson et al. (2009, 2011) and Roderick et al. (2016).
Results: Logistic regression analysis performed by including the 15 independent variables
that presented ahigh level of statistical significance in the univariate analyses.
The choice of the variables in this model performed according to the clinical plausibility
for a diagnosis of TBO. Only number of foci > 1.0 (p=0.00002), WBC≤11.0 (p=0.004),
bands ≤ 120.0 х 106/l (p=0.002), lymphocytes ≤ 52 % (p=0.0005) and CRP> 0.2 mg/l (p=0.003)
remained independent risk factors that distinguished NBO from TBO patients. The R2
of the Nagelkerke test was 0.66. The diagnostic rule formulates according to sensitivity,
specificity and DOR analysis: criteria allowing to differentiate non-bacterial osteomyelitis
from TB osteomyelitis are negative bone microbiota tests (sensitivity – 100.0%, specificity
– 100.0%) – major discriminative criteria or at least four from the five additional
criteria. These criteria could be useful at the stages when histological and bacteriological
results have not yet ready or if it is impossible to do they. Applying of NBO diagnostic
tests may misdiagnose TBO as NBO (table).
Conclusion: We offer to use our criteria only as additional diagnostic set in combination
with all previously created tests. Further investigations required for the creation
of more sensitive and specific tests. It is necessary to have high suspicion about
TBO and biopsy needed at least in all monofocal cases.
This work supported by the Russian Foundation for Basic Research (grant № 18-515-57001).
Disclosure of Interest
None Declared
Table 1 (abstract P2043).
Diagnostic power, sensitivity, and specificity of NBO diagnostic sets
The set of criteria
The maximal possible number of patients with TBO, who may be false-diagnosed as NBO,
n (%)
RR (95%CI)
Se
Sp
Jansson, 2009
29/33 (87.9)
0.14 (0.06-0.35)
0.12
0.12
Jansson 2011
7/33 (21.2)
3.7 (1.9-7.3)
0.79
0.79
Roderick, 2016
5/33 (15.2)
5.6 (2.5-12.7)
0.85
0.85
Our criteria
For NBO
Major criteria
0 (100.0)
na
1.0
1.0
≥2 minor criteria
32/91 (35.2)
1.84 (1.3-2.5)
0.65
0.65
≥3 minor criteria
11/91 (12.1)
7.3 (4.2-12.7)
0.88
0.88
≥4 minor criteria
0/91 (0.0)
na
1.0
1.0
P2044 The features and distribution of chronic non-bacterial osteomyelitis in Russian
Federation
Mikhail Kostik1, Maria Makhova1, Vyacheslav Zorin2, Evgeny Suspitsin1,3, Eugenia Isupova1,
Shamai Magomedova4,5, Inna Kostik6, Alexander Mushkin2
1Saint-Petersburg State Pediatric Medical University; 2Science research Institute
of Phthisiopulmonology; 3N.N. Petrov Institute of Oncology, Saint-Petersburg; 4Republican
Children's Clinical Hospital; 5Dagestan State Medical Academy, Makhachkala; 6Children's
Rehabilitation Center “Detskye Duny”, Saint-Petersburg, Russian Federation
Correspondence: Mikhail Kostik
Introduction: Data about the incidence and prevalence of chronic non-bacterial osteomyelitis
(CNO) in Russia is scarce.
Objectives: Our study aimed to evaluate the clinical features and prevalence of CNO
in Russia.
Methods: The diagnosis of CNO made with criteria, proposed by Jansson (2007, 2009),
after the exclusion of other causes of bone disease. Our cohort consists of three
main subtypes: i) early-onset (<5 years) CNO (n=17); ii) CNO, associated (n=20) and
iii) not associated (n=59) with rheumatic diseases (RD).
Results: The patients with early-onset (<5 years) CNO characterized by 1) early onset;
2) all children were initially diagnosed as having tuberculosis (TB) due to bone morphology
findings (granulomatous, e.g., tuberculosis-like inflammation), but had a negative
TB culture test; 3) initial treatment with combination of 3-4 anti-MBT drugs during
1-2 years was ineffective, patient continued to form new inflammatory bone foci; 4)
patients had more severe clinical and radiological signs of disease, compared to others
and 5) all patients have North Caucasus origin (area with high prevalence of consanguinity).
These patients have earlier onset age, more foci number, a high incidence of symptomatic
arthritis, femur and foot involvement (table 1).
Conclusion: We have found the unique regional subtype of CNO in North Caucasus region
with at least nine times higher prevalence. We have not yet seen similar patients
in other nationalities of Russia.
This work supported by the Russian Foundation for Basic Research (grant № 18-515-57001)
Disclosure of Interest
None Declared
Table 1 (abstract P2044).
Characteristic of clinical and laboratory features of patients with CNO
Parameter
EO-CNO(n=17)
“CNO w/o RD” (n=59)
CNO with RD (n=20)
p1
Onset age, years
3.0 (2.1-4.8)
7.3 (2.8-11.7)
10.3 (8.2-12.2)
0.0009
Gender, females
8 (47.1)
27 (45.8)
14 (70.0)
0.17
Fever at onset
9/16 (56.3)
23 (39.0)
5 (25.0)
0.16
Foci number
5.0 (1.5-6.0)
3.0 (1.0-4.0)
2.0 (1.0-6.0)
0.048
Symptomatic arthritis
15/16 (93.8)
33 (55.9)
17 (85.0)
0.003
North Caucasus origin
17 (100.0)
0 (0.0)
0 (0.0)
<0.00001
Granulematosus inflammation (tuberculosis-like)
17 (100.0)
0 (0.0)
0 (0.0)
<0.00001
Prevalence of CNO
1: 55,000
1:450,000
1:1,375,000
<0.00001
P2045 Kawasaki disease shock syndrome: clinical characteristics and possible use of
IL-6, IL-10 and IFN-gamma as biomarkers for early recognition
Meiping Lu1, Yandie Li2, Qi Zheng2
1Zhejiang University; 2Children’s Hospital of Zhejiang University, Hangzhou, China
Correspondence: Meiping Lu
Introduction: As an acute febrile and inflammatory disease, Kawasaki disease (KD)
could develop Kawasaki disease shock syndrome (KDSS) sometimes. However its pathogenesis
was still not well known.
Objectives: This study was to learn more about the clinical features and evaluate
the role of cytokines in the pathogenesis of KDSS.
Methods: All 27 patients with KDSS who were hospitalized at our hospital from Jan
2014 to Oct 2017 were enrolled in our study retrospectively. Clinical features, laboratory
evaluations including white blood cell (WBC) count, C-reactive protein (CRP), Erythrocyte
Sedimentation Rate (ESR), procalcitonin (PCT), liver and kidney function, blood coagulation
function, echocardiographic data, cytokine levels and outcomes were collected. Cytokines
IL-2, IL-4, IL-6, IL-10, TNF-α and IFN-γ in serum were assayed using flow cytometric
bead array.
Results: 2203 patients with KD were seen in our hospital during the study period.
Of those, 27 (1.23%) met our inclusive criteria of KDSS. The patients with KDSS were
older age (43.41±31.42 vs 28.81±21.51,p<0.05), longer duration of fever(10.63±5.12
vs 6.98±2.45, p<0.05), higher WBC count, neutrophils, CRP, ESR, PCT and D-dimer, and
lower hemoglobin and albumin, more severe hyponatremia and hypokalemia, more refractory
to IVIG therapy, more coronary artery abnormalities (CAAs), aseptic meningitis, and
longer duration of hospitalization than patients with KD. There was higher level of
serum IL-6, IL-10, TNF-α and IFN-γ in patients with KDSS than patients with KD. ROC
curves showed that 66.7 pg/ml of IL-6, 20.85 pg/ml of IL-10 and 8.35 pg/ml of IFN-γ
had sensitivity and specificity for indentifying KDSS as 85.2% and 62.8 %; 66.7% and
83.7%; 74.1% and 74.4 % respectively. No fatality was recorded in this series.
Conclusion: Increased production of IL-6, IL-10, TNF-α and IFN-γ cytokines may pay
a key role in the pathogenesis of KDSS. KDSS were more prone to developing CAA and
IVIG non-responsiveness. IL-6 above 66.7 pg/ml, IL-10 above 20.85 pg/ml, and IFN-γ
above 8.35 pg/ml suggested higher risk for KDSS.
Disclosure of Interest
None Declared
P2046 Outcomes following tonsillectomy in patients with periodic fever, aphthous stomatitis,
pharyngitis, and adenitis (PFAPA) syndrome
Kalpana Manthiram1, Sivia Lapidus2, Karyl Barron3, Amanda Ombrello1, Daniel Kastner1,
Kathryn Edwards4
1National Human Genome Research Institute, NIH, Bethesda; 2Hackensack University Medical
Center, Hackensack; 3National Institute of Allergy and Infectious Diseases, NIH, Bethesda;
4Vanderbilt University School of Medicine, Nashville, United States
Correspondence: Kalpana Manthiram
Introduction: Tonsillectomy has been reported to induce complete resolution of fever
episodes in patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis
(PFAPA) syndrome. However, predictors of lack of resolution and management of continued
episodes after tonsillectomy are not well understood.
Objectives: To determine the response to tonsillectomy in subjects with PFAPA, clincial
features associated with lack of response to tonsillectomy, and subsequent management
in subjects who did not respond to tonsillectomy.
Methods: Patients from Vanderbilt Children’s Hospital and the National Institutes
of Health (NIH) who met the original diagnostic criteria for PFAPA and underwent tonsillectomy
were enrolled and interviewed about their symptoms before and after tonsillectomy.
Clinical features of patients who had complete and incomplete resolution of symptoms
after tonsillectomy were compared with the chi-square test.
Results: Sixty-four patients (41 from Vanderbilt and 23 from NIH) were followed for
an average of 61 months after tonsillectomy. In total, 48% of participants reported
complete resolution of PFAPA episodes (63% had full resolution at Vanderbilt and 22%
at NIH), while 6% subsequently had only one or two more PFAPA episodes, 22% had a
reduction in severity or frequency of episodes, 17% had a period of remission ranging
from 12 months to 7 years with recurrence of stereotypical episodes, and 6% had no
change in episodes following tonsillectomy. The table shows the percentage of patients
with and without each feature during flares who had complete resolution of episodes
after tonsillectomy; episode shortening with corticosteroids and absence of abdominal
pain and limb pain were predictive of complete resolution. In the multivariable model,
episode shortening with corticosteroids (aOR=12.5, p=0.04) and lack of limb pain (aOR=0.11,
p=0.001) remained significant predictors of complete response to tonsillectomy. Twenty
patients (61% or 20/33) with continued febrile episodes after tonsillectomy required
medical intervention. In these patients, 7 out of 12 (58%) had resolution of each
episode with one dose of corticosteroid, and 63% (5/8) had resolution of each episode
with one dose of anakinra while 37% (3/8) required multiple doses of anakinra during
each flare. After tonsillectomy, 86% of patients (6/7) who took cimetidine prophylaxis
had improvement in the severity or frequency of flares compared to 44% (4/9) of those
who took colchicine prophylaxis.
Conclusion: Most patients with PFAPA had an improvement in the frequency and severity
of symptoms following tonsillectomy. Differences in outcome at Vanderbilt and NIH
likely reflect referral bias as patients seen at NIH are more likely to be refractory
to conventional therapies. Patients with abdominal pain, limb pain and lack of episode
resolution with steroids were less likely to respond completely to tonsillectomy.
These patients may have lymphoid tissue outside the palatine tonsils that triggers
PFAPA episodes or may have alternate mechanisms of disease. Cimetidine was an effective
prophylactic agent in patients with episodes following tonsillectomy, indicating that
further study of the effect of cimetidine on myeloid and lymphoid cells is needed.
Disclosure of Interest
None Declared
Table 1 (abstract P2046).
See text for description
Characteristic
% without feature who had complete resolution after tonsillectomy
% with feature with complete resolution after tonsillectomy
P value
Aphthous ulcer
53.3%
46.9%
0.67
Pharyngitis
40.0%
49.2%
1.00
Lymphadenopathy
63.6%
45.3%
0.27
Headache
45.5%
51.6%
0.62
Abdominal pain
60.6%
35.5%
0.04
Vomiting
51.3%
44.0%
0.57
Limb pain (arthralgia or myalgia)
70.6%
23.3%
<0.001
Episode shortens with steroid
12.5%
53.5%
0.03
P2047 Relationship between MEFV gene and clinical findings of chronic recurrent multifocal
osteomyelitis
Sümeyra Özdemir Çiçek1, Nihal Şahin1, Zehra F. Karaman2, Sema N. Taşkın1, Ayşenur
Paç Kısaarslan1, Zübeyde Gündüz3, Muammer H. Poyrazoğlu1, Ruhan Düşünsel1
1Pediatric Rheumatology; 2Pediatric Radiology, Erciyes University Medical Faculty;
3Pediatric Rheumatology, Acıbadem Hastanesi, Kayseri, Turkey
Correspondence: Sümeyra Özdemir Çiçek
Introduction: Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory
disorder that characterized byrecurrent flares and remissions due to sterile bone
inflammation. CRMO may be accompanied by different autoinflammatory diseases.
Objectives: To determine CRMO patients’ features, involvement patterns, clinical course
and treatment followed in our pediatric rheumatology clinic.
Methods: Seventeen patients who were diagnosed of CRMO and followed in our clinic
between 2012-2018 were analyzed retrospectively.
Results: The mean age of symptoms onset was 10,41 (±3,79 ) years, and the mean age
at diagnosis was 11,36 (±3,68) years. Between time of symptoms onset and diagnosis
was 5 months (min-max:1,5-55), The disease duration was 25,82 (±17,26 ) months. Ten
(58,8%) patients were male. The lesions were evaluated by regional MRI on 8 patients,
whole body MRI on 9 patients, and skeletal scintigraphy on 9 patients. Bone biopsy
was performed in 6/17 (35,29%) patients. The most affected areas were femur (70,58%),
tibia (58,82%) and vertebra (47,05%). A total number of lesions were 110 during the
disease course. The mean number of affected areas was 6,47 (±4,04 ) per patient. Three
of the patients had skin signs and five of patients had aphthous stomatitis. Six (35,29%)
patients had concomitant familial Mediterranean fever (FMF) and four of them had M694V
homozygous mutations. Compared to those who carried MEFV mutation and not carriers,
time of symptomes onset, disease duration, number of affected areas, clinical and
radiological remission, sacroiliitis, C-reactive protein and erithrocyte sedimentation
rate at the beginning of disease were not significant differencies statistically.
The treatments were NSAI drugs on 16 (94,11%), colchicine on 7 (41,17%), DMARDs on
8 (47,05%), and biologic DMARDs on 6(35,29%) patients. Six of the patients were receiving
colchicine treatment due to fmf, and one of patients due to recurrent oral aphthae.
Conclusion: Previous studies have shown that CRMO is associated with various inflammatory
diseases. CRMO patients should be evaluated for MEFV gene carriage.
Disclosure of Interest
None Declared
P2048 Behçet’s disease with pseudotumor cerebri and cerebral venous sinus thrombosis:
a case report
Sümeyra Özdemir Çiçek1, Nihal Şahin1, Sema N. Taşkın1, Ayşenur Paç Kısaarslan1, Zübeyde
Gündüz2, Muammer H. Poyrazoğlu1, Ruhan Düşünsel1
1Pediatric Rheumatology, Erciyes University Medical Faculty; 2Pediatric Rheumatology,
Acıbadem Hastanesi, Kayseri, Turkey
Correspondence: Sümeyra Özdemir Çiçek
Introduction: Behçet’s disease (BD) is a vasculitis that can affect arteries or veins
of any size. BD manifests with the clinical triad of aphthous stomatitis, genital
ulceration and uveitis. Neurologic involvement may be parenchymal or nonparenchymal.
The non parenchymal involvement is usually a benign hypertension with papilledema
and is often due to venous sinus thrombosis. Here we present a BD patient admitted
with pseudotumor cerebri and appeared venous sinus thrombosissix months later on his
follow up.
Objectives: A case report
Methods: a case report
Results: A 16-year-old boy with BD for 3-years admitted redness of eye, blurred vision,
progressive headache for seven days and nausea, vomiting for two days. He was on colchicine
theraphy for three years. On physical examination, he had oral and genital ulcers.
On the eye excamination he had not uveitis or papilledema. He had sixth cranial nerve
palsy on the right eye. Cranial MRI showed pseudotumor cerebri signs .There were not
any parencimal lesions or venous thrombosis.The cerebrospinal fluid pressure was detected
40 cmH2O. Protein, glucose, and cell levels of CSF were normal. A lumbar puncture
performed to reduce intracranial pressure. Corticosteroid and acetazolamide treatment
were started. His clinical findings improved with this theraphy, his oral and genital
ulcers healed. After being discharged he didn’t come his routine controls and didn’t
use his medications. Five mounths later he presented with headache and blurred vision.
His eye excamination revealed papilledema and he had bilateral nasal scotoma. MR angiography
revealed irregularity on bilateral carotis interna and branches, and MR venography
revealed occlusions on left transvers, sigmoidal and right transvers sinuses. Enoxaparin,
steroid and azathioprin treatment was started. Three months later control MR venography
showed improvement in venous sinuses thromosis but his increased intracranial pressure
didn’t improve. İnfliximab treatment was initiated and follow-up continued.
Conclusion: The most common neurologic manifestation is cerebral venous sinus thrombosis
in children with BD. Pseudotumor cerebri is one of the Behçet’s disaese’s neurologic
involvement that needed rapidly invention. It occurs with or without venous sinus
thrombosis
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2049 The use of next generation sequencing panel in undifferentiated autoinflammatory
diseases identify a separate subset of colchicine-responder recurrent fevers distinct
from PFAPA syndrome
Riccardo Papa1, Marta Rusmini2, Stefano Volpi1, Roberta Caorsi1, Paolo Picco1, Alice
Grossi2, Francesco Caroli2, Francesca Bovis3, Valeria Musso1, Laura Obici4, Cinza
Castana5, Angelo Ravelli1, Marielle E. Van Gijn6, Isabella Ceccherini2, Marco Gattorno1
1Pediatric Rheumatology Clinic; 2Medical Genetics Unit, IRCCS Giannina Gaslini Institute;
3Department of Health Sciences (DISSAL), University of Genoa, Genova; 4Amyloidosis
Research and Treatment Centre, Biotechnology Research Laboratories, IRCCS Fondazione
Policlinico San Matteo, Pavia; 5Pediatric Clinic, ARNAS Civico Di Cristina Benfratelli,
Palermo, Italy; 6Department of Medical Genetics, University Medical Center Utrecht,
Utrecht, Netherlands
Correspondence: Riccardo Papa
Introduction: The number of monogenic innate immune system disorders classified as
systemic autoinflammatory diseases (SAID) has increased during the recent years. However,
more than 70% of patients with clinical manifestations of SAID not achieved a molecular
diagnosis, thus getting into the so-called undifferentiated or undefined SAID (uSAID).
Objectives: The aim of the present study is to characterize a subgroup of patients
with recurrent fever episodes distinct to PFAPA that turned out to be negative to
a large 41-gene NGS panel.
Methods: We designed an NGS panel including 41 genes clustered in seven subpanels.
The clinical characteristics of genetically negative patients with recurrent fevers
were compared to different PFAPA cohort reported in the literature.
Results: Fifty patients were enrolled in the study. 34 patients (72%) displayed recurrent
fevers and sixteen presented a chronic inflammatory disease course. A total of 100
gene variants were found (mean 2 per patient; range 0-6). Mutations with a sure or
possible diagnostic impact were detected in five patients (10%). Differently from
PFAPA syndrome (table), genetically negative patients with recurrent fevers presented episodes that
lasted on averange of six days (P<0.0001). Abdominal pain and limb pain were the most
common symptoms. The classic PFAPA triad (pharingotonsillitis, apthousis and cervical
lymphadenopathy) was less frequently reported (P<0.0001) while skin rash and arthritis
were more frequent (P<0.0001). Eighteen patients were exclusively treated with steroid
on demand with a high response rate (94%). In 18 patients, colchicine treatment was
used with an overall complete or partial response of 78%.
Conclusion: Even with a low molecular diagnostics rate, an NGS-based approach is able
to provide a final diagnosis in a proportion of uSAID patients. It also allows the
identification of a subgroup of genetically negative patients with recurrent fever
responding to steroid on demand and colchicine.
Disclosure of Interest
None Declared
Table 1 (abstract P2049).
Clinical features of patients with undifferentiated recurrent fevers compared to PFAPA
syndrome
Clinical features
Our cohort(34 patients)
Thomas et al.(82 patients)
Hofer et al.(301 patients)
Batu et al.(131 patients)
Pehlivan et al.(359 patients)
P value
Mean duration of episodes (days; ±SD)
5.9 ± 1.4
NR
NR
NR
4.0 ± 3.1
<.0001
Median interval between episodes (weeks; ±SD)
3.0 ± 0.3
NR
NR
NR
3.3 ± 1.5
NS
Abdominal pain
17 (50)
40 (49)
136 (45)
60 (46)
102 (29)
NS
Arthritis
7 (21)
NR
8 (3)
NR
7 (0)
<.0001
Skin rash
11 (32)
7 (9)
38 (13)
7 (5)
NR
<.0001
Pharyngotonsillitis
13 (38)
59 (72)
271 (90)
126 (96)
359 (100)
<.0001
Cervical lymphadenopathy
6 (18)
72 (88)
236 (78)
70 (53)
215 (60)
<.0001
Oral aphthosis
13 (38)
57 (70)
171 (57)
56 (43)
317 (88)
<.0001
Response to colchicine
14/18 (78)
0/1 (0)
NR
5/11 (45)
24/45 (53)
NS
Values are number of patient (%) when not specified. NR = not reported. NS = not significant.
P values were assessed using Chi square test or T-test as appropriate. If significant
interactions were determined, a post-hoc test for multiple comparison was performed
P2050 Epidemiology and clinical features of PFAPA in Western Sweden
Karin Rydenman1,2, Hanna Fjeld3, Anna Karlsson4, Stefan Berg1,5, Anders Fasth1,5,
Per Wekell1,2
1Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University
of Gothenburg, Gothenburg; 2NU Hospital Group, Uddevalla; 3Örebro University, Örebro;
4Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska
Academy, University of Gothenburg; 5Queen Silvia Children's Hospital, Gothenburg,
Sweden
Correspondence: Karin Rydenman
Introduction: Periodic fever, aphtous stomatitis, pharyngitis and cervical adenitis
(PFAPA) syndrome is generally seen as the most common autoinflammatory disease, but
the epidemiology of the disease is largely unknown. In a Norwegian study, the annual
incidence was calculated to 2.3/10000 children <5 years of age (1). In Sweden and
other parts of the world, the incidence has not been studied.
Objectives: To estimate the annual incidence and describe the clinical features of
PFAPA in Western Sweden.
Methods: Children <18 years of age diagnosed with PFAPA during the years 2006-2017
and living in the area of Western Sweden served by the two hospitals NU Hospital Group
and Queen Silvia Children’s Hospital were included retrospectively. Patients were
identified through search for relevant diagnostic codes in the comprehensive electronic
medical record (Melior, Cerner Sweden) and data was obtained through review of case
records. For estimation of incidence, patients with onset of symptoms 1st of Jan 2006
to 31st of Dec 2016 were included. Population data for the study area during this
period of time was retrieved from Statistics Sweden (2).
Results: In our study, a total of 236 patients diagnosed with PFAPA were identified.
Of these, 122 (52%) were girls and 112 (48%) were boys (no data on 2 patients). Frequency
of typical symptoms during fever episodes is depicted in table 1. Data on CRP during
episodes was obtainable for 80 patients, with a median value of 75 (range 12-358)
mg/L. Data on CRP between episodes was obtainable for 96 patients and all of these
patients except two had a CRP <5 mg/L. The remaining two had a CRP of 7 and 17 mg/L,
respectively. Treatment was symptomatic in most patients with acetaminophen and/or
ibuprofen. 120 patients received betamethasone to abort single febrile episodes, however
patients were advised to use the drug only on rare occasions due to concerns of side-effects.
Tonsillectomy was performed on 73 patients.
For calculation of incidence, 216 patients with onset of symptoms 1st of Jan 2006
to 31st of Dec 2016 were identified and of these 171 had disease onset <5 years of
age. The mean annual incidence was estimated to 0.8/10000 for children <18 years of
age and 2.3/10000 children <5 years of age respectively.
Conclusion: The mean annual incidence of PFAPA (2.3/10000 children <5 years of age)
was in the same range as estimated by Forsvoll et al (1). Our study also suggests
an annual incidence of 0.8/10000 for PFAPA in children up to 18 years of age. Clinical
features were similar to those seen in the Eurofever registry (3). However, there
was a slight female predominance among patients in this study in contrast to previous
studies. Tonsillectomy was a common treatment option in this cohort.
1. Forsvoll J, Kristoffersen EK, Oymar K. Incidence, clinical characteristics and
outcome in Norwegian children with periodic fever, aphthous stomatitis, pharyngitis
and cervical adenitis syndrome; a population-based study. Acta Paediatr. 2013;102(2):187-92.
2. Statistics Sweden. Retrieved 14th of Jan 2019 from http://pxwebb2017.vgregion.se/PXWeb/sq/618a266b-d273-4923-8f86-01f6c7bb1a84
3. Hofer M, Pillet P, Cochard MM, Berg S, Krol P, Kone-Paut I, et al. International
periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis syndrome cohort:
description of distinct phenotypes in 301 patients. Rheumatology (Oxford). 2014;53(6):1125-9.
Disclosure of Interest
None Declared
Table 1 (abstract P2050).
Frequency of typical symptoms during PFAPA episodes (% of patients)
Symptom
Always
Sometimes
Never
Data missing
Total
Pharyngitis
151 (64)
64 (27)
2 (0.8)
19 (8)
236
Aphthous stomatitis
22 (9)
83 (35)
57 (24)
74 (31)
236
Cervical adenitis
114 (48)
62 (26)
8 (3)
52 (22)
236
P2051 Observations in a patient with PFAPA-like disease associated with erysipelas-like
erythema and R202Q variant in MEFV
Per Wekell1,2, Mia Olsson3, Peter Söderkvist4, Anna Karlsson5, Stefan Berg2, Anders
Fasth2
1Department Pediatrics, NU-Hospital Group, Uddevalla; 2Department of Pediatrics, Institute
of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg; 3Department
of Medicine, Center for Molecular Medicine, Karolinska Institute, Stockholm; 4Department
of Clinical and Experimental Medicine, Linköping University, Linköping; 5Department
of Rheumatology and Inflammation Research, Institute of Medicine, Gothenburg, Sweden
Correspondence: Per Wekell
Introduction: The genetic predisposition to develop periodic fever, aphthous stomatitis,
pharyngitis, and cervical adenitis (PFAPA) syndrome is not known, but variants in
NLRP3 inflammasome proteins such as NLRP3 and CARD8 has been proposed to contribute.
PFAPA has also been associated with an increased frequency of variants in the gene
for familial Mediterranean fever (MEFV) indicating that such variants may modify the
disease expression in PFAPA.
Objectives: To investigate if there is a genetic basis for erysipelas-like erythema
(ELE) presented in a child with a PFAPA-like picture.
Methods: Genetic variants in the classical periodic fever genes MVK, MEFV, TNFRSF1A,
NLRP3 and NLRP12 were analyzed.
Results: We report, a 9-year-old girl of Scandinavian origin with a PFAPA-like presentation
and an ELE considered to be pathognomonic for FMF. No established disease-causing
variants was found in the classical periodic fever genes depicted above. The patient
was heterozygous for several single nucleotide polymorphisms (SNPs): S52N (rs7957619)
in MVK, R202Q (rs224222) in MEFV and Q703K/Q705K (rs35829419) in NLRP3.
Conclusion:
If we consider PFAPA a complex disease, its etiology would be a combination of rare
and common genetic factors providing a propensity for disease in response to (unknown)
environmental trigger(s). In the present patient, the two low-penetrance variants
Q703K and R202Q, could provide such a combination that contributes to her typical
and atypical clinical PFAPA features in response to a, e.g., tonsillar trigger.
Furthermore, the patient’s heterozygosity for R202Q with a PFAPA-like presentation
including ELE, support the concept that MEFV variants in general and R202Q in particular
may have pathophysiological effects as disease modifier(s) in PFAPA.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2052 YAO syndrome versus familial Mediterranean fever
Qingping Yao1, Peter Gorevic2
1Medicine, Stony Brook University, Stony Brook; 2Medicine, Mount Sinai Hospital, NY,
United States
Correspondence: Qingping Yao
Introduction: Autoinflammatory diseases include monogenic periodic fever syndromes
and genetically complex diseases. Familial Mediterranean fever (FMF) is a prototypic
monogenic periodic fever syndrome. Yao syndrome (YAOS, OMIM 617321), formerly termed
NOD2-asssociated autoinflammatory disease, is considered to be polygenic disease.
YAOS is characterized by periodic fever, dermatitis, arthritis, and swelling of the
distal extremities, as well as gastrointestinal and sicca-like symptoms and linked
to certain NOD2 variants. These diseases share the overlapping clinical phenotypes,
which may cause diagnostic dilemma in the absence of genetic testing.
Objectives: To illustrate the similarities and differences between YAOS and FMF.
Methods: A case is exemplified coupled with the literature review.
Results: A 66-year-old Caucasian female presented with recurrent episodes of high
fever, abdominal pain, rash and arthralgia for three years. Typically, the patient
experienced flu-like symptoms followed by fever of 101 to 103 0F with chills lasting
up to 36 hours. Abdominal pain was generalized with non-bloody diarrhea often lasting
for four days and occasionally several months. She reported a nonitchy patchy erythema
on her face and chest, lasting up to two weeks with each episode (Figure 1). She also
had pain and swelling in her knees and ankles, diffuse myalgia/stiffness, and mouth
burning sensation. Her febrile episodes led to hospitalizations three times. The disease
flares were initially concerned for FMF in the absence of MEFV mutations and decreased
with colchicine 0.6mg twice daily, which was eventually discontinued because of lack
of efficacy and side effects. Complete blood counts, complete metabolic panel, and
urinalysis were essentially normal except occasional leukocytosis, thrombocytosis
and eosinophilia. C-reactive protein was 12.7(<5 pg/ml), and erythrocyte sedimentation
rate and serum amyloid A were normal. Extensive serologic markers were negative for
systemic autoimmune diseases. Testing for food allergy, serum IgE and tryptase level
was normal. Other immunoglobulins were normal except IgA 31(81-463 mg/dl). A thorough
workup for infectious etiology was negative.Gastrointestinal workup, including DQ2/DQ8
testing for celiac disease, computed tomography and endoscopy, was essentially normal
without inflammatory bowel disease. Cytokine levels in plasma were normal for IL-1,
IL-6, TNFα and IL-5. She also had fibromyalgia and rhinitis/ asthma. Maternal and
paternal families both originated from Czechoslovakia, and there was no known history
of periodic fever syndromes. She was allergic to a sulfa antibiotic. Physical examination
was positive for multiple tender spots. Next generation sequencing for periodic fever
syndrome 6-gene panel (MEFV, NLRP3, TNFRSF1A, MVK, NLRP12 and NOD2) was only positive
for heterozygous NOD2 IVS8+158 and R702W. In this well-studied case, the clinical
phenotype and genotype NOD2 IVS8+158/R702W are consistent with YAOS. The diagnostic
criteria for YAOS include the characteristic phenotype, specific NOD2 variants, and
rigorous exclusion of overlapping disease entities. One of the major differential
diagnoses is FMF since YAOS and FMF share some clinical phenotypes; however, they
are distinct in clinical manifestations otherwise and genotypes (Table1).
Conclusion: Given the shared phenotypes and that the current diagnostic criteria for
FMF remain clinical, molecular genetic testing to cover both MEFV and NOD2 may be
imperative for distinguishing these two diseases. It may be particularly true for
those patients who present with atypical phenotype for FMF and/or poor response to
colchicine. To prove this hypothesis, further study is warranted to unveil cases of
YAOS in the disease population with unspecified autoinflammatory features.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2053 May some of the MEFV gene variants cause PFAPA syndrome like symptoms?
Amra Adrovic, Mehmet Yildiz, Ipek Ulkersoy, Neslihan Gucuyener, Oya Koker, Sezgin
Sahin, Kenan Barut, Ozgur Kasapcopur
Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul,
Turkey
Correspondence: Mehmet Yildiz
Introduction: PFAPA syndrome is characterized by periodic fever, aphthous stomatitis,
pharyngitis and cervical adenitis. As there is not any gold standard diagnostic test
and diagnosis usually depends on clinical diagnostic criteria, sometimes it can be
difficult to distinguish this clinical entity from the other periodic fever syndromes.
Especially in regions endemic for FMF, it could be challenging to identify PFAPA patients
due to many common disease characteristics.
Objectives: The objective of the study is to evaluate the PFAPA patients’ MEFV gene
variation frequencies (if it was performed) and relations between detected variants
and clinical manifestations in a large cohort of pediatric PFAPA patients.
Methods: Nine hundred and thirty-seven patients that were recorded to our database
as PFAPA syndrome were evaluated. Firstly, demographic features and MEFV gene variations
(if it was performed) were recorded from the patients’ database. Then, patients were
reached by phone and asked about characteristics of their fever episodes, presence
of acute phase reactant elevation, pharyngitis/cryptic tonsillitis, aphthous stomatitis,
cervical lymphadenopathy, arthralgia, arthritis, abdominal pain, headache, nausea
or vomiting, chest pain, diarrhea, skin changes, myalgia and conjunctivitis in the
course of fever attack, if they had tonsillectomy, ifthey were attack-free after tonsillectomy
and if they had clinical response to steroid or colchicine.
Results: There were 937 PFAPA patients in our database. MEFV gene analysis was performed
in 407 (%43) of PFAPA patients and 305 of them had at least one mutation. Most common
MEFV mutations of patients were: R202Q heterozygotes, M694V heterozygotes, E148Q heterozygotes
and P369S heterozygotes, respectively. 45.8% of detected mutations were located in
exon 2, 40,3% of them were located in exon 10 and 13,9% of them were located in exon
3 of the MEFV gene. Patients were divided into five groups according to their mutations:
those with exon 2 mutations, with exon 3 mutation, with exon 10 mutation, those that
didn’t have mutation and patients whose MEFV mutation analysis hasn’t been performed.
Groups were compared according to clinical features. There were significant differences
between groups according to presence of pharyngitis/cryptic tonsillitis, arthralgia,
abdominal pain, myalgia and tonsillectomy history (Table 1).
Conclusion: In this study, we reported increased frequency of MEFV mutations in a
large PFAPA patients cohort.Frequency differences of clinical features between groups
suggest that some of the MEFV gene mutations may modify phenotype ofPFAPA syndrome.
Furthermore, underlying MEFV gene mutations possibly lead toPFAPA like clinical presentation
in FMF patients. Another remarkable finding of this study is the relatively high P369S
mutation rates in patients with PFAPA syndrome. Further studies are needed to investigate
the relationship between this mutation and PFAPA disease.
Disclosure of Interest
None Declared
Table 1 (abstract P2053).
Comparison of patients according to their mutations’ location and clinical features
Exon 2
Exon 3
Exon 10
No Mutation
MEFV study not performed
p
Pharyngitis
Yes
21(87,5)
9(40,9)
45(80,4)
28 (87,5)
168(87,5)
<0,05
No
3(12,5)
13(59,1)
11(19,6)
4(12,5)
24(12,5)
Aphthous stomatitis/Cryptic tonsillitis
Yes
15(62,5)
8(36,4)
21(37,5)
17 (53,1)
102(53,1)
0,11
No
9(37,5)
14(63,6)
35(62,5)
15(46,9)
90(46,9)
Cervical lymphadenopathy
Yes
10(41,7)
8(36,4)
21(37,5)
14(56,3)
77(40,1)
0,97
No
14(58,3)
14(63,6)
35(62,5)
18(43,7)
115(59,9)
Arthralgia
Yes
5(20,8)
11(50)
22(39,3)
19(59,4)
66(34,5)
0,02
No
19(79,2)
11(50)
34(60,7)
13(40,6)
126(65,5)
Arthritis
Yes
1(4,2)
3(13,6)
1(1,8)
2(6,3)
11(5,7)
0,35
No
23(95,8)
19(86,4)
55(98,2)
30(93,7)
181(94,3)
Abdominal Pain
Yes
17(70,8)
12(54,5)
27(48,2)
16(50)
56(70,8)
<0,05
No
7(29,2)
10(45,5)
29(51,8)
16(50)
136(29,2)
Myalgia
Yes
0(0)
8(36,4)
9(16,1)
7(21,9)
24(12,5)
0,006
No
24(100)
14(63,6)
47(83,9)
25(78,1)
168(87,5)
Tonsillectomy
Yes
14(58,3)
5(22,7)
21(38,9)
20(62,5)
109(57,1)
0,005
No
10(41,7)
17(77,3)
33(66,1)
12(37,5)
82(42,9)
Steroid Response
Yes
17(94,4)
8(88,9)
35(89,7)
20(90,9)
139(89,7)
0,97
No
1(5,6)
1(11,1)
4(10,3)
2(9,1)
16(10,3)
Non-monogenic SAIDs (basic science)
P2054 Next generation sequencing analysis of familial haemophagocytic lymphohistiocytosis
related genes in macrophage activation syndrome and secondary HLH
Chiara Passarelli1, Manuela Pardeo2, Ivan Caiello2, Elisa Pisaneschi1, Antonella Insalaco2,
Francesca Minoia3, Andrea Taddio4, Francesco Licciardi5, Antonio Novelli1, Fabrizio
De Benedetti2, Claudia Bracaglia2
1Unit of Laboratory of Medical Genetics; 2Division of Rheumatology, IRCCS Ospedale
Pediatrico Bambino Gesù, Rome; 3Reumatologia Pediatrica, IRCCS Istituto Giannina Gaslini,
Genoa; 4Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, University
of Trieste, Trieste; 5SCDU Pediatria II, Immunoreumatologia, Ospedale Pediatrico Regina
Margherita, Turin, Italy
Correspondence: Claudia Bracaglia
Introduction: Macrophage activation syndrome (MAS), a severe complication of paediatric
rheumatic disease, is currently classified among the secondary forms of HLH (sHLH).
Primary HLH (pHLH) are caused by mutation of genes coding for proteins involved in
cytotoxic functions. Mice carrying heterozygous mutations in more than 1 pHLH gene
carry a higher risk to develop HLH following viral infection, suggesting that accumulation
of partial genetic defects may be relevant in HLH.
Objectives: To analyse, with next generation sequencing (NGS), genes involved in pHLH
in MAS in the context of different rheumatic diseases and in sHLH.
Methods: A targeted resequencing was performed on all patients using a panel including
the 7 principal HLH-related genes (PRF1, UNC13d, STX11, STXBP2, Rab27a, XIAP, SH2D1A)
on MiSeq® and NextSeq550® platforms (Illumina, San Diego, CA). All variants identified
were confirmed by Sanger. We took into account variants with an allelic frequency
in the global population up to 5% in the dbSNP and Ensembl databases.
Results: We analysed 125 patients: 47 MAS, (39 developed this complication in the
context of systemic Juvenile Idiopathic Arthritis (sJIA), and 8 in the context of
different rheumatic diseases), 32 sHLH, 22 sJIA (without history of MAS) and 24 with
different autoinflammatory diseases (AID). sJIA and AID patients were used as control
groups. We identified at least 1 heterozygous variant in one of the pHLH genes in
41 patients with MAS or sHLH, with a detection rate of 52%, (45% of MAS and 62% of
sHLH patients). More than one variant was identified in 37% patients from both groups,
with 19% of both MAS and sHLH patients carrying polygenic variants. The frequency
of variants was lower in AID patients compared to the other groups of patients but
the difference was significant only comparing AID patients with sHLH who carry one
variant (p=0.029). The frequency of variants between the 39 sJIA patients with history
of at least one episode of MAS and the 22 sJIA patients without history of MAS was
similar (41% versus 54%). The distribution of variants among the genes in the group
of patients was comparable. PRF1 and UNC13d were the most involved genes in both MAS
and sHLH patients, and A91V and R928C were the most common variants identified, respectively.
The A91V variant in PRF1 gene was identified in 19% of both MAS and sHLH patients,
while this variant was present, respectively, in only 5% of sJIA and 4% of AID patients.
The R928C variant in UNC13d gene was identified in 32% of MAS, 18% of sHLH, in 9%
of sJIA and 17% of AID patients. Considering the patients clinical characteristics,
relapse, CNS involvement, ICU admission and death, we observed that three of the 6
sHLH patients (50%) carrying multiple variants had recurrent episodes of HLH and 2
of them (33%) presented a severe disease with exitus.
Conclusion: Monoallelic variants in pHLH-related genes are more frequent in MAS, sHLH
and sJIA and less in AID patients, suggesting different molecular mechanisms involved
in the diseases. Re-occurrence and severity of disease seem to be more frequent and
more severe in patients who carry mutations in two genes in sHLH group. These data
may support a polygenic model of sHLH.
Disclosure of Interest
C. Passarelli: None Declared, M. Pardeo: None Declared, I. Caiello: None Declared,
E. Pisaneschi: None Declared, A. Insalaco: None Declared, F. Minoia: None Declared,
A. Taddio: None Declared, F. Licciardi: None Declared, A. Novelli: None Declared,
F. De Benedetti Grant / Research Support from: Novartis, Novimmune, Hoffmann- La Roche,
SOBI, AbbVie, Pfizer, C. Bracaglia: None Declared
P2055 Evaluation of the new classification criteria for PFAPA syndrome
Fabio Crimi1, Véronique Hentgen2, Glory Dingulu2, Isabelle Koné-Paut3, Sophie Georgin-Lavialle4,
Pascal Pillet5, Michaël Hofer1
1CHUV, Lausanne, Switzerland; 2CH de Versailles, Le Chesnay; 3CHU de Bicêtre, Le Kremlin
Bicêtre; 4Hôpital Tenon, Paris; 5CHU de Bordeaux, Bordeaux, France
Correspondence: Michaël Hofer
Introduction: Modified Marshall criteria used for PFAPA syndrome (Periodic Fever,
Adenitis, Pharyngitis, Aphtous stomatitis) have never been validated and are little
used by the experts because the symptoms of monogenic fevers often overlap with PFAPA
ones. A previous study realized a new set of classification criteria based on an international
survey and a consensus conference in Genoa in 2018. The aim of our study is to evaluate
the performance of the new criteria in a real-life setting.
Objectives: Evaluate and test the performance of the Genoa 2018 classification criteria
for PFAPA syndrome
Methods: This is a multicentric, prospective and descriptive cohort study, through
the recurrent fever module of the JIRcohorte platform. 417 patients diagnosed with
PFAPA (187), monogenic fever syndromes (167) or unclassified recurrent fever syndrome
(UPF=63) from Swiss and French centers were enrolled in the study. The new classification
criteria were applied to this cohort and we calculated their performance. We then
analyzed which of the criteria performed the less well.
Results: 114/187 (61%) PFAPA patients met the new criteria, as well as 20/230 non-PFAPA
patients (FMF: 3, MKD: 4, UPF: 13); 73 PFAPA patients did not meet the criteria. We
calculated a specificity of 91.3% and a sensitivity of 60.9%. The least satisfied
criterion among PFAPA patients not meeting the criteria was “absence of skin rash”.
By removing this criterion, the sensitivity improved (81.2%), but the specificity
decreased slightly to 86%.
Conclusion: Genoa 2017 classification criteria for PFAPA syndrome showed a good specificity
but an insufficient sensitivity. Excluding the less satisfied criterion, the set reaches
a sensitivity and specificity around 80% which could be a fair compromise for PFAPA
classification criteria. Our study highlights the difficulty in establishing classification
criteria due to the lack of gold standard for PFAPA diagnosis.
Disclosure of Interest
None Declared
P2056 Human (pro)caspase-1 variants influence cell death and mechanical properties
of human monocytes/macrophages
Felix Schulze1, Franz Kapplusch2, Sabrina Rabe-Matschewsky1, Susanne Russ1, Maik Herbig3,
Ursula Range4, Angela Rösen-Wolff1, Stefan Winkler1, Christian M. Hedrich2,5, Jochen
Guck3, Sigrun R. Hofmann1
1Pediatrics, Universitätsklinikum C.G. Carus, TU Dresden, Dresden, Germany; 2Department
of Women's & Children's Health, Institute of Translational Medicine, University of
Liverpool, Liverpool, United Kingdom; 3Biotechnology Center for Molecular and Cellular
Bioengineering, TU Dresden; 4Institute for Medical Informatics and Biometry, Medizinische
Fakultät C.G. Carus, TU Dresden, Dresden, Germany; 5Paediatric Rheumatology, Alder
Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
Correspondence: Sigrun R. Hofmann
Introduction: Procaspase-1 (CASP1) variants trigger febrile episodes and systemic
sterile inflammation in a subset of patients with autoinflammatory diseases despite
altered enzymatic activity of procaspase-1 and reduced IL-1β release. These on the
first view contradictory observations of reduced IL-1β expression and systemic inflammation
could at least partially be explained by increased NF-κB activation through prolonged
interaction of CASP1 variants with receptor interacting protein kinase 2 (RIP2). However,
little is known about the exact molecular basics how CASP1 variants initialize other
pro-inflammatory signaling pathways.
Objectives: Therefore, we aimed to characterize how CASP1 variants influence cell
death mechanisms, cell proliferation, phagocytosis of macrophages and mechanical properties
of monocytes/macrophages.
Methods: Establishing an in vitro model of a virally transduced human monocytic cell
line (THP-1) with shRNA knock-down of endogenous procaspase-1, expressing either wild
type or enzymatically inactive procaspase-1 fusion-reporter proteins we analyzed subcellular
distribution, inflammasome complex formation, the induction of pyroptosis after NLRP3-inflammasome
stimulation using fluorescence and confocal microscopy, life-time imaging and Western
blot. Proliferation and phagocytosis was assessed by using the IncuCyte® live-cell
analysis system in combination with pH sensitive probes (e.g. pHrodo E. coli microparticle).
Real time deformability cytometry (RT-DC) was assessed to define cell mechanical properties
of monocytes/macrophages, which could be altered by CASP1 variants and then contribute
to disease pathogenesis (by influencing cell migration).
Results: Macrophages with CASP1 variants strongly influenced formation of cytosolic
macromolecular complexes (pyroptosomes/specks). The p.C285A and p.R240Q variants show
increased pyroptosome size, which could contribute to the amplification of inflammatory
signals if specks are released to the extracellular space. The p.L265S variant additionally
showed disturbed nuclear localization. Proliferation and phagocytosis of monocytes/macrophages
was not significantly influenced by CASP1 variants, but RT-DC revealed monocytic shape
changes and deformation by CASP1 variants compared to procaspase-1 wildtype.
Conclusion: These findings reveal abnormal pyroptosome formation, impaired nuclear
localization and changes in monocyte cell shape and deformation as further mechanisms,
how CASP1 variants could trigger increased inflammation despite reduced IL-1β release.
Further investigations are needed to confirm these data in vivo.
Disclosure of Interest
None Declared
P2057 Patient with NOD2, NLRP1 and C9 variants with recurrent fever attacks, infectious
susceptibility and osteomyelitic lesions indicative of NAID?
Christian Høst1, Mette Christiansen2, Sofie E. Jørgensen3, Troels Herlin1, Mia Glerup1,
Birgitte Mahler1, Trine Mogensen4
1Pediatrics; 2Clinical Immunology, Aarhus University Hospital, Aarhus N; 3Biomedicine,
Aarhus University, Aarhus C; 4Infectious diseases, Aarhus University Hospital, Aarhus
N, Denmark
Correspondence: Christian Høst
Introduction: Variants in the Nucleotide-binding Oligomerization Domain-containing
protein 2 (NOD2) have been associated with a variety of immunological diseases, such
as Crohns disease, sarcoidosis and the rare monogenic autoinflammatory disease Blau
syndrome(BS). Recently, NOD2 associated inflammatory disease (NAID) was described
as a disease sharing clinical resemblance to BS. While BS seems to arise from gain
of function mutations in the NOD2 gene, little is known of the NOD2 variants commonly
associated with NAID.
Objectives: To describe the genetic, immunological and therapeutic aspects of recurrent
fever episodes in a patient with variants in the NOD2, NLRP1, and C9 genes.
Methods: Oct 2016 a 12-year-old girl presented with recurrent fever, bone pain, arthralgia,
and elevated ESR and CRP. MRI revealed osteomyelitic lesions in both tibiae showing
unspecific inflammatory changes on biopsy. Cultures were negative. Whole exome sequencing
(WES) was performed on DNA extracted from whole blood. Peripheral blood mononuclear
cells (PBMCs) from the patient and healthy controls were stimulated with NF-kB inducers
(TNFα and LPS), a NOD2 ligand (MDP), or left untreated. Phosphorylated IkBα, as a
measure of NF-kB activation, was measured by Luminex technology. Functional complement
analysis was performed to ascertain the role of the C9 variant.
Results: WES identified three heterozygous variants in the NOD2 gene (c.140C>T, p.S47L,
CADD score (CS) 21.5, gnomAD frequency (GF) 0.0002;c.3019dupC, p.L.1007fs*2, CS35.0,
GF 0.015; and c.2798+158C>T (IVS8+158), CS 0, GF 0.10), a heterozygous variant in
the NLRP1 gene (c.923G>A, p.R308Q, CS 0.01, GF 0.0013), and a rare heterozygousvariant
in the C9 gene (c.214C>T, p.Q72*, CS 36.0; GF 0.000007).
Patient PBMCs demonstrated normal NF-kB activation. Upon stimulation, phosphorylated
IkBα increased, but comparably to control levels, and was unaffected by MDP. Cytokine
analyses are pending.Activation of lectin pathway was 0%, and plasma MBL <100μg/L.
Initially, CNO was suspected and bisphosphonate treatment was initiated. Recurrent
fever episodes of 4-8 weeks duration questioned the diagnosis. Nevertheless, adalimumab
was initiated 40 mg e.o. week, but due to poor response, substituted with anakinra
2 mg/kg/day after half a year. On this treatment she suffered a new and long attack
of daily fever for 8 consecutive weeks with abdominal pain and markedly raised ESR
and CRP levels. PET-CT and new MRI remained unremarkable. During fever episodes she
continued to develop minor skin and mucosal infections with herpes simplex virus and
staphylococci, but despite relevant antibiotic treatment fever episodes continued.
Renewed literature review on NOD2 variants raised the suspicion of the recently described
NAID, also known as Yao Syndrome. It is characterized by recurrent fever episodes,
weight loss, fatigue, polyarthralgia/polyarthritis, and often increased acute phase
laboratory findings. Genetically, one or more variants in the NOD2 gene are typically
found.
Conclusion: We believe our patient has NAID due to the presence of two NOD2 variants
IVS8+158 and 1007fs commonly associated with this condition. We speculate that a defective
NOD2 dependent phagocytosis leads to bacterial persistence and secondary inflammatory
changes. Additionally, the variants in NLRP1 and C9 might contribute to her overall
hyperinflammation and infectious susceptibility. Pending cytokine analyses might further
clarify whether these immune responses act through inflammasome-dependent or -independent
cellular pathways.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2058 The cytokines profiles in chronic non-bacterial osteomyeilitis non-systemic
juvenile idiopathic arthritis and healthy controls
Mikhail Kostik1, Daria Kozlova2,3, Dmitry Vasiliev2,3, Olga Karlina2,4, Maria Makhova1,
Lubov Sorokina1, Vyacheslav Zorin5, Eugenia Isupova1, Shamai Magomedova6,7, Inna Kostik8,
Alexander Mushkin5
1Saint-Petersburg State Pediatric Medical University; 2LLC “Scientific and Production
Company “Abris+”; 3Sechenov Institute of Evolutionary Physiology and Biochemistry
RAS; 4Saint-Petersburg State Institute of Technology; 5Science research Institute
of Phthisiopulmonology, Saint-Petersburg; 6Republican Children’s Clinical Hospital;
7Dagestan State Medical Academy, Makhachkala; 8Children's Rehabilitation Center “Detskye
Duny”, Saint-Petersburg, Russian Federation
Correspondence: Mikhail Kostik
Introduction: Chronic non-bacterial osteomyelitis (CNO) is an immune-mediated disease associated
with cytokine dysbalance.
Objectives: The aim of our study was to evaluate the cytokines levels in CNO and compare
to other immune-mediated disease and healthy controls.
Methods: The diagnosis of CNO made with criteria, proposed by Jansson (2007, 2009),
after the exclusion of other causes of bone disease. We included 35 patients with
NBO, 18 patients with non-systemic juvenile idiopathic arthritis (JIA) and five healthy
controls (HC). We evaluated plasma levels of 14-3-3 protein, calprotectin, and interleukine-6
in 3 groups by the ELISA. Statistical analysis was carried out with Statistica 10.0
software. We utilized descriptive statistics (Me; IQR), Mann-Whitney and Wilcoxon
tests, Pierson's and Spearmen’s correlation analysis. We used the Bonferroni’s correction,
so significant level was <0.017 for group comparison.
Results: We have found differences in the proinflammatory biomarkers between CNO,
JIA, and HC. Patients with NBO had higher levels of 14-3-3- protein, calprotectin
and interleukin-6 compare to HC, but lower levels of 14-3-3 protein and interleukine-6
then in JIA patients (table 1).
We have found positive correlation between 14-3-3- protein and ESR (r=0.41, p=0.04
for whole group and r=0.52’ p=0.047 for NBO), and negative correlation with multifocal
involvement (r=-0.45, p=0.016) and hemoglobin (r=-.072, p=0.028). There were not found
differences in the studied biomarkers in CNO patients depend on age, onset age, type
of bone inflammation (granulomatosis vs non-granulomatosis), fever, spine involvement
and type of treatment.
Conclusion: Patients with CNO had proinflammatory activity but less then JIA patients,
further investigations required for finding new more precise biomarkers.
This work supported by the Russian Foundation for Basic Research (grant № 18-515-57001)
Disclosure of Interest
None Declared
Table 1 (abstract P2058).
Comparison of the cytokine levels between CNO, JIA, and HC
Parameter
CNO (n=35)
JIA (n=18)
HC (n=5)
р
р1
р2
р3
ESR, mm/h
25.0 (8.0-43.0)
9.0 (3.0-14.0)
5.0 (2.0-5.0)
0.007
0.018
0.008
0.174
CRP, mg/l
10.1 (6.0-40.6)
1.75 (0.7-5.6)
0.5 (0.2-0.5)
0.0001
0.007
0.0001
0.024
14-3-3 protein, ng/ml
19.9 (18.3-27.1)
51.9 (39.7-60.0)
2.4 (1.5-5.1)
0.00001
0.0000001
0.000003
0.00006
Calprotectin, ng/ml
5.9 (5.2-6.7)
3.95 (3.1-14.3)
0.75 (0.68-0.84)
0.004
0.122
0.000003
0.00006
Interleukin-6, ng/ml
45.5 (40.0-51.0)
445.1 (69.3-530.5)
4.0 (3.2-4.9)
0.00001
0.0000001
0.000003
0.00006
p – all groups, р1 CNO vs JIA; р2NBO and HC; р3 JIA vs HC
P2059 Genetic analysis of the patients with early-onset chronic non-bacterial osteomyelitis
from north Caucasian regions of Russia
Mikhail Kostik1, Maria Makhova1, Evgeny Suspitsin1,2, Anna Sokolenko1,2, Vyacheslav
Zorin3, Eugenia Isupova1, Shamai Magomedova4,5, Inna Kostik6, Hiroshi Takayanagi7,
Alexander Mushkin3, Evgeny Imyanitov1,2
1Saint-Petersburg State Pediatric Medical University; 2N.N. Petrov Institute of Oncology;
3Science research Institute of Phthisiopulmonology, Saint-Petersburg; 4Republican
Children's Clinical Hospital; 5Dagestan State Medical Academy, Makhachkala; 6Children’s
Rehabilitation Center “Detskye Duny”, Saint-Petersburg, Russian Federation; 7Tokyo
University, Tokyo, Japan
Correspondence: Mikhail Kostik
Introduction: Chronic non-bacterial osteomyelitis (CNO) is a heterogenic group of
immune-mediated inflammatory bone diseases with unclear pathogenesis. At present,
only a few genes associated with this condition have identified.
Objectives: The aim of the study was to evaluate the spectrum of mutations in genes
associated with primary immunodeficiency syndromes (PIDs) and autoinflammatory diseases
(AIDs) in the cohort of patients with early-onset CNO from North Caucasus (Dagestan
and Chechnya).
Methods: We selected a subgroup of the CNO patients (n=22) having the following features:
1) early disease onset (<5 years); 2) all children were initially diagnosed as having
tuberculosis (TB) due to bone morphology findings (granulomatosis, e.g. tuberculosis-like
inflammation), but had negative TB culture test; 3) initial treatment with a combination
of 3-4 anti-MBT drugs during 1-2 years was ineffective, and the patient continued
to develop new inflammatory bone foci; 4) patients had very severe clinical and radiological
signs of disease; 5) all patients were from areas with traditionally high prevalence
of consanguinity. Targeted next-generation sequencing (NGS) analysis of 302 genes
related to PIDs and AIDs was performed.
Results: Rare variants of PID genes were detected in 7/22 (32%) patients. Mutations
affecting the genes previously associated with CNO were found only in two patients:
one of them carried heterozygous variant IL1RN c.170G>T (p.C57F), and another had
IL1RN c.512T>C (p.V171A). No mutation of LPIN2 was revealed. Other detected variants
included one pathogenic MEFV p.M694V mutation in the heterozygous state and some VUS
in CD40LG, NLRP12, CR2, NLRP3, IL12B, PLCG2, SH3BP2, CARD14, IRF8, CASP10, and NFKB1A
genes.
Conclusion: Mutations in known genes were detected only in a minor fraction of CNO
patients from Dagestan and Chechnya.
This work supported by the Russian Foundation for Basic Research (grant № 18-515-57001)
and by Japan Medical Research Foundation (grant № 18jmrf001).
Disclosure of Interest
None Declared
P2060 Proteomic profile of peripheral blood mononuclear cells in Behçet’s disease
Asli Kirectepe Aydin1, Yesim Ozguler2, Didar Ucar3, Emire Seyahi2, Hasan Yazici2,
Eda Tahir Turanli1,4
1Molecular Biology-Genetics & Biotechnology Department, Dr Orhan Öcalgiray Molecular
Biology-Biotechnology & Genetics Research Centre, Graduate School of Science, Engineering
& Technology, Istanbul Technical University; 2Division of Rheumatology, Department
of Internal Medicine, Cerrahpasa Medical School; 3Division of Ophthalmology, Department
of Surgical Medicine, Cerrahpasa Medical School, Istanbul University – Cerrahpasa;
4Department of Molecular Biology & Genetics, Faculty of Science Literature, Istanbul
Technical University, Istanbul, Turkey
Correspondence: Eda Tahir Turanli
Introduction: Behçet’s disease (BD) is a systemic inflammatory disorder with unknown
etiology. Although HLA-B51 has been previously described as the most associated allel
with BD, presence of BD patients without the B51 allel (42.8%), healthy individuals
with HLA-B51 allel (18.1%) were reported. Also, various genetic associations with
BD revealed through several genome-wide association and linkage analysis indicate
that genetic and environmental factors may play role in BD pathogenesis.
Objectives: Investigation of proteome profile is crucial to elucidate disease pathogenesis
and related molecular pathways especially in phenotypes like BD with complex genetics
and clinical heterogeneity. In this study, we aimed to identify differentially expressed
proteins in BD and related pathways through proteomic analyses performed on peripheral
blood mononuclear cell (PBMC) samples.
Methods: Study groups were composed of active BD (N=33), inactive BD (N=26), and healthy
controls (N=28). Isolated PBMC protein samples from each group were pooled and then
separated using 2D-DIGE. Protein spots with at least 2 fold-changes or statistical
significance in terms of spot density were compared among the groups, and identified
by MALDI-TOF-MS. Bioinformatic pathway analyses were carried out through KEGG, PANTHER,
and STRING databases. Western blot analyses were performed for WDR1, PGK1, and calreticulin
to confirm 2D-DIGE results.
Results: A total of 369 protein spots were detected by 2D-DIGE. A number of differentially
expressed spots were found: 115 for active vs inactive BD, 118 for active BD vs healthy
controls, 129 for inactive BD vs healthy controls. Among them, the strongest 45 spots
were further analyzed through MALDI-TOF-MS. Following differentially expressed proteins
were determined as the final candidates: calreticulin, WD repeat-containing protein-1
(WDR1), Fructose-bisphosphate aldolase-C, ficolin-1, fibrinogen alpha chain, fibrinogen
beta chain, filamin-A, FUSE-binding protein-1, phosphoglycerate kinase-1 (PGK1), stathmin,
vinculin, hnRNP-M, HSPA8, myosin light polypeptide-6, talin-1, and tropomyosin alpha-3
chain. Western blot analyses of WDR1 and PGK1 confirmed that WDR1 is decreased (1.3
fold), whereas PGK1 is increased (1.5 fold) in BD patients, although the differences
were not statistically significant. However, although decreased calreticulin level
was observed in BD patients compared to healthy controls by 2D-DIGE analysis, we detected
increased calreticulin level in BD patients by western blot analysis.
Conclusion: We identified proteins related to glycolysis, coagulation, ER stress,
and cytoskeleton by 2D-DIGE analysis. Although none of these proteins have been previously
implicated in BD, lower levels of stathmin, WDR1, and calreticulin having roles in
inflammation was revealed in BD patients. Also increased PGK1 level was observed in
BD patients, which is a glycolytic enzyme and previously suggested to have a role
in rheumatoid arthritis. The expression of proteins involved in ER protein processing
(calreticulin, HSPA8, GRP78-BiP) were down-regulated in BD patients compared to healthy
controls, which hints the involvement of ER stress in BD and will be investigated
in more detail.
Disclosure of Interest
None Declared
P2061 IL1RAP as a candidate gene for autosomal dominant Behçet’s disease
Gamze Turan1, Ilker Karacan1, Serdal Ugurlu2, Selcuk Dasdemir3, Huri Ozdogan2, Aslihan
Tolun4, Eda Tahir Turanli1
1Department of Molecular Biology and Genetics, Istanbul Technical University; 2Department
of Rheumatology, Istanbul University Cerrahpasa; 3Department of Medical Genetics,
Istanbul University; 4Department of Molecular Biology and Genetics, Bogazici University
, Istanbul, Turkey
Correspondence: Eda Tahir Turanli
Introduction: Behçet’s Disease (BD) is a chronic inflammatory disorder with unknown
aetiology. Higher prevalence along the Silk Route and familial cases suggest a genetic
contribution to its pathogenesis. We present a Turkish family diagnosed with BD involving
the father and three of the four children, all with disease onset before age 16. All
affected individuals meet the International Study Group criteria for BD. Oral/ genital
ulcers and ostiofolliculitis were shared by all probands. Posterior uveitis and deep
vein thrombosis were diagnosed in the father while recurrent arthritis was prominent
in the affected children.
Objectives: This study aimed to identify the putative gene responsible for autosomal
dominant BD.
Methods:Exome sequencing was performed for unaffected mother and the four affected
family members. Heterozygous, rare (MAF <0.005) and exonic/splicing variants were
selected from among the shared variants, and those shared also with mother were excluded.
Candidate variants that were chosen after analysis via bioinformatics tools were tested
by Sanger sequencing of aforementioned members along with an unaffected and an undiagnosed
sibling. Those variants were also screened in 152 healthy controls with high resolution
melting (HRM) method. To evaluate the effect of the strongest candidate gene to autoinflammation,
levels of IL1β isolated from PBMC cells in four healthy controls and an affected member
in exacerbation period were compared by ELISA method.
Results: Exome analysis showed that patients did not carry variants in TNFAIP3 which
is the known gene for autosomal dominant BD. Six rare, heterozygous variants which
were shared among four affected members but absent in unaffected mother were selected
as initial candidates. Three of those variants were eliminated because they were present
in a healthy sib. The remaining three prominent candidate variantsc.35A>T (p.D12V)
in NAGK (rs150821125), c.1490C>G (p.A497G) in SLC9A2and c.11T>G (p.L4R) in IL1RAP
(rs200782803) were absent in control samples. Furthermore, variants in SLC9A2and IL1RAP
were not reported in gnomAD, 1000G, ExAC and ESP6500 databases. They are predicted
as deleterious by computational prediction tool such as Mutationtaster, SIFT. Due
to its involvement in IL1 signaling, IL1RAP stood out as the most prominentcandidate.No
significant difference in IL1β levels were observed between the affected member and
the healthy controls (165.4 μg/ml vs 165.4 μg/ml respectively).
Conclusion: Our results suggest that in this family the most relevant candidate isc.11T>G
(p.L4R) in IL1RAP.This is the first report suggesting a possible association of IL1RAP
with autosomal dominant BD. Further studies are needed to better define IL1RAP effect
in BD pathogenesis.
Disclosure of Interest
None Declared
Systemic-onset JIA and AOSD
P2062 Canakinumab in systemic juvenile idiopathic arthritis: clinical inactive disease
rate and safety initalian patients
Manuela Pardeo1, Claudia Bracaglia1, Anna Lucia Piscitelli1, Arianna De Matteis2,
Jessica Tibaldi3, Maria Alessio2, Achille Marino4, Giovanni Conti5, Maria Cristina
Maggio6, Clotilde Alizzi6, Francesco Licciardi7, Alma Nunzia Olivieri8, Giovanni Filocamo9,
Francesca Orlando2, Silvana Martino7, Rolando Cimaz4, Angelo Ravelli3, Fabrizio De
Benedetti1
1Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome; 2Department
of Pediatrics, Rheumatology Unit, University Federico II, Naples; 3Department of Paediatric
Rheumatology, University of Genova and Giannina Gaslini Institut, Genoa; 4Department
of Neurosciences, Psychology, Drug Research and Child Health, Rheumatology Unit, Meyer
Children's Hospital, University of Florence, Florence; 5Unit of Pediatric Nephrology
and Rheumatology, University of Messina, Messina; 6University Department Pro.Sa.M.I.
“G. D'Alessandro”, University of Palermo, Palermo; 7Department of Pediatrics and Infectious
Diseases, University of Turin, Turin; 8Department of Woman, Child, and General and
Specialistic Surgery, Second University of Studies of Naples, Naples; 9Intermediate
Pediatric Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan,
Italy
Correspondence: Manuela Pardeo
Introduction: Systemic juvenile idiopathic arthritis (sJIA) is a polygenic autoinflammatory
disease. The pathophysiology is still unclear, it is now well known that innate immune
mechanisms play a central role with overproduction of inflammatory cytokines. The
increased knowledge on the role of these cytokines has provided a change in the natural
history of the disease with the introduction of the targeted treatments. Remarkable
results has been observed with canakinumab, an anti-interleukin-1β monoclonal antibody,
in two clinical trials but little information are available in real life.
Objectives: To evaluate clinical inactive disease rate and safety of canakinumab in
Italian patients with sJIA.
Methods: We have collected retrospectively clinical and laboratory data of patients
with sJIA treated with canakinumab in 9 Italian Paediatric Rheumatology centers. Clinically
inactive disease (CID) at 6 months was defined according to Wallace criteria.We analyzed
the effect of canakinumab on fever, rash, number of actives joints, erythrocyte sedimentation
rate (ESR), C-reactive protein (CRP) and physician’s global assessment of disease
activity score. Clinical and laboratory data were obtained using a standard data collection
form.
Results: Forty seven patients (26 F) were included in the analyses. The median age
(range) at the diagnosis and at the beginning of treatment with canakinumab was 7.6 (1-14.7)
and 10.2 (1.7-22.2) years, respectively. Twenty seven patients (57.4%) had been previously
treated with other biologic agents (18 with anakinra, 1 with tocilizumab, 6 with both
and 2 with etanercept), withdrawn for inefficacy in 15/27 (55.5%). Thirty patients
(63.8%) were receiving concomitant treatment with glucocorticoids at the median dose
(range) of 0.69 (0.02-2.75) mg/kg/die. Thirty nine out of 47 patients had > 6 months
of follow-up. Among these 39 patients, 27 (69.2%) achieved CID at 6 months and 5/27
(18.5%) were still on glucocorticoids. Of the 30 patients who received concomitant
glucocorticoids at baseline, 24 achieved 6 months of follow-up and 12 (50%) of these
were able to withdraw glucocorticoids. Minor adverse events were reported in 5/30
(16.6%) patients:upper respiratory tract infections in 4 and transient injection site
reaction in 1. No cases of macrophage activation syndrome was reported.
Conclusion: Our results provide initial real world evidence of the efficacy of treatment
with canakinumab in patients with sJIA. In our study the percentage of patients who
reached CID at 6 months is slightly higher (69.2%) than reported at the end (from
3 months to one year) of the 2 published randomized trials (60%) (1). No serious adverse
events were recorded in our population.
Reference
(1) N. Ruperto et al. Two randomized trials of Canakinumab in systemic juvenile idiopathic
arthritis.N Engl J Med, 367 (2012), pp. 2396-2406.
Disclosure of Interest
M. Pardeo: None Declared, C. Bracaglia: None Declared, A. L. Piscitelli: None Declared,
A. De Matteis: None Declared, J. Tibaldi: None Declared, M. Alessio: None Declared,
A. Marino: None Declared, G. Conti: None Declared, M. C. Maggio: None Declared, C.
Alizzi: None Declared, F. Licciardi: None Declared, A. N. Olivieri: None Declared,
G. Filocamo: None Declared, F. Orlando: None Declared, S. Martino: None Declared,
R. Cimaz: None Declared, A. Ravelli Grant / Research Support from: Angelini, AbbVie,
Bristol-Myers Squibb, Johnson & Johnson, Novartis, Pfizer, Reckitt-Benkiser, and Roche,Consultant
for: Angelini, AbbVie, Bristol-Myers Squibb, Johnson & Johnson, Novartis, Pfizer,
Reckitt-Benkiser, and Roche, F. De Benedetti Grant / Research Support from: Novartis,
Novimmune, Hoffmann- La Roche, SOBI, AbbVie, Pfizer
P2063 Whole blood phosphorylated STAT1 levels in patients with active macrophage activation
syndrome and secondary hemophagocytic lymphohistiocytosis
Antonia Pascarella, Claudia Bracaglia, Emiliano Marasco, Ivan Caiello, Gian Marco
Moneta, Luciapia Farina, Giulia Marucci, Alessia Arduini, Manuela Pardeo, Fabrizio
De Benedetti, Giusi Prencipe
Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Antonia Pascarella
Introduction: A large body of evidence demonstrates the pivotal role of interferon
gamma (IFNγ) in the pathogenesis of secondary hemophagocytic lymphohistiocytosis (sHLH)
and macrophage activation syndrome (MAS). IFNγ is a key endogenous activator of macrophages
and exerts its biological activities by phosphorylation of the transcription factor
Signal transducer and activator of transcription 1 (STAT1).
Objectives: In this study, we aimed to investigate whether the phosphorylation status
of STAT1 in whole blood cells represents a good biomarker for the identification of
patients at early stages of MAS/ sHLH.
Methods: Whole blood samples from patients with suspected untreated MAS/sHLH (n=7)
and suspected treated (glucocorticoids) MAS/sHLH (n=9) were collected prospectively.
As controls, whole blood samples from patients with active systemic Juvenile Idiopathic
Arthritis (sJIA) without MAS at sampling (n=6) and healthy subjects (HS, n=7) were
used. Fresh whole blood cells were left unstimulated or stimulated with different
concentrations of IFNγ (0.01, 0.1, 1, 10 ng/ml) for 10 minutes. The intracellular
phosphorylation levels of Tyrosine (701) STAT1 (pSTAT1) were evaluated by flow cytometry.
Results have been expressed as Delta mean fluorescence intensity (MFI), calculated
by subtracting the MFI of cells stained with isotype control antibody (Ab) from that
stained with anti-pSTAT1 Ab. Anti CD3, CD14 and CD16 staining was performed to discriminate
the monocyte, neutrophil, natural killer- and T- cell subpopulations.
Results: In both treated and untreated MAS/sHLH patients, flow cytometric analyses
showed no significant differences in pSTAT1 levels in unstimulated monocyte, neutrophil,
natural killer and T cell subpopulations, compared to sJIA and healthy subjects. Interestingly,
we found that, compared to sJIA and healthy subjects, in patients with untreated MAS/sHLH,
pSTAT1 levels were significantly higher in monocytes (p<0,01 Vs HS, p<0,05 Vs sJIA
and p<0,01 Vs HS, p<0,05 Vs sJIA, for stimulation with 1 and 10 ng/ml of IFNg respectively)
and neutrophils (p<0,05 Vs HS, p<0,05 Vs sJIA and p<0,01 Vs HS, p<0,01 Vs sJIA) stimulated
with the higher concentrations of IFNγ (1 and 10 ng/ml). In contrast, we did not find
differences in the levels of pSTAT1 observed in stimulated monocytes and neutrophils
from treated MAS/sHLH patients or those observed in cells from active sJIA and healthy
subjects.
Conclusion: Our results demonstrate that the combined evaluation of pSTAT1 levels
by flow cytometry in monocytes and neutrophils stimulated with high doses of IFNγ
show high levels of pSTAT1 and might contribute to the identification of patients
at early stages of MAS/sHLH. In addition, our results further support the involvement
of IFNγ in the development of the diseases, as suggested by the increased phosphorylated
STAT1 levels exclusively in patients with active MAS/sHLH and not in patients with
active sJIA.
Disclosure of Interest
None Declared
P2064 Whole blood cells from patients with systemic juvenile idiopathic arthritis
(SJIA) in clinical inactive disease displayed a dysregulated response to TLR-4 stimulation
Antonia Pascarella, Manuela Pardeo, Ivan Caiello, Claudia Bracaglia, Marianna N. Rossi,
Giulia Marucci, Emanuela Sacco, Fabrizio De Benedetti, Giusi Prencipe
Bambino Gesù Children’s Hospital, Rome, Italy
Correspondence: Giusi Prencipe
Introduction: Systemic juvenile idiopathic arthritis (sJIA) is a polygenic autoinflammatory
disease. Innate immune mechanisms appear to play a central role in the pathogenesis
of the disease. Nevertheless, a better understanding of the pathophysiology of sJIA
is still needed to identify patients responsive to IL-1 or IL-6 targeted therapies.
Objectives: In this study, we evaluated the production of IL-1β, IL-6 and TNF-α by
fresh whole blood cells isolated from sJIA patients in disease remission, after stimulation
with the TLR-4 ligand lipopolysaccharide (LPS), and we investigated whether sJIA patients
that respond or not-respond to treatment with the IL-1 receptor antagonistanakinra
show a different response.
Methods: We collected fresh whole blood samples from sJIA patients during clinical
inactive disease (inactive sJIA, n=19) and sJIA patients during active disease (active
sJIA n=4). Active and inactive disease was defined at time of sampling. As controls,
fresh whole blood samples from healthy subjects (HS, n=10) were used. Whole blood
cells were left unstimulated or stimulated with 10ug/mL of LPS for 24 hours. Cytokine
levels (IL-1β, IL-6 and TNF-α) released in the supernatants were measured by ELISA.
Response to anakinra was defined as achievement of clinical inactive disease off glucocorticoids
at 6 months after initiation of anakinra treatment.
Results: We found that LPS-stimulated cells from inactive sJIA patients released significantly
higher amounts of all the inflammatory cytokines tested, compared to HS (p<0.01).
In addition, cells from inactive sJIA patients produced significantly higher levels
of IL-1β also compared to active sJIA patients (p<0.05). When we divided inactive
sJIA patients in two groups (responders and non-responders), depending on the clinical
response to anakinra treatment, we observed that in both groups of patients IL-1β,
IL-6 and TNF-α levels were significantly higher than those observed in HS. In addition,
we found that LPS-stimulated whole blood cells from non-responder inactive sJIA patients
released significantly higher levels of IL-1β and TNF-α compared to responder inactive
sJIA patients.
Conclusion: Our preliminary results show a dysregulated production of inflammatory
cytokines by whole blood cells from sJIA patients in remission disease, when stimulated
with a TLR-4 agonist.
Disclosure of Interest
None Declared
P2065 Anakinra drug retention rate and predictive factors of drug survival in systemic
juvenile idiopathic arthritis and adult onset Still’s disease
Jurgen Sota1, Donato Rigante2, Antonella Insalaco3, Paolo Sfriso4, Salvatore de Vita5,
Rolando Cimaz6, Giuseppe Lopalco7, Giacomo Emmi8, Francesco La Torre9, Claudia Fabiani10,
Alma N. Olivieri11, Marco Cattalini12, Daniele Cammelli13, Romina Gallizzi14, Maria
Alessio15, Raffaele Manna16, Ombretta Viapiana17, Micol Frassi18, Armin Maier19, Carlo
Salvarani20, Rosaria Talarico21, Roberta Priori22, Maria C. Maggio23, Manuela Pardeo3,
Carla Gaggiano24, Salvatore Grosso24, Fabrizio de Benedetti25, Antonio Vitale26, Luca
Cantarini26
1Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic,
Department of Medical Sciences, Surgery and Neurosciences,, University of Siena, Siena;
2Institute of Pediatrics , Fondazione Policlinico A. Gemelli IRCCS; 3Division of Rheumatology,
Department of Pediatric Medicine, Bambino Gesù Children's Hospital IRCCS, Rome; 4Rheumatology
Unit, Department of Medicine, University of Padua, Padua; 5Department of Medical and
Biological Sciences, Rheumatology Clinic, Univeristy of Udine, Udine; 6Rheumatology
Unit, Meyer Children's Hospital, University of Florence, Florence; 7Department of
Emergency and Organ Transplantation-Rheumatology Unit, University of Bari, Bari; 8Department
of Experimental and Clinical Medicine, University of Florence, Florence; 9Pediatric
Rheumatology Section, Pediatric Oncoematology Unit, Vito Fazzi Hospital, Lecce; 10Ophthalmology
Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena;
11Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Seconda
Università degli Studi of Naples, Naples; 12Pediatric Clinic, University of Brescia
and Spedali Civili di Brescia, Brescia; 13Experimental and Clinical Medicine Department,
University of Florence, Florence; 14Department of Pediatrics, Azienda G. Martino,
University of Messina, Messina; 15Department of Pediatrics, University Federico II,
Naples; 16Periodic Fever Research Center, Università Cattolica Sacro Cuore, Rome;
17Rheumatology Section, Department of Medicine, University of Verona, Verona; 18Rheumatology
and Clinical Immunology Unit, Department of Clinical and Experimental Sciences, University
of Brescia and Spedali Civili di Brescia, Brescia; 19Struttura Semplice di Reumatologia,
Ospedale di Bolzano, Bolzano; 20Rheumatology Unit, Department of Internal Medicine,
Azienda Ospedaliera ASMN IRCCS,, Reggio Emilia; 21Rheumatology Unit, Department of
Clinical and Experimental Medicine, University of Pisa, Pisa; 22Department of Internal
Medicine and Medical Specialties, Rheumatology Unit, Sapienza University of Rome,
Rome; 23Universitary Department “Pro.S.A.M.I.”, University of Palermo, Palermo; 24Clinical
Pediatrics, Department of Molecular Medicine and Development, University of Siena,
Siena; 25Division of Rheumatology, Department of Pediatric Medicine, Bambino Gesù
Children's Hospital, IRCCS, Rome; 26Research Center of Systemic Autoinflammatory Diseases
and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences,University
of Siena, Siena, Italy
Correspondence: Jurgen Sota
Introduction: Only a few studies have reported the long-term efficacy of interleukin
(IL)-1 inhibition in systemic juvenile idiopathic arthritis (sJIA) and adult onset
Still’s disease (AOSD). We herein describe Anakinra (ANA) effectiveness expressed
in terms of drug retention rate (DRR) and evaluate predictive factors of drug survival
in sJIA and ASOD patients.
Objectives: Examine the overall DRR of ANA in sJIA and AOSD patients. Explore the
influence of biologic line of treatment, and the concomitant use of disease modifying
anti-rheumatic drugs (cDMARDs) on DRR in the whole sample and stratified according
to the disease thereafter; find eventual predictive factors associated with events
leading to drug discontinuation. The corticosteroid (CS)- and cDMARDS-sparing effect,
the impact of treatment delay on survival and the record of safety profile constituted
ancillary aims.
Methods: Medical records from 61 sJIA and 76 AOSD patients treated with ANA in 24
Italian tertiary referral centers were retrospectively reviewed.
Results: The cumulative retention rate of ANA at 12-, 24-, 48- and 60-months of follow-up
was 74.3%, 62.9%, 49.4% and 49.4% respectively, without any significant differences
between sJIA and AOSD patients (p=0.164), and between patients treated in monotherapy
compared to the subgroup co-administered with conventional cDMARDs (p=0.473). On the
other hand, a significant difference in DRR was found between biologic-naive patients
and those previously treated with biologic drugs (p=0.009), which persisted even after
adjusting for pathology (p=0.013). In regression analysis, patients experiencing adverse
events (AEs) (HR=3.029 [C.I. 1.750-5.242], p<0.0001) and those previously treated
with other biotechnologic agents (HR=1.818 [C.I. 1.007-3.282], p=0.047) were associated
with a higher hazard ratio of ANA discontinuation. The median treatment delay was
significantly higher among patients discontinuing ANA (p<0.0001). A significant CS-
(p=0.033) and cDMARDs-sparing effect (p<0.0001) was also recorded. Less than one third
of our cohort developed AEs and 85% were deemed mild in nature, with 70% involving
the skin.
Conclusion: Our findings display an overall excellent DRR of ANA on the long run for
both sJIA and AOSD that may be further optimized by closely monitoring patient’s safety
issues and employing this IL-1 inhibitor as a first-line biologic as early as possible.
Moreover, ANA allowed a significant drug-sparing effect while showing a good safety
profile.
Disclosure of Interest
None Declared
P2066 Predictors of effectiveness of anakinra in systemic juvenile idiopathic arthritis
Jessica Tibaldi1, Bendetta Saccomanno1, Francesca Minoia2, Francesca Bagnasco3, Angela
Pistorio3, Andreessa Guariento4, Roberta Caorsi3, Alesandro Consolaro1, Marco Gattorno3,
Angelo Ravelli1
1Istituto G. Gaslini/Università degli Studi di Genova, Genoa; 2Fondazione IRCCS Ca’
Granda, Ospedale, Milan; 3Istituto G. Gaslini, Genoa, Italy; 4Instituto de Criança
– FMUSP, Rio de Janeiro, Brazil
Correspondence: Jessica Tibaldi
Introduction:Systemic juvenilei diopathicarthritis (sJIA) is the most severe and a
rather distinct subtype of JIA. It is common viewthatsJIAis the most severe form of
childhood arthritis and the most difficult to treat. Recently the use of interleukin(IL)-1
antagonists has led to a significant improvement of the disease’s long-term evolution
and has confirmed this cytochin’s key-role in the pathogenesis of sJIA. A number of
potential predictors of the therapeutic effectiveness of IL-1 inhibitors have been
reported, which include less severe joint disease and increased white blood cell count,
shorter disease duration, older age at disease onset and use of IL-1 blockade as first-line
therapy. However, because the experience gained so far is still limited, there is
a need of further data to better characterize the profile of sJIA patients who are
more susceptible to respond to IL-1 blockade.
Objectives: To seek predictors of therapeutic response to the interleukin (IL)-1 inhibitor
anakinra in children with systemic-onset juvenile idiopathic arthritis (sJIA).
Methods: The clinical charts of all patients with sJIA who were newly treated with
anakinra at our center between 2004 and 2017 were reviewed retrospectively. Predictors
included baseline demographic, clinical, and laboratory variables as well as previous
or concomitant therapies. The effectiveness of anakinra was assessed at 1 year after
treatment start. Complete clinical response (CCR) was defined as absence of fever,
physician’s global assessment ≤1, count of active joints ≤1, negative C-reactive protein,
and ≥75% reduction of corticosteroid dose. According to the intention-to-treat principle,
patients who had anakinra discontinued before 1 year for any reasons other than disease
remission were classified as nonresponders. Statistics included univariate and multivariable
analyses.
Results: Of the 62 patients included in the study, 24 (39%) met the criteria for CCR
at 1 year, whereas 38 (61%) did not. On multivariable analysis, independent correlations
with achievement of CCR were identified for shorter disease duration, lower active
joint count, higher ferritin level, and greater activity of systemic manifestations.
The area under the curve of the model was 0.83.
Conclusion: Our findings help to delineate the clinical profile of patients with sJIA
who are more likely to benefit from IL-1 blockade. They also underscore the need for
studies aimed at examining the therapeutic role of early IL-1 inhibition and to identify
biomarkers predicting response to either IL-1 or IL-6 antagonists.
Disclosure of Interest
J. Tibaldi: None Declared, B. Saccomanno: None Declared, F. Minoia: None Declared,
F. Bagnasco: None Declared, A. Pistorio: None Declared, A. Guariento: None Declared,
R. Caorsi: None Declared, A. Consolaro: None Declared, M. Gattorno Consultant for:
SOBI,Speaker Bureau of: SOBI, A. Ravelli: None Declared
Table 1 (abstract P2066).
Best-fitting model obtained through logistic regression procedures
Baseline explanatory variable
OR (95% CI)
P£
Diseaseduration ≤ 3.9 years
6.78 (1.30-35.27)
0.012
Active joint count ≤ 10
8.25 (1.26-53.91)
0.012
Ferritin > 444 ng/dL
4.75 (1.16-19.50)
0.020
Systemicmanifestationscore > 3
6.44 (1.38-24.62)
0.007
P2067 Canakinumab treatment in adult-onset Still’s disease: case series
Serdal Ugurlu1, Gul Guzelant1, Berna Yurttas1, Bilgesu Ergezen1, Ediz Dalkilic2, Timucin
Kasifoglu3, Burcu Yagiz2, Huri Ozdogan1
1Istanbul University, Cerrahpasa Medical Faculty, Department of Internal Medicine,
Division of Rhematology, Cerrahpaşa Medical Faculty, Istanbul; 2Uludag University,
Medical Faculty, Department of Internal Medicine, Division of Rhematology, Uludag
Medical Faculty, Bursa; 3Osmangazi University, Medical Faculty, Department of Internal
Medicine, Division of Rheumatology, Osmangazi Medical Faculty, Eskisehir, Turkey
Correspondence: Serdal Ugurlu
Introduction: In Adult-onset Still’s disease (AOSD), cases refractory to typical DMARDs,
Canakinumab (an anti-IL-1ß monoclonal antibody) has been reported to be effective
in a limited number of refractory cases (1).
Objectives: The aim of this retrospective study was to represent AOSD patients treated
with Canakinumab in 3 centers.
Methods: The follow up data of 11 AOSD patients (8 female, 3 male), who were followed
up in outpatient clinics of 3 tertiary centers were reviewed retrospectively. The
initial characteristics and follow up findings were reported.
Results: The mean timespan between the initial diagnosis and Canakinumab treatment
43.2 ± 28 months (mean ± SD). Before the onset of Canakinumab therapy, all patients
were exposed to methotrexate, 1 to leflunomide, 9 to Tocilizumab and 8 to Anakinra.
As for the biologic agents, 3 patients were also treated beforehand with Infliximab,
2 with Adalimumab, 3 with Etanercept and 2 with Rituximab. Canakinumab therapy was
initiated in all patients with the indication of refractory disease under other medications,
except for the one in whom neutropenia became evident under anakinra. The mean number
of Canakinumab injections was 11,8 ± 6. The mean follow-up period of patients treated
with Canakinumab was 42.2 ± 31 months. Five of 8 patients are still being treated
with Canakinumab of 150 mg/month, one of 300 mg/month and two of 150 mg/every 2 months.
One patient had a single injection and was fully controlled. The mean ferritin measure
of 9 patients was reduced from 1292.3 ± 1530 ng/ml to 218.1 ± 327.1 ng/ml following
the Canakinumab therapy (p=0.056). The mean of patient-reported global visual analogue
scale (PG-VAS) scores was reduced from 7.9 ± 2.4 to 1.4 ± 2 with Canakinumab (p<0.0001).
Mean Erythrocyte sedimentation rate (ESR) was reduced from 51 ± 39.4 to 18.8 ± 21.6
with the help of Canakinumab therapy (p = 0.036). Seven patients are still on prednisolone
at a maximum dose of 10 mg/day. The indication of therapy termination in the remaining
1 patient was the diagnosis of tuberculosis at 9th month of the treatment despite
isoniazid prophylaxis. The patient was also treated with multiple biological agents
beforehand, therefore it is not easy to conclude that treatment with Canakinumab induces
tuberculosis flares.
Conclusion: Canakinumab treatment seems to be effective in refractory AOSD patients
who were previously treated with various agents. We state that an IL-1 blocking agent,
Canakinumab is a relatively safe and effective alternative in managing refractory
AOSD cases. On the other hand, randomized controlled trials are needed to further
investigate the role of Canakinumab in these cases as well as its use as the first
choice of biologic agents.
REFERENCE
1-Kontzias A, Efthimiou P. The use of Canakinumab, a novel IL-1β long-acting inhibitor,
in refractory adult-onset Still's disease. Semin Arthritis Rheum. 2012;42(2):201-5.
Disclosure of Interest
None Declared
Table 1 (abstract P2067).
See text for description
Before Canakinumab
After Canakinumab
p
Ferritin value (mean ± SD) (ng/ml)
1292.3 ± 1530
218.1 ± 327.1
0.056
Patient-reported global visual analogue scale (PG-VAS)
7.9 ± 2.4
1.4 ± 2
<0.0001
Mean Erythrocyte sedimentation rate (ESR)
51 ± 39.4
18.8 ± 21.6
0.036
Therapy of systemic auto-inflammatory diseases
P2068 Microbiota transplant to control inflammation in a NLRC4-related disease patient
with recurrent hemophagocytic lymphohistiocytosis (HLH)
Claudia Bracaglia1, Giulia Marucci1, Federica Del Chierico2, Alessandra Russo2, Manuela
Pardeo1, Antonella Insalaco1, Giusi Prencipe1, Ivan Caiello1, Sarka Fingerhutova3,
Pavla Dolezalova3, Fabrizio De Benedetti1, Lorenza Putignani2,4
1Division of Rheumatology; 2Unit of Human Microbiome, IRCCS Ospedale Pediatrico Bambino
Gesù, Rome, Italy; 3Paediatric Rheumatology and Autoinflammatory Diseases Unit, General
University Hospital, Prague, Czech Republic; 4Unit of Parasitology, IRCCS Ospedale
Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Claudia Bracaglia
Introduction: The NLRC4 inflammasome activation is essential in host defence, particularly
against enteric pathogens. Gain-of-function mutations in NLRC4 are associated with
a distinct autoinflammatory syndrome characterized by enterocolitis and recurrent
HLH.
Objectives: To report safety and efficacy of faecal microbiota transplantation (FMT)
in a patient carrying a de novo missense mutations in NLRC4, with gut inflammation
and gut colonization by multi-drug resistant (MDR) pathogens.
Methods: Subject and donors were screened for potential FMT according to Cammarota et
al. (Gut, 2017) with modifications introduced by Ospedale Pediatrico Bambino Gesù
Committee for paediatric FMT procedures. Culture-based and NGS-based microbiota profiling
were performed to address MDR persistence and microbial associated communities coupled
to inflammatory profiling. After wide donor screening, a universal adult donor was
selected and infusion performed twice by colonoscopy from fresh and frozen faeces,
respectively. A one year FMT follow up was ensured to address clinical outcomes.
Results: A Caucasian 16 months old boy presented, from 1 month of life, with recurrent
HLH, diarrhoea and vasculitic skin lesions, secondary to a de novo missense mutation
in NLRC4 (I343N). His disease was not controlled despite treatment with repeated high
dose of intravenous methylprednisolone pulses and chronic daily glucocorticoid therapy,
cyclosporine-A (5 mg/kg) and anakinra (ranging from 5 to 25 mg/kg/day). Because of
recurrent HLH episodes, the patient was treated with emapalumab (anti-IFNgamma antibody)
for three months, with HLH control. However, the patient presented persistent diarrhoea
with gut inflammation and colonization by MDR pathogens (Enterobacter cloacae and Enterococcus
faecalis), leading by translocation to systemic infections and, hence, HLH reactivation.
Moreover, he developed severe intestinal meteorism with subsequent paralytic-ileus
that required ileostomy. Based on the hypothesis that his intestinal dysbiosis concurred
in the persistent gut inflammation related to his underlying disease, he received
a first FMT with initial clinical improvement. Therefore, ileal anastomosis was performed
with recanalization, and a second FMT was performed a month later. The patient did
not develop any complication. The stool cultures no longer showed the presence of
enteropathogenic germs and since the last FMT (12 months of follow-up) he did not
present any symptom of gut inflammation or HLH reactivations.
Conclusion:
NLRC4-related disease is typically characterized by enterocolitis and NLRC4, highly
expressed in intestinal macrophages, is critical for pathogen restriction by phagocytes
in the gut lamina propria. The chronic gut inflammation of NLRC4-patients is a stimulus
for systemic inflammation. Moreover, pathogens present in the gut can trigger HLH
episodes. A presence of a selected microbiota from appropriate donor can decrease
gut inflammation. FMT may represent a valid and safe therapeutic option in NLRC4-patients
in order to reduce chronic inflammatory stimuli.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
C. Bracaglia: None Declared, G. Marucci: None Declared, F. Del Chierico: None Declared,
A. Russo: None Declared, M. Pardeo: None Declared, A. Insalaco: None Declared, G.
Prencipe: None Declared, I. Caiello: None Declared, S. Fingerhutova: None Declared,
P. Dolezalova: None Declared, F. De Benedetti Grant / Research Support from: Novartis,
Novimmune, Hoffmann- La Roche, SOBI, AbbVie, Pfizer, L. Putignani: None Declared
P2069 Emapalumab, an anti-interferon gamma monoclonal antibody in two patients with
NLRC4- related disease and severe hemophagocytic lymphohistiocytosis (HLH)
Claudia Bracaglia1, Giusi Prencipe1, Antonella Insalaco1, Ivan Caiello1, Giulia Marucci1,
Manuela Pardeo1, Raffaele Pecoraro2, Pavla Dolezalova3, Sarka Fingerhutova3, Maria
Ballabio4, Cristina de Min4, Fabrizio De Benedetti1
1Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù; 2Pediatric Department,
La Sapienza University of Rome, Rome, Italy; 3Paediatric Rheumatology and Autoinflammatory
Diseases Unit, General University Hospital, Prague, Czech Republic; 4Novimmune, S.A.,
Geneva, Switzerland
Correspondence: Claudia Bracaglia
Introduction: Interferon gamma (IFNγ) plays a pathogenic role in primary and secondary
HLH. An ongoing phase 2/3 trial with emapalumab in primary HLH provides encouraging
preliminary data and a pilot trial in MAS in the context of sJIA has just been initiated.
Gain-of-function mutations in NLRC4 are associated with a distinct autoinflammatory
syndrome, with recurrent HLH.
Objectives: To report safety and efficacy of emapalumab treatment in two patients
carrying de novo missense mutations in NLRC4, with severe early onset HLH.
Methods: Cytokine levels were measured by multiplex assay and by specific ELISAs and
expression of IFNγ in freshly isolated PBMCs by cytometry.
Results: Pt 1. Caucasian male, presented, at age 20 days, fever and rash and progressively
developed clinical and laboratory features of HLH leading to multi-organ failure.
A de novo missense mutation in NLRC4 (T337N) was found. High-dose glucocorticoids
and cyclosporine-A (CyA) led only to partial improvement. A sepsis triggered HLH reactivation.
Emapalumab was started (compassionate use) on background of dexamethasone (13.6 mg/m2)
and CyA. After 3 months, the child was discharged in excellent conditions (prednisone
0.3 mg/kg). Infections resolved during treatment with emapalumab. After 7 months of
emapalumab treatment, all therapies, including emapalumab, were discontinued, without
clinical or laboratory signs of HLH reactivation. Pt 2. This is 16 months old Caucasian
boy with recurrent HLH and vasculitic skin lesions, since 1 month of life, secondary
to a de novo missense mutation in NLRC4 (I343N). His disease was not controlled despite
treatment with repeated methylprednisolone pulses and chronic daily glucocorticoid
therapy, CyA (5 mg/kg) and anakinra (ranging from 5 to 25 mg/kg/day). When anakinra
was withdrawn prior to start emapalumab he immediately developed high-grade fever,
skin rash with vasculitic lesions and diarrhoea with laboratory features of HLH. Emapalumab
was started (compassionate use) on background of methylprednisolone and CyA with rapid
resolution of fever and improvement in biochemical parameters.During emapalumab treatment
the patient resolved his initial HLH flare and presented two HLH episodes of mild
intensity controlled with moderate intensification of glucocorticoid therapy. These
episodes were triggered by systemic infections caused by pathogens translocated from
the gut. His diarrhoea persisted with low grade inflammation; emapalumab was eventually
withdrawn after 3 months. His subsequent course was characterized by additional mild episodes
of MAS. In both patients increased production of IFNγ was demonstrated by high levels
of CXCL9 (pt.1: 5670 pg/ml, pt.2: 3310 pg/ml), a chemokine induced specifically by
IFNγ, by increased IFNγ expression in NK cells and CD8T cells, and by presence of
high levels of total IFNγ bound to circulating emapalumab.
Conclusion: In both patients with HLH secondary to NLRC4-related disease, treatment
with emapalumab was well tolerated, no safety concerned emerged, normalization of
all HLH clinical and laboratory abnormalities was achieved. Pt. 1 showed no disease
reactivation even in the absence of treatments. In pt. 2 IFNγ neutralization has provided
control of HLH, while his underlying disease and, in particular, gut inflammation
and gut colonization by MDR pathogens remained unchanged.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
C. Bracaglia: None Declared, G. Prencipe: None Declared, A. Insalaco: None Declared,
I. Caiello: None Declared, G. Marucci: None Declared, M. Pardeo: None Declared, R.
Pecoraro: None Declared, P. Dolezalova: None Declared, S. Fingerhutova: None Declared,
M. Ballabio Employee of: Novimmune S.A., C. de Min Employee of: Novimmune S.A., F.
De Benedetti Grant / Research Support from: Novartis, Novimmune, Hoffmann- La Roche,
SOBI, AbbVie, Pfizer
P2070 IL-1 blockade in paediatric recurrent pericarditis: a multicentric retrospective
study of the Italian cohort
Roberta Caorsi, Antonella Insalaco, Chiara Longo, Giorgia Martini, Marco Cattalini,
Rita Consolini, Giovanni Filocamo, Alessandro Rimini, Silvia Federici, Camilla Celani,
Maria Cristina Maggio, Micol Romano, Barbara Teruzzi, Andrea Taddio, Angela Miniaci,
Silvana Martino, Francesco Latorre, Alessandro De Fanti, Giulio Cavalli, Berbara Bigucci,
Antonio Brucato, Fabrizio De Benedetti, Marco Gattorno and The Italian study group
on anti-IL-1 drugs’ efficacy in recurrent pericarditis
Center of Autoinflammatory Diseases and Immunodeficiencies, Department of Pediatrics
and Rheumatology, Istituto G. Gaslini, Genova, Italy
Correspondence: Roberta Caorsi
Introduction: Acute pericarditis is an inflammatory condition causing the occurrence
of pericardial effusion. In a third of patients, the disease is recurrent. First line
treatment of idiopathic pericarditis consists in non-steroidal anti-inflammatory drugs
(NSAIDs) and colchicine; glucocorticoids represent the second line treatment in resistant
or intolerant cases. A recent clinical trial has enlightened the effectiveness of
anakinra in adults and paediatric patients with colchicine-resistant recurrent pericarditis.
Objectives: To describe the clinical characteristics and response to treatment in
a cohort of paediatric patients with recurrent pericarditis treated with IL inhibitors.
Methods: paediatric patients with recurrent pericarditis followed at 19 Italian centers
of paediatric rheumatology or cardiology and treated with IL1 inhibitors were included
in the study. Demographic, clinical and response to treatment data were retrospectively
collected.
Results: 55 patients were included in the study. The mean age at onset of the first
episode of pericarditis was 12.53 years. The mean number of relapses of pericarditis
before the beginning of treatment with IL1 inhibitors was of 3.4 (range 1 -10). 53
out of 55 patients had previously received treatment with NSAIDS and 44 with colchicine.
44 patients received steroidal treatment: 2 of them displayed a steroidal-resistance
and 39 steroidal-dependence with reoccurrence of the symptoms following any attempt
to reduce or withdraw this treatment. Anakinra (mean dosage of 1.67 mg/kg/day) was
used as first Il-1 inhibitor in 54 of the 55 patients, Canakinumab (150 mg every 4
weeks) in one. 53 out of 54 patients treated with anakinra displayed a complete clinical
response to treatment within a mean of 2 days (range 1-7): NSAIDs, glucocorticoids
and colchicine were withdraw in 25 out of 26, 31 out of 35 and 15 out of 32 patients
respectively. 50 of 54 patients displayed a complete response; among these, three
were switched to Canakinumab, 17 patients continued treatment at the same dosage while
in 30 patients a reduction of treatment was attempted. 12 patients presented, during
anakinra tapering, a disease flare, promptly resolved after an increasing of the dosage.
The remaining 18 patients did not present any flare despite the reduction of the drug.
Anakinra was withdrawn in 16 patients, with recurrence of the symptoms in 11. 5 patients
were treated with Canakinumab: 1 as first anti-IL1 drug, 4 were switched from anakinra
(two for poor compliance, one for side effects and one for incomplete control of the
disease). 2 out of five patients had a complete control of the diseases, 2 patients
discontinued the treatment because of inefficacy and 1 patient required low dose of
glucocorticoids to control the disease. At last follow-up 34 patients were on anakinra,
7 on anakinra and colchicine, 2 on canakinumab, 1 oncanakinumab plus colchicine and
NSAIDs. In 9 patients all treatments were withdrawn for complete control of the disease.
Conclusion: This study confirm the effectiveness of IL-1 blockade in paediatric patients
with recurrent pericarditis. However most of the patients require prolonged treatment
to maintain clinical remission. Moreover, in our cohort of patients the rate of response
was higher for anakinra then for canakinumab, suggesting a possible role of IL1α in
the pathogenesis of this condition.
Disclosure of Interest
None Declared
P2071 Efficacy and safety of anakinra in the treatment of inflammatory heart failure
in myocarditis
Giacomo De Luca, Corrado Campochiaro, Giulio Cavalli, Silvia Sartorelli, Lorenzo Dagna
Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital,
Vita-Salute San Raffaele University, Milan, Italy
Correspondence: Giacomo De Luca
Introduction: Virus-negative myocarditis (VNM) is a severe, inflammatory heart disease
with a poor prognosis, and is a leading cause of inflammatory dilated cardiomyopathy(i-DCM).
Therapies are limited. Preliminary data indicate that interleukin-1 (IL-1) plays a
key role in the initiation and maintainance of the inflammatory heart response, sustaining
an auto-inflammatory cycle [1,2].
Objectives: to evaluate the efficacy and safety of anakinra (ANK) in improving Left
Ventricular Ejection Fraction (LVEF) on transthoracic echocardiography (TTE) and other
cardiovascular parameters in patients with VNM.
Methods: Biopsy-proven VNM patients were enrolled and treated with ANK 100 mg daily
subcutaneously. All patients also received treatment with the maximum tolerated dose
of any beta blockers and ACE-inhibitors, according to current guidelines. At baseline
and 8±4 weeks after ANK therapy initiation, all patients underwent a full evaluation
with assessment of their functional status (New York Heart Association [NYHA]), measurement
of high-sensitive troponin T (hs-TnT) and NT-proBNP serum levels, electrocardiography
(ECG), 24h-ECG Holter, TTE and cardiac magnetic resonance (CMR). Any myocarditis-related
complication, cardiovascular deaths and adverse events (AEs) were recorded during
follow-up. Continuous variables were assessed with the Wilcoxon signed-rank test for
non-parametric tests and a p value<0.05 was considered statistically significant.
Results: eleven patients with EBM-proven myocarditis were enrolled and treated with
ANK. Nine patients received ANK as first line therapy, and in 5 cases ANK was used
as monotherapy; ANK was combined with prednisone (mean dose 31,7±16,7 mg daily) in
6 patients, 5 of them were concomitantly treated with azathioprine. Demographic and
baseline clinical characteristics of our cohort are summarized in table 1. Mean LV-EF
on TTE at baseline was 38,7%±19,6, with comparable findings on CMR (36,45%±18,0),
and 8 patients (72.7%) had a depressed LV-EF(<55%). At baseline, mean levels of hs-TnT
and NT-proBNP were 150,0 ± 153,9 ng/L and 6968,8 ± 10788,4 pg/ml, respectively. Hs-TnT
and NT-proBNP levels were elevated in 10 (90.9%) and 9 patients (81.8% respectively.
At 8 weeks, LV-EF improved in 10 patients (90.9%). The LV-EF increase was >10% in
5 patients (45.5%) and between 5-10% in 5 cases (45.5%); only 1 patient showed a <10%
LV-EF decrease. Mean LV-EF at the end of follow-up improved to 49,4%±10,8 (p=0.059).
When evaluating the 8 patients with baseline reduced LV-EF, the LV-EF improvement
was statistically significant (baseline 29,25% ±12,9; after ANK 45.2% ±9.2, p=0.025).
The LV-EF amelioration was paralleled by clinical improvements in all patients, since
the majority of them (90.9%) were in NYHA class I-II at the end of follow-up(vs 27.3%
at baseline). Consistently, hs-TnT declined after 8 weeks (64,6±100,7 ng/L,p=0,028),
and a similar trend was observed for NT-proBNP, even though this not reach statistical
significance(2582,6±5048,1 pg/ml,p=0,06). We did not observe any myocarditis-related
death or complications, nor any ANK-related AEs.
Conclusion: Our pilot study supports the efficacy and safety of anakinra in the treatment
of inflammatory heart failure in VNM and provides the first clinical evidence to support
the therapeutic blockade of IL-1 in myocarditis.
Disclosure of Interest
None Declared
Table 1 (abstract P2071).
See text for description
Females/males, n
5/6
Mean age, years
46,2±12,2
Clinical onset, n(%)
Heart failure (LV-EF<55%)
8(72.7)
Chest pain
2(18.2)
Dyspnea
1(9.1)
NYHA class III-IV, n(%)
8(72.7)
EBM classification*, n(%)
i-DCM
6(54.5)
Acute/active/chronic VNM
3(27.3)/1(9.1)/1(9.1)
* according to histologic and immunohistochemical criteria
[3-4]
P2072 Efficacy, safety and cost-effectiveness of a vial-sharing programme for canakinumab
treatment for paediatric patients with cryopyrin-associated periodic syndrome
Abdulkadir A. Elmi1, Karen Wynne2, Iek L. Cheng2, Despina Eleftheriou2, Helen J. Lachmann3,
Philip N. Hawkins3, Paul Brogan1,2
1Infection Inflammation and Rheumatology Section, University College London Institute
of Child Health; 2Department of Paediatric Rheumatology, Great Ormond Street Hospital
NHS Foundation Trust; 3National Amyloidosis Centre, UCL Centre for Amyloidosis and
Acute Phase Proteins, London, United Kingdom
Correspondence: Abdulkadir A. Elmi
Introduction: Cryopyrin-associated periodic syndrome (CAPS) is a rare autoinflammatory
disease, caused by gain of function mutation in NLRP3 resulting in excess production
of interleukin-1 (IL-1). Canakinumab is a human monoclonal antibody against IL-1β,
licensed for the treatment of CAPS.
Objectives: To describe the feasibility and cost-effectiveness of a canakinumab vial-sharing
programme for paediatric patients with CAPS.
Methods: Retrospective case series and clinical service description of a national
specially commissioned CAPS clinic at Great Ormond Street Hospital (GOSH). Efficacy
was assessed using the CAPS disease activity score (DAS) and serum amyloid A protein
(SAA). Adverse events were collected to determine safety. The number of canakinumab
vials saved were considered when investigating the cost-effectiveness of vial-sharing.
Results: Nineteen/20 (95%) of our paediatric patients achieved minimally active clinical
disease activity with canakinumab monotherapy; and 75% achieved both minimally active
clinical disease and serological remission using a pre-specified definition based
on the CAPS DAS and SAA level. Canakinumab was well tolerated, with only one child
developing an infection requiring hospitalisation during the study.Canakinumab vial
sharing resulted in 117 vials of canakinumab saved over a 24-month period, equating
to a direct drug-related cost saving of £1,385,821, and a conservative estimated 5-year
cost-saving of £3,464,552.50.
Conclusion: We provide further evidence for the efficacy and safety of canakinumab
in children with CAPS, and highlight the cost-effectiveness of a vial-sharing programme
for this high cost medicine. We suggest that this could have important implications
for the delivery of other high cost medicines used in paediatric practice.
Disclosure of Interest
None Declared
P2073 Anti-IL-1 therapies in patients with familial Mediterranean fever related AA-amyloidosis
Serdal Ugurlu1, Bilgesu Ergezen2, Oguzhan Selvi1, Bugra H. Egeli1, Huri Ozdogan2
1Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty;
2University of Istanbul - Cerrahpasa, Istanbul, Turkey
Correspondence: Bilgesu Ergezen
Introduction: The most devastating complication of Familial Mediterranean Fever (FMF)
is secondary AA amyloidosis and is still a problem in many cases. Efforts have been
paid to prevent AA amyloidosis or to control an already formed amyloidosis in order
to prevent organ function loss, particularly renal insufficiency. There are emerging
therapies in FMF related amyloidosis.
Objectives: We aimed to evaluate the role of anti-IL-1 regimens, anakinra and canakinumab
regarding their efficacy and safety in FMF related amyloidosis.
Methods: In this single center study, 44 patients diagnosed with FMF and had a histologically
proven diagnosis of amyloidosis, were exposed to Anakinra or canakinumab. Patients
who received anti IL-1 therapy for at least 3 months were evaluated for treatment
response. All of the patients recruited in this study received colchicine and are
either resistant or intolerant. Patients were questioned with regards to FMF related
characteristics and comorbidities. MEFV gene status, laboratory measures, side events
and therapy outcomes were tested and followed.
Results: Four patients were excluded because they received treatment less than 3 months.
Among remaining 40 patients, anakinra was switched to canakinumab due to allergic
reactions or insufficient response in 15 patients. There are 16 patients still on
anakinra and 10 with canakinumab after a mean of 25.92±11.31 months. The patients
were divided into two subgroups with regards to their initial creatinine levels: Group
1 creatinine levels below 1.5 mg/dL and Group 2 above 1.5 mg/dL. The analysis of clinical
outcome is summarized in Table 1. The decrease in proteinuria is more modest (p=0.01)
in Group 1 in comparison with Group 2 (p<0.01). The decrease in the mean patient global
assessment scores was significant for both groups. It decreased from 6.82 to 1.2 in
Group 1 and from 6 to 2.5 in Group 2. At the time of this review 8 patients were still
on hemodialysis. Three patients had renal transplantation. The only side effect observed
was injection-site reaction in patients receiving anakinra (n=3). Patients on canakinumab
developed pneumonia, flare of psoriasis, and lichen planus one each.
Conclusion: We suggest that anti-IL-1 therapies are effective and tolerable in FMF
related amyloidosis by controlling the acute phase response, as well as improving
renal function and quality of life. These agents are particularly effective when administered
during the early stages of renal disease. The anti-IL-1 agents are well tolerated
and the related side effects are generally reversible.
Disclosure of Interest
None Declared
Table 1 (abstract P2073).
The parameters of renal functions and acute phase reactants in patients with initial
creatinine level below 1.5mg/dL (Group 1) and above 1.5mg/dL (Group 2)
Before treatment
After treatment
p
Before treatment
After treatment
p
Before treatment
After treatment
p
Group 1
Anakinra(n= 19)
Canakinumab (n=10)
All anti IL-1 (n=23)
Creatinine (mg/dl)
0,9 ± 0,28
0,9 ± 0,44
<0,01
1,35 ± 1,57
1,78 ± 1,93
0,01
0,8 ± 0,25
1,3 ± 1,5
<0,01
Proteinuria (mg/day)
2686 ± 3257
2328 ± 4458
<0,01
6000 ± 5550
3730 ± 5030
<0,01
2780 ± 3323
1365 ± 2365
<0,01
ESR(0-20 mm/h)
43,5 ± 31,3
19,3 ± 26,4
<0,01
51,22 ± 33,54
17,1 ± 31,2
<0,01
44,8 ± 31,1
17,6 ± 31,1
<0,01
Group 2
Anakinra(n= 13)
Canakinumab (n=9)
All anti IL-1 (n=17)
Creatinine (mg/dl)
3,3 ± 2,4
3,4 ± 2,4
<0,01
3,1 ± 2,4
3,2 ± 2,5
<0,01
3,54 ± 2,62
3,5 ± 2,59
<0,01
Proteinuria (mg/day)
5482 ± 8040
3651 ±4635
0,01
7670 ± 7600
7585 ± 6830
0,01
5347 ± 7377
3130 ± 4764
0.01
ESR (0-20 mm/h)
56,8 ± 35,1
31,3 ± 17,8
<0,01
51,22 ± 33,54
34,55 ± 27,19
<0,01
56,8 ± 34,6
38,8 ± 27,6
<0,01
P2074 Anti-interleukin-1 prescription in adult patients with familial Mediterranean
fever: a real-life study from the French national reference center
Antoine Fayand1, Léa Savey1, Véronique Hentgen2, Pierre Quartier3, Claude Bachmeyer1,
Joris Galland1, Serge Amselem4, Camille Louvrier4, Irina Giurgea4, Gilles Grateau1,
Sophie Georgin-Lavialle1 and French National Reference Center for Autoinflammatory
Diseases
1Internal Medicine, AP-HP, Tenon Hospital, PARIS; 2General Pediatry, CH Versailles,
André Mignot, Versailles; 3Pediatric Rheumatology, AP-HP, Necker Hospital; 4Medical
Genetics, AP-HP, Trousseau Hospital, PARIS, France
Correspondence: Sophie Georgin-Lavialle
Introduction: Familial Mediterranean fever (FMF) is the most common monogenic auto-inflammatory
disease in the world. Long-term treatment of the disease is based on daily intake
of colchicine, which has proven its effectiveness in the occurrence of acute attacks
and AA amyloidosis. In cases of poor tolerance, ineffectiveness or contraindication,
anti-interleukin-1 (IL-1) biotherapies have been effectively tested.
Objectives: To report on the experience of using IL-1 biotherapies in real life among
FMF patients followed in the French National Reference Centre (NRC).
Methods: All French adult FMF records were reviewed; for those receiving or having
received IL1 biotherapy, the all medical file was available.
Results: Among the 603 FMF patients, 3.5% (n=21) were included (12 women/9 men); 81%
displayed M694V homozygous MEFV mutation and 13 had AA amyloidosis. Anti-IL1 biotherapy
used were: anakinra (n=20) and canakinumab (n=2)0. Colchicine was maintained in 18
patients at a median dose of 1 mg/d.
The prescription of IL1 biotherapy was justified by:
1/ AA amyloidosis responsible for renal failure that did not allow the colchicine
dose to be increased: n=13 (2.2% of the overall FMF population);
2/ Insufficient control with colchicine: n=4 (0.7%)
3/ Coexistence of an inflammatory or neoplastic disease participating in the poor
control of FMF: n=4 (0.7%);
3/ In one patient, renal failure on AA amyloidosis and colchicine resistance coexisted.
In all our patients, the use of anti-IL1 has allowed clinical and biological control
of their disease. There was no evidence of poor tolerance of anti-IL1 except for reactions
at injection sites for anakinra and weight gain.
Conclusion: In our clinical experience, the first cause of prescription of anti-IL1
biotherapy is the existence of AA amyloidosis with renal failure, which corresponds
to more than half of the indications and 2.2% of FMF patients followed on our CNR.
Colchicine resistance is lower than expected, 1% of our patients, compared to 5 and
10% that were recently published. This can be explained by potential “false resistances”
to be eliminated as a priority: either poor compliance or insufficient dosage. Finally,
in the case of true resistance to colchicine, our patients displayed another inflammatory
disease associated to FMF.
In conclusion, situations constituting an indication for IL1 biotherapies in FMF are
rare (3.5% of patients) and their prescription requires great vigilance on the part
of the clinician, which is why they should always be the subject of a collegial discussion,
after having eliminated all organic causes of FMF deregulation.
Disclosure of Interest
A. Fayand: None Declared, L. Savey: None Declared, V. Hentgen: None Declared, P. Quartier:
None Declared, C. Bachmeyer: None Declared, J. Galland: None Declared, S. Amselem:
None Declared, C. Louvrier: None Declared, I. Giurgea: None Declared, G. Grateau:
None Declared, S. Georgin-Lavialle Consultant for: SOBI and NOVARTIS
P2075 Effectiveness of anti-IL6 drug (Tocilizumab) in pulmonary alveolar proteinosis
associated to severe persistent systemic inflammation: a case report
Ilaria Gueli1, Roberta Caorsi1, Oliviero Sacco2, Donata Girosi2, Gian Michele Magnano3,
Angelo Ravelli1, Marco Gattorno1, PaoloPicco1
1Rheumatology Unit; 2Pulmonology Unit; 3Radiology Unit, Giannina Gaslini Institute,
Genoa, Italy
Correspondence: Ilaria Gueli
Introduction: Pulmonary alveolar proteinosis (PAP) consists in accumulation of pulmonary
surfactants in the alveolar space. It is supposed to be caused by reduced number and/or
impaired function of alveolar macrophages, with resultant reduced clearance of surfactant.
It could be an autoimmune, a congenital or a secondary disease associated to a very
large spectrum of pathologies and has recently been described as an extremely rare
but potentially fatal complication of systemic juvenile idiopathic arthritis (sJIA).
We describe a case of a very severe and persistent systemic inflammation complicated
by PAP who had a dramatic recovery and also an improvement of lung injury, under anti
IL6-treatment with Tocilizumab.
Results: Case report: A 14-year-old boy has been affected by a very severe systemic
inflammation (flares of fever, generalized lymph-nodes enlargement, rash, fugacious
small joints arthritis, increase of blood acute phase reactants), with features consistent
with sJIA, since the age of 11. Once malignancies were ruled out (bone marrow examination;
lymph-node biopsy; total body PET), systemic steroid was started (prednisone 1mg/kg/die)
with only a transient benefit, as he relapsed during the progressive tapering. Among
the tried treatments used in association with steroids (Cyclosporine; Micophenolate
Mofetil; Anakinra), only high-dose Canakinumab (300 mg/4 weeks) lead to a complete
disease control. In the following months steroid tapering was performed with disease
flares at low steroids doses. Due to parental decision, Canakinumab was discontinued
and alternative medicine was followed for at least nine months. During this period
the patient presented a very severe inflammatory relapse, which was complicated by
pulmonary manifestations, such as dry cough and dyspnea. Radiological images (chest-TC),
functional test (DLCO with moderate impairment of predicted value, 49%; spirometry
with mild restrictive alteration) and, finally, lung biopsy, lead to the diagnosis
of PAP. Anti-IL6 drug (Tocilizumab, 10mg/kg), was started with dramatic response both
on systemic inflammation and on pulmonary impairment (cough resolution, no dyspnea,
DLCO with mild impairment of predicted value, 70%). Maintenance therapy with Tocilizumab
led to long-term clinical stability.
Conclusion: Secondary PAP could be a severe complication of persistent and uncontrolled
systemic inflammation and may respond to treatment of the underlying disease. Both
IL-1 and IL-6 inhibitors are effective in systemic inflammation diseases such as sJIA;
though, their possible direct causative role in the occurrence of PAP has been proposed.
Anyway, the case we presented showed anti IL-6 treatment (Tocilizumab) being effective
either on systemic inflammation and on lung impairment, leading to a long-term control
of such a severe respiratory complication. In conclusion anti IL-6 treatment could
be an effective choice in severe lung complications of systemic inflammatory diseases,
such as PAP.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2076 Is fibrodysplasia ossificans progressiva an interleukin-1 driven auto-inflammatory
syndrome?
Ruby Haviv1, Veronica Moshe1, Noa Rabinowicz1, Giusi Prencipe2, Fabrizio De Benedetti2,
Yosef Uziel1
1Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center and Sackler
School of Medicine (Tel-Aviv University), Kfar Saba, Israel; 2Division of Rheumatology,
Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
Correspondence: Ruby Haviv
Introduction:
Fibrodysplasia ossificans progressiva (FOP) is a very rare condition. It is the most
catastrophic form of heterotopic ossification, caused by ongoing intra-cellular signaling
through the bone morphogenic protein (BMP) pathway, which results in chondrocyte formation
and complete ossification of soft tissues. The ACVR1/ALK2 gene produces the Activin
1 receptor, which serves as the heterodimer of the BMP type I receptor. The typical
R206H activating mutation occurs within the highly conserved glycine-serine region
of the cytoplasmic domain, adjacent to a protein kinase domain.
Painful, soft tissue swellings usually appear by the age of 3-4 years, but the typical,
bilateral deformity of the large toes can be noted at birth. Average life expectancy
is 45 years. Morbidity and mortality are commonly related to ankylosis of the temporomandibular
joints and thoracic insufficiency syndrome.
Currently, no treatment has proven effective. Some use anti-leukotrienes, non-steroidal
anti-inflammatory drugs, and other agents, as prophylaxis. When swelling appears,
corticosteroids, along with bisphosphonates, are usually used. Anti-TNFa agents were
reported unsuccessful.
The recurrent paroxysmal appearance of local tender swellings, with erythematous skin,
which partially react to anti-inflammatory agents, accompanied by elevated inflammatory
markers during flares, suggest that FOP might be an auto-inflammatory disease. We
hypothesized that treatment with anti-interleukin-1 (IL-1) agents helps ameliorating
progression of this devastating disease, and report our experience.
Objectives: To try lowering the rate of FOP paroxysms, and/or limit symptoms and residual
lesions, with anti-IL-1 agents in one patient with FOP.
Methods: Patient’s clinical data and blood IL-1b levels were analyzed to characterize
the effects of anti-IL-1 treatments in ameliorating the natural progression of FOP
Results: A 13.5-year-old Arab male was diagnosed with FOP, clinically and genetically
(the typical R206H mutation was found). Treatment with high-dose corticosteroids,
pamidronate infusions, and daily celecoxib and monteleukast did not affect the course
of the disease, and new swellings, lasting 5-7 days, continued to appear, at an approximate
rate of one new swelling every 8 days. Anakinra treatment was commenced (100mg/day,
as the patient weighed more than 100 kg). After marked improvement was noted during
a 2-month period, with no side effects, he was switched to monthly canakinumab (300mg/dose)
for 5 months. Markedly lower rate of flare-ups was documented (a new swelling every
22-25 days), with shorter duration (2-3 days). The swellings were smaller and easier
to control, with shorter courses of methylprednisolone during flares. Treatment was
withdrawn, but renewed after 6.5 weeks, due to appearance of a large swelling below
his left scapula. High plasma levels of IL-1b were found during this flare (18.17-21.52pg/ml).
In contrast, the 3 previous blood samples, obtained during treatment with anakinra
or canakinumab, showed undetectable IL-1b levels (<0.125pg/ml), (Figure).
Conclusion: This case may suggest, that FOP flares are mediated by IL-1, and that
FOP may be included under the umbrella of auto-inflammatory syndromes. Anti-IL-1 agents
might have a role in ameliorating the natural progression of FOP. Further exploration
and international experience with additional FOP patients are needed.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2077 Kawakinra: a phase IIA multicenter trial to assess the efficacy, and safety
of anakinra in patients with intravenous immunoglobulin-resistant Kawasaki disease
Isabelle Koné-Paut1, Stephanie Tellier2, Karine Brochard2, Virginie Lambert3, Corinne
Guitton1, Alexandre Belot4, Perrine Dusser1, Linda Rossi-Semerano1, Isabelle Marie1,
Gregory Allain5, Helene Agostini5, Celine Piedvache5
1Pediatric Rheumatology, APHP, Bicetre Hospital, Le Kremlin Bicêtre; 2Pediatrics,
CHU Purpan, Toulouse; 3Pediatric Cardiology, Montsouris Institute, Paris; 4Pediatric
Rheumatology, CHU Lyon, Lyon; 5Clinical Research Unit, APHP, Bicetre Hospital, Le
Kremlin Bicêtre, France
Correspondence: Isabelle Koné-Paut
Introduction: The development of more potent therapeutic approaches of KD is an urgent
need because intravenous immunoglobulin (IVIg) treatment is not effective in 20% of
patients, increasing the risk of coronary dilatations/ aneurysms. The combination
of genetic and transcriptomic data revealed the key role of interleukin-1 (IL-1) signaling
in KD vasculitis and mouse model of KD has shown that anakinra (IL1RA: IL-1R1receptor
antagonist) could prevent the development of vascular aneurysms.
Objectives: To assess as primary objective, the efficacy of anakinra in patients with
KD who fail to respond to at least one infusion of 2g/kg of IVIg
To assess as secondary objectives, its safety and tolerability and its effect on disease
activity, systemic inflammation and coronary lesions.
Methods: A 45-day, phase IIa proof of concept study open labeled with anakinra dose
escalation, with a target of at least 12 patients completing the study Eligible patients
had KD according to the AHA criteria, duration of fever ≤ 14 days, and were ≥ 3 months
and 5 Kg. They had persistent (or relapsing) fever (≥38°C) within 48h of the last
IVIG infusion, had not received other alternative treatment including steroids, and
had no others exclusion criteria. After informed consent, they received a starting
dose of 2mg/kg (patients <10kg and/or <8 months: 4mg/kg) of anakinra, which could
be increased every 24h of 2mg/kg until a maximum of 6mg/kg (patients <10kg and/or
<8 months: 8mg/kg), in case of persistent fever. Anakinra treatment duration was 15
days. Outcome measures were fever, KD symptoms, blood inflammation and cardiac echography.
Total study duration was 45 days. Clinical trials: NCT02390596. The study is supported
by a grant from the French ministry of health, APHP, national PHRC 2014. IRB approval
was obtained and all patients (parents) gave informed consent.
Results: 18 patients were screened and 16 were included and 13 have completed the
study. Anakinra was started in 16 patients (14 boys, 2 girls) at a median age 2 years
(3 months to 6 years) and at a median of 9.5 days after the onset of fever. 4 patients
escaped early for SAE, and 1 had sJIA final diagnosis. The maximum dose of anakinra
was 6mg/kg in 6 patients, 4mg/kg in 6, and 2mg/kg in 4. Mean PGA decreased from 7.80
(4-10) to 1.2 (0-3) at D14. Median temperature was 37.6°C (36.7-39.7) at day 3 and
37.2°C at D7 (36.7- 37.9)). Median CRP was 135mg/L at screening and decreased to 9.5
mg/L at D7. 8/14 evaluated patients had coronary dilatation (Z score max ≥2.5mm) at
inclusion, 5/14 at D14 and 3/14 at D45. 3/14 patients who increased Z score at D14
decreased it at J45. We observed 3 severe adverse events (SAE) where treatment was
discontinued: anakinra overdose, MAS in a patient evolving to sJIA and increase of
coronary dilatation. Others AE included cytolytic hepatitis (2 patients), hypereosinophilia
(1), injection site reaction (1) and pancreatitis (1) without treatment discontinuation.
Conclusion: We have realized the first experimental trial assessing IL-1 blockade
in severe refractory KD. 15 day-duration of anakinra treatment, given early in the
course of IVIG-resistant KD, was rapidly effective on KD symptoms, biologic inflammation
and coronary dilatations in almost all patients, with a good tolerability. This study
calls for further investigation of IL1 blockade in KD.
Disclosure of Interest
I. Koné-Paut Grant / Research Support from: SOBI,Consultant for: SOBI, S. Tellier:
None Declared, K. Brochard: None Declared, V. Lambert: None Declared, C. Guitton:
None Declared, A. Belot: None Declared, P. Dusser: None Declared, L. Rossi-Semerano:
None Declared, I. Marie: None Declared, G. Allain: None Declared, H. Agostini: None
Declared, C. Piedvache: None Declared
P2078 Continuous effectiveness of canakinumab treatment in Schnitzler’s syndrome:
a 4-year open-label multi-center study
Karoline Krause1, Hanna Bonnekoh1, André Ellrich1, Athanasios Tsianakas2, Nicola Wagner3,
Jörg Fischer4, Marcus Maurer1
1Charite - Universitaetsmedizin Berlin, Berlin; 2Universitätsklinikum Münster, Münster;
3Klinikum Erlangen, Erlangen; 4Universitätsklinik Tübingen, Tübingen, Germany
Correspondence: Karoline Krause
Introduction: Schnitzler’s syndrome (SchS) is a prototype adult-onset autoinflammatory
disease characterized by urticarial exanthema and monoclonal gammopathy combined with
systemic inflammatory symptoms. We have previously reported the efficacy of canakinumab
treatment in a 4-month randomized placebo-controlled multi-center study involving
20 patients with SchS.
Methods: All patients who successfully completed the initial 4-month trial were eligible
to enter an open-label study extension for a maximum period of 4 years. Patients received
canakinumab 150 mg or 300 mg injections as needed based on individual disease activity
and response to treatment within the first 4 months. Efficacy was monitored by changes
in disease activity (physician global assessment [PGA; range 0-20]), inflammation
markers (C-reactive protein [CRP], serum amyloid A [SAA]) and quality of life (DLQI,
SF-36). Safety assessment included adverse event reporting and routine clinical and
laboratory assessments.
Results: A total number of 17 patients entered the open-label extension of the study.
Of these, 15 patients completed the whole study period of 4 years.
During this study, continuous effectiveness of canakinumab treatment was demonstrated
by significantly lower PGA scores as compared to baseline scores throughout the study.
The clinical response was mirrored by normalized inflammation markers CRP and SAA
in most patients and stabilized quality of life as determined by DLQI and SF-36. Relapse
of symptoms was rare and occurred after canakinumab interruption or infections.
During the open-label extension of the study, seven serious adverse events (SAEs)
were noted. These included infections such as pneumonia and sepsis in two elderly
patients, one of them with fatal outcome. Also, one patient developed plasmocytoma
and left the study.
Conclusion: In this long-term open-label study, canakinumab treatment provided continuous
symptom control in most patients. Canakinumab may be considered a therapeutic option
in these patients but requires close monitoring for potential infections.
Disclosure of Interest
K. Krause Grant / Research Support from: Novartis, Roche,Speaker Bureau of: Novartis,
Roche, SOBI, H. Bonnekoh: None Declared, A. Ellrich: None Declared, A. Tsianakas:
None Declared, N. Wagner: None Declared, J. Fischer: None Declared, M. Maurer: None
Declared
P2079 Long-term effectiveness of canakinumab in patients with monogenic periodic fever
syndromes – first interim analysis of the CAPS subgroup
Jasmin B. Kuemmerle-Deschner1, Norbert Blank2, Michael Borte3, Ivan Foeldvari 4, Gerd
Horneff5, Prasad Oommen6, Catharina Schuetz7, Frank Weller-Heinemann8, Julia Weber-Arden9,
Tilmann Kallinich10
1Pediatrics, University Hospital Tuebingen, Tuebingen; 2Rheumatology, University Hospital
Heidelberg, Heidelberg; 3ImmnoDeficiencyCenter, Hospital St. Georg, Leipzig; 4Center
for Pediatric and Adolescence Rheumatology, Hamburg; 5Asklepios Clinic, Sankt Augustin;
6Pediatrics, University Hospital Duesseldorf, Duesseldorf; 7Pediatric Immunology,
University Hospital Carl Gustav Carus, Dresden; 8Pediatric Rheumatology, Prof. Hess
Kinderklink, Bremen; 9Novartis Pharma GmbH, Nuremberg; 10Pediatrics, Charité University
Hospital, Berlin, Germany
Correspondence: Jasmin B. Kuemmerle-Deschner
Introduction: Treatment options for autoinflammatory diseases include anti-interleukin
(IL)-1 therapies and IL1 inhibitors since the IL-1 pathway is crucial in immune dysregulation
in patients with monogenic periodic fever syndromes.
Objectives: The aim is to gain further insights from routine clinical practice with
respect to long-term effectiveness and safety of canakinumab (CAN) in pediatric and
adult patients with CAPS (cryopyrin-associated periodic syndrome, including Muckle-Wells
syndrome [MWS], familial cold autoinflammatory syndrome [FCAS], neonatal onset multisystem
inflammatory disease [NOMID]/chronic infantile neurological cutaneous and articular
syndrome [CINCA]), FMF (familial Mediterranean fever), TRAPS (tumor necrosis factor
receptor-associated periodic syndrome) and HIDS/MKD (hyperimmunoglobulinemia D syndrome/mevalonate
kinase deficiency).
Methods: RELIANCE is a prospective, non-interventional, multi-center, observationalstudy
based in Germany with a 3-year follow-up enrolling pediatric (age ≥2 years) and adult
patients with clinically confirmed diagnoses of CAPS, FMF, TRAPS and HIDS/MKD who
routinely received CAN. 6-monthly clinical assessment and evaluation of patient-reported
outcomes is aligned with routine clinic visits. The endpoints will assess the effectiveness
and safety of CAN under standard clinical practice conditions.
Results: The interim analysis includes 52 CAPS patients with prior long-term CAN treatment
(43.1% females) enrolled by September 2018. 44.2% of the patients participated in
the β-Confident studypreviously. The mean age was 20.7 years (4.0–79.0 years) at baseline
and the mean duration of prior CAN treatment was 5.4 years (0.0–11.0 years). 40 patients
(76.9%) were diagnosed with MWS, the other patients had FCAS (2), NOMID/CINCA (7)
or atypical CAPS (1). CAPS disease activity was determined by physicians’ and patients’
assessment of disease activity at baseline and 6 months (table 1) demonstrating sustained
remission in patients receiving long-term CAN treatment. Serious adverse events were
reported for 2 patients including a case of tonsillitis and a preterm birth at week
31.
Conclusion: TheRELIANCE study longitudinally monitors the effectiveness of CAN in
patients with monogenic periodic fever syndromes. An initial interim analysis including
the CAPS subgroup which had prior CAN treatment showed that CAN is an effective and
safe treatment in those patients.
Disclosure of Interest
J. Kuemmerle-Deschner Grant / Research Support from: Novartis, SOBI,Consultant for:
Novartis, SOBI, N. Blank Grant / Research Support from: Novartis, SOBI,Consultant
for: Novartis, SOBI, M. Borte Grant / Research Support from: Novartis, Pfizer, Shire,
I. Foeldvari Grant / Research Support from: Novartis,Consultant for: Novartis, G.
Horneff Grant / Research Support from: Abbvie, Chugai, Roche, Pfizer, MSD, Novartis,Speaker
Bureau of: Chugai, Novartis, BMS, P. Oommen Grant / Research Support from: Novartis,
C. Schuetz Grant / Research Support from: Novartis, F. Weller-Heinemann Grant / Research
Support from: Novartis, J. Weber-Arden Employee of: Novartis, T. Kallinich Grant /
Research Support from: Novartis
Table 1 (abstract P2079).
Disease activity by physicians’ and patients’ assessment
Baseline, all patients, N=52
Baseline, analysis cohort, N=31
Month 6, analysis cohort, N=31
Disease activity by physicians’ assessment:
absent, mild/moderate, severe, % of patients
Urticarial skin rash
71.4, 20.4,4.1
67.7, 19.4, 6.5
74.2, 25.8, 0.0
Arthralgia
67.3, 30.6, 2.0
67.7, 32.3, 0.0
61.3, 29.0, 9.7
Myalgia
91.8, 6.1, 0.0
87.1, 9.7, 0.0
83.9, 16.1, 0.0
Conjunctivitis
71.4, 26.5, 2.0
64.5, 32.3, 3.2
77.4, 12.9, 6.5
Headaches
69.4, 22.4, 6.1
64.5, 22.6, 9.7
61.3, 19.4, 19.4
Abdominal pain
81.6, 14.3, 4.1
83.9, 9.7, 6.5
67.7, 22.6, 9.7
Patients’ assessment
Mean disease activity, visual analog scale (VAS) 0–10
2.1
2.0
1.8
Mean Fatigue, VAS 0–10
2.6
2.5
2.7
Impairment of social life, %
52.6
54.5
24.0
P2080 The effectiveness of anti-TNF therapy in association of familial Mediterranean
fever and ankylosing spondylitis
Sevgi Atar, Baris Colak, Omer Kuru
Departmant of Physical Medicine and Rehabilitation Division of Rheumatology, University
of Health Sciences, Istanbul Okmeydani Research and Training Hospital , Istanbul,
Turkey
Correspondence: Omer Kuru
Introduction:
Familial Mediterranean Fever (FMF) among most of Mediterranean Mediterranean peoples,
especially it’s a disease that is seen between Turkish, Arab, Spanish Jews and Armenians,
with increased acute phase reactants, acute inflammation of serous membranes such
as recurrent peritoneum, pleural and synovium, fever and self-limiting attacks. It
is an otosomal recessive disease. The interval between attacks is unclear, and it
is difficult to predict the attacks.
As with different attacks, different symptoms may be seen in different patients. The
disease occurs for the first time in childhood or young adulthood. The onset of the
disease after the fourth decade is very rare. Although some studies have reported
that men are more frequent (M / F: 1.5-2 / 1) by the Turkish FMF study group showed
that similar rates in both sexes (M / F: 1,2 / 1).
Ankylosing spondylitis (AS) is a chronic rheumatic disease primarily affects axial
skeleton, characterised by inflammatory back pain and stiffness in the morning. AS
is associated with FMF was related to gene mutations. It is also thought to increase
the prevalence of ankylosing spondylitis or spondyloarthritis in FMF patients.
Objectives:
In this study, we aimed to discuss the improvement in clinical and laboratory findings
of anti-TNF treatment in the perspective of literature with the association of FMF
and AS, prolonged fever and serositis attacks in spite of high doses of colchicine.
Methods:
Case:
46-year-old female patient had abdominal pain, diarrhea, nausea and vomiting for 5
days in last 2 years. She had not fever attacks, concomitant joint pains and low back
pain. Colchicum dispert used 1.5 mg / day. There was no alcohol and no smoking. Her
past medical history revealed that she had familial acute fever and her sister passed
on hypertension and thyroid disease. Except for erythrocyte sedimentation rate and
high C-reactive protein levels, no additional features were detected in laboratory
tests. Anti-TNF (etanercept) treatment was started.
Results:
Patient had no episode during 1st month and 3rd month control. Erythrocyte sedimentation
rate and C-reactive protein values were found to be regressed.
Conclusion:
In our case, we achieved clinical improvement with anti-TNF in acute attacks of FMF.
We believe that this treatment efficacy should be investigated with larger prospective
studies.
Key words: anti-TNF therapy, familial mediterranean fever
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2081 Desensitization to anakinra in refractory recurrent pericarditis
C. Longo1, S. Signa1, M. D'Alessandro1, M. Bustaffa1, R. Consolini2, M. Tosca3, L.O.
Mendonça4, A. Ravelli1,5, R. Caorsi5, M. Gattorno5
1Department of Pediatrics, Università degli studi di Genova, Genoa; 2Department of
Pediatrics, Università degli studi di Pisa, Pisa; 3U.O. Pneumologia, G. Gaslini Institute,
Genoa, Italy; 4Clinical Immunology and Allergy Department, HC-FMUSP, Sao Paulo, Brazil;
5Clinica Pediatrica e Reumatologia, G. Gaslini Institute, Genoa, Italy
Correspondence: C. Longo
Introduction: Recurrent pericarditis (RP) is a possible complication of acute pericarditis
(15–30%). It can be idiopathic or it can occur after a pericardial procedure (post-pericardiotomic).
First line treatment consists of a combination of high-doses of NSAIDs with colchicine;
corticosteroids represent the second line in resistant or intolerant cases. Different
biologics and immunosoppressant have been used as third line treatment, with variable
responses: by now the most promising results have been obtained with anakinra, enlightening
the possible role of IL-1 in the pathogenesis of this condition.
Objectives: To describe the clinical course and the outcome of desensitization procedure
to anakinra in a patient with steroid-dependent pericarditis, who withdrawn anakinra
for adverse reactions and did not respond to IL-1β blockade with canakinumab.
Methods: A 9-years old girl started to complain with recurrent pericarditis at the
age of 6 years old, after surgical correction of an atrial septal defect. NSAIDs were
not effective and colchicine was withdrawn for intolerance; oral steroids were started
with good response, then gradually tapered, with prompt relapse after the steroid
discontinuation, requiring pericardiocentesis. The child showed a steroid-dependent
course of the disease, with several relapses after tapering attempts. In March 2016,
after 5 relapses, anakinra (2 mg/kg/day) was started with a fast and complete clinical
response; however, it was discontinued after 2 weeks for the appearance of severe
local side effects. She was firstly evaluated in our Center in April 2016; in July
2016 therapy with canakinumab 150 mg (4 mg/kg) every 4 weeks was started. She experienced
four relapses during this treatment (July 2016 -December 2017), following every attempt
to reduce steroidal dosage, despite the modification of the schedule (4 mg/kg every
three weeks) and the reintroduction of colchicine. Due to inadequate response, canakinumab
was withdrawn and, in light of the effectiveness previously demonstrated by anakinra,
it was decided, after an allergologic consultation, to attempt to reintroduce this
therapy, performing a process of desensitization as reported by Mendonca et al (J
clin immunology, 2017).
Results: In January 2018 desensitization to anakinra was started. The patient received
five to three consecutive injections per day of gradually increasing anakinra doses
and dilutions from days 1 to 9. Each injection was spaced by 15 minutes intervals,
raising the dose at each step. On Day 2, due to the appearance of skin reactions at
injection site, it was decided to enlarge the interval between the injections (30
minutes) and increase the dilution, restarting desensitization protocol. The full
target dosage (80 mg/day; 2mg/kg/day) at standard dilution (divided in 4 different
administrations) was reached on Day 8. Since Day 11 anakinra was administrated twice
a day, once a day after one month. Antihistaminic and steroids were administrated
during all the desensitization process, then discontinued, without recurrence of both
skin reactions and disease manifestations. In June 2018 low-dose colchicine was progressively
tapered and finally discontinued.
Conclusion: Desensitization process to anakinra allowed to achieve full control of
the disease in a patient with severe refractory recurrent pericarditis, not responding
neither to first line treatment nor to IL-1β blockade and becoming steroids-dependant.
Even further data are required, the divergent response to the two antagonists of IL-1
could suggest a prominent role of IL-1α in the pathogenesis of this disease.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2082 One decade real life experience with anti-IL1 therapy in monogenic and multifactorial
autoinflammatory diseases
Leonardo O. Mendonca, Andressa Guariento, Roberta Caorsi, Sara Signa, Ilaria Gueli,
Angelo Ravelli, Marco Gattorno
Pediatric Rheumatology Clinic, Istituto Giannina Gaslini, Genoa, Italy
Correspondence: Leonardo O. Mendonca
Introduction: The immunological concept of autoinflammation made possible genetic
dissection of inflammation, development of new cytokine target therapies and catalogue
the a.k.a. Autoinflammatory Diseases (AID). However, in 50% or more, no causative
gene can be found going down to Undefined Inflammatory Syndromes (UIS). The identification
of the pathogenic mechanisms related to most of the monogenic and multifactorial auto
inflammatory diseases prompted the evidence of IL-1 as a crucial target for treatment.Moreover,the
success of these treatments in the most frequent autoinflammatory diseases, suggested
their off-label use in many other rare conditions, including in the undifferentiated
AID.
Objectives: This paper aims to retrospectively report 10 years experience with different
IL-1 blocking agents in monogenic and non monogenic disorders in a single, pediatric
reference center in Italy.
Methods: All patients followed by the Pediatrics and Rheumatology Unit ogf Gaslini
Institutewho start an anti-IL1 treatment , from 2005 to 2018 were retrospectively
reviewed. Patient’s descriptive characteristics were reported as mean, standard deviation,
minimal and maximum values. The variables associated with response in the univariate
analysis (p<0.20) were included in the multivariate model.
Results: From 2005, 108 consecutive patients receive at least one anti-IL-1 treatment,
namely Anakinra or Canakinumab. Among monogenic AID (60,1%), 18% were CAPS, 16% TRAPS,
13% Hyper IgD/MKD, 8% PAPA, 1% DADA2. Anti-IL1 was also used in many multifactorial
conditions, mainly SJIA (n=51), undefined SAID (n=18), and recurrent recurent idiopathic
pericarditis (n=6) and one patient with SAPHO syndrome. Among the monogenic forms,
CAPS, TRAPS and Mevalonate Kinase Deficiency, that started on anakinra (n=19) 73,7%
(n=14) achieved a complete or partial control of their condition. Switching to canakinumab
(n=12) or starting direct with canakinumab (n=9) resulted in 85% of disease control.
UIS presented high rate of response to anakinra, 75% versus 52% of SJIA. Biologic
drug could be discontinued in 6 patients after clinical remission. Just one patient,
with severe phenotype of MVK did not achieve clinical control with anakinra and was
successfully submitted to HSCT. In the univariate model, using p value <0,20 , statically
difference could be obtained with the following characteristics: symptoms started<1
year, presence of chest pain, macrophage activation syndrome, pericarditis, periodic
fever, poliartrhitis and psoriasis. Using the multivariate model, just periodic fever
remained as a positive predictor of response to anti-IL1 and the presence of poliartrhitis
remained as a negative predictor.
Conclusion: Different anti-IL1 strategies can be used to disease control for the monogenic
forms of AID as well as for undefined AID.
Disclosure of Interest
None Declared
P2083 A prospective outcome of all 17 consecutive pediatric patients with chronic
nonbacterial osteomyelitis treated with intravenous pamidronate and followed at a
single center over 15 years
Paivi Miettunen1, Chloe M. Stephenson1, Seamus L. Stephenson1, XIng-Chang Wei2
1Pediatrics; 2Radiology, University of Calgary, Calgary, Canada
Correspondence: Paivi Miettunen
Introduction:Intravenous pamidronate ( IV-PAM) has been reported to be effective in
pediatric patients with severe chronic nonbacterial osteomyelitis (CNO)in short term. Little
is known about longterm outcome in CNO after IV-PAM.
Objectives: To describe a consecutive series of pediatric CNO (pCNO) patients who
were prospectively followed after treatment with IV-PAM between 2003-2018 at a single
center regarding: 1) The effect of IV-PAM on pain and Whole Body Magnetic Resonance
Imaging (WBMRI) documented inflammation initially and after flare; 2) Relapse rate
and; 3) Spinal CNO outcome and4) Urine N-telopeptide/creatinine ratio (UNtx/Cr, a
product of collagen 1 breakdown) correlation with active CNO.
Methods: Patients: All pCNOpatients (age at diagnosis <18 years) with WBMRI confirmedactive
disease who required at least one dose of IV-PAM between 2003-2018 were included.
IV-PAM dosing: 0.5 mg/kg (maximum 30 mg) for the first dose and 1 mg/kg (maximum 60
mg) for all subsequent doses (maximum annual dose 11.5 mg/kg). The initial IV-PAM
was administered once monthly x 9; with potential flares IV-PAM was given until resolution
of pain and/or resolution/stabilization of CNO lesions on imaging (max 9 doses/year).
Pain response: Visual analogue scale for pain (VAS) with “0” indicating no pain and
“10” maximum pain was administered at baseline, at each IV-PAM treatment, and at suspected
flare.
Imaging:WBMRI was administered before 1st IV-PAM, at 6 and 12 months, at suspected
flare and after retreatment. CNO resolution was documented as complete (CR) if there
was 95% improvement in the WBMRI signal, as partial resolution (PR < 95 % improvement),
or as no response. Spinal x-rays were performed at baseline and then yearly.
UNtx/Cr was measured at baseline, after each IV-PAM and with suspected flare.
Results: 17 patients (9F, 8M) were included. The median [range] age at CNO diagnosis
was 10.3[4-15] years, and at first IV-PAM 11.6[4-20] years. The median [range] follow-up
was 9.2[1-15] years. Six patients had unifocal CNO, (n=1 femur, 1 radius, 3 mandible,
1 clavicle), 4 had spinal CNO (3 with extraspinal sites, 2 with baseline vertebral
fractures) and remaining 6 had multifocal non-spinal CNO. VAS was uniformly 10/10
at baseline and decreased to 0-1/10 within first month after IV-PAM. CR was achieved
by all at 6 months, which persisted at 12 months. Four patients, 3 unifocal and one
multifocal, had no further flares. Twelve patients had WBMRI confirmed flare at previously
active sites at 9-36 months and 11 received 1-9 further doses of IV-PAM. With flare,
VAS ranged from 4-9/10 and decreased to 0-3/10 within first month after re-initiation
of IV-PAM.On final WBMRI, 12/17 (70%) had CR and 5/17 (30%) stable mild increased
signal but no clinical symptoms. No further spinal compression fractures occurred.
One patient required a third course of IV-PAM. Regarding UNtx/Cr, each patient hadappropriate
reduction after first IV-PAM. No patients flared whileUNtx/Cr remained suppressed.
Three patients developed arthritis and one acne. At last follow-up, 10/17 (59%) patients
were on no medications, 4/17 (24%) required prn Naproxen for CNO and 3/17 (18%) were
on Naproxen and/or disease modifying medications for arthritis.
Conclusion:Long-term follow-up ofpCNO patients treated with IV-PAM confirms that while
severalpatients eventually flare, the flares are less painful and have an excellent
response to IV-PAM retreatment. No further spinal fractures occurred . No flares occurred
while UNtx/Cr remained suppressed, suggesting a role of osteoclasts in CNO. Further
prospective multicenter studies are now required to define the long-term clinical
and imaging response to IV-PAM.
Disclosure of Interest
None Declared
P2084 Efficacy of anakinra in the treatment of recurrent idiopathic pericarditis in
pediatric population: experience in a tertiary hospital
Sara Murias1, Luis García-Guereta2, Rosa Alcobendas1, Diana Salas2, Clara Udaondo1,
Pablo Fernandez1, Catarina Fervenza1, Agustin Remesal1
1Pediatric Rheumatology; 2Pediatric Cardiology, University Hospital La Paz, Madrid,
Spain
Correspondence: Sara Murias
Introduction: Although there is growing evidence on the efficacy of anakinra in the
treatment of recurrent pericarditis, its use in pediatric patients is still very limited.
Objectives: Our aim is to review the experience of our center in the use of this therapeutic
option in children with recurrent pericarditis who did not respond to classical therapy.
Methods: Descriptive study of a series of cases by collecting data through the clinical
history.
Results: 7 patients were included (6 girls, 1 boy). All of them presented recurrent
symptomatic pericarditis with poor outcome despite several treatments (ibuprofene,
colchicine, steroids).
All had a quick response to treatment with complete resolution of systemic and cardiologic
symptoms, associated to normalization of laboratory parameters thus allowing steroids
withdrawal.
Two out of the three patients in whom anakinra was eventually discontinued required
reintroduction due to recurrences. One remains asymptomatic after two years without
treatment.
Six patients are still on anakinra (variable dosage), with absence of flares and with
no significant side effects.
Conclusion: Anakinra is very useful for the treatment of recurrent pericarditis in
pediatric patients. The good response observed through this sample supports the autoinflammatory
etiopathogenesis of some cases of recurrent pericarditis.
The duration of treatment needs to be prolonged, and its withdrawal may involve flares
that quickly respond to ANK reintroduction.
Disclosure of Interest
None Declared
Table 1 (abstract P2084).
Clinical characteristics of 6 girls and 1 boy with recurrent pericarditis and complete
response to anakinra
Pacient 1
Pacient 2
Pacient 3
Pacient 4
Pacient 5
Pacient 6
Pacient 7
Age at onset (years)
9
11
3
12
15
17
1.2
Time from onset to first ANK use
9
24
12
24
2
2
6
Former therapies
Ibuprofene
Colchicine
Prednisone
Ibuprofene
Dexametasone
Colchicine
Ibuprofene
Prednisone
Colchicine
Ibuprofene
Prednisone
Colchicine
Ibuprofene
Prednisone
Colchicine
Ibuprofene
Prednisone
Colchicine
Indometacine
Colchicine
Prednisolone
Symptoms associated to pericarditis*
Fever
Asthenia
Pleuritis
Peritonitis
Fever
Asthenia
Skin rash
Pleuritis
Fever
Abdominal pain
Pachypleuritis
Fever
Asthenia
Febricula
Pleuritis
Hepatomegaly
CRP (mg/L)*
104
250
162
350
56
150
16
Related disease
No
SoJIA and MAS
No
FMF (mutations M694l and R202Q)
No
Renal trasplantation due to vasculitis
No
CRP (mg/L)**
0.54
0.8
1.63
0.59
2.43
48
Not done yet
Number offlares after starting ANK
0
1 flare, 30 days after ANK withdrawal
0
1 flare, 35 days after voluntarily stopping ANK
0
0
0
Current treatment
None (ANK withdrawn: september 2015)
ANK 100 mg /day
ANK 75 mg every 72 hours
ANK 100 mg/day
ANK 75 mg every 72 hours
ANK 100 mg/day
ANK 50 mg/day
*Maximum values during a typical flare
**First laboratory examinations performed after starting ANK
(ANK: Anakinra. CRP: C-Reactive Protein. SoJIA: Systemic onset Juvenile Idiopathic
Arthritis. MAS: Macrophage Activation Syndrome. FMF: Familial Mediterranean Fever)
P2085 Clinical manifestations and treatment of idiopathic recurrent aseptic meningitis
(IRAM)
Michele Nehrebecky1, David Beck1, Amanda Ombrello1, Ariane Soldatos2, Bryan Smith2,
Patrycja M Hoffman1, Lauren Reoma2, Avindra Nath2, Karyl S. Barron3, Anne Jones1,
Ivona Aksentijevich1, William A. Gahl1, Camilo Toro1, Daniel L. Kastner1
1NIH/NHGRI; 2NIH/NINDS; 3NIH/NIAID, Bethesda, United States
Correspondence: Michele Nehrebecky
Introduction: Idiopathic Recurrent Aseptic Meningitis (IRAM) is an autoinflammatory
syndrome characterized by non-infectious episodic fevers, malaise and meningeal inflammation
associated with cerebral spinal fluid (CSF) pleocytosis, punctuated by symptom-free
intervals.
Objectives: We aim to characterize clinical, imaging, laboratory and molecular features
of a cohort of patients with IRAM, learn about pathophysiological mechanisms and share
our experience with anakinra as a therapeutic option.
Methods: A single center cohort of 12 patients with features of IRAM were evaluated
from the National Institutes of Health’s (NIH) Clinical Center in Bethesda, Maryland.
Ages ranged from 12-74 years (5 females, 7 males) with majority adult onset.Duration
of symptoms prior to NIH evaluation ranged from 4 months to 29 years. The most common
clinical features were recurrent periodic fevers, fatigue, headache, decreased appetite,
sensorineural hearing loss (SNHL), CSF pleocytosis, elevated inflammatory markers
and resolution of symptoms between episodes. Frequency of episodes varied from 1 to
approximately 50 episodes per year.A multidisciplinary evaluation including infectious
disease studies, whole exome sequencing (WES), cranial magnetic resonance imaging,
lumbar puncture and audiologic assessment were performed to further characterize the
phenotype and pathophysiology of the disorder.Symptomatic treatment with the IL-1
receptor antagonist anakinra at a starting daily dose of 100mg subcutaneously was
attempted in six patients.
Results: Whole exome sequencing was performed in all 12 subjects.Diagnoses were confirmed
in 2/12 patients (1 with a pathogenic germline NLRP3 mutation and one subsequently
found to have CNS cysticercosis via detailed infectious studies)
Cranial MRI imaging revealed meningeal enhancement in 2 of the 10 subjects.5 of the
10 subjects had elevated ESR and CRP.Lumbar punctures (performed during acute episodes
in 10) revealed evidence of CSF lymphocytic pleocytosis. PCR for herpes family viruses
was negative in all.Audiology assessment was performed on 6 of the 10 subjects and
revealed SNHL in all evaluated.
For the six patients who received anakinra, dose escalation was required for three
up to 500mg per day.Clinical improvement as defined by reduced frequency and severity
of episodes was reported by four of the six subjects.
Conclusion: Patients with IRAM may represent a molecularly heterogeneous group of
patients with episodic systemic and intrathecal innate immune system activation including
patients with germline NLRP3 mutation.Preliminary observations on the response to
anakinra supports a role of innate immune activation in this disorder and a potential
role of IL-1 inhibition of the management of this condition.
Disclosure of Interest
None Declared
P2086 Autoinflammatory syndrome caused by mutations in TRNT1: successful treatment
of two cases with etanercept
Francesca Orlando1,2, Roberta Naddei2, Carlo Maria Gallinoro2, Daniela Melis2, Maria
Alessio2
1Department of Pediatrics, Santobono-Pausilipon Children’s Hospital; 2Department of
Mother and Child, University of Naples Federico II, Naples, Italy
Correspondence: Francesca Orlando
Introduction:
TRNT1 is a nuclear gene encoding a ubiquitous enzyme (CCA-adding tRNA nucleotidyl
transferase enzyme) necessary for aminoacylation of both mitochondrial and cytosolic
tRNA. TRNT1 mutations are associated to heterogeneous phenotypes and systemic involvement
of variable severity and progression.
Objectives: To characterise clinical features, laboratory assessment and treatment
strategies of two patients affected by an autoinflammatory syndrome caused by TRNT1
mutations.
Methods: The patient 1 (P1) is a twenty years old female. From the first month of
life she experienced recurrent fever associated to painful cutaneous lesions, edema
of the hands, raised inflammatory markers and anemia. The symptoms were moderately
controlled by corticosteroid therapy. One of these episodes was characterized by severe
anemia (Hb 6.6 g/dl), requiring blood transfusion. At the age of 8 months she was
found to have mild hypogammaglobulinemia, but no other alterations were found on immunological
investigations. She showed normalization of the immunoglobulin levels at the age of
22 months. The physical examination found facial dysmorphisms, brittle hair, developmental
delay and microcephaly. Splenomegaly was reported by abdomen ultrasound. Isolated
Growth Hormone Deficiency (GHD) was diagnosticated at the age of 3 years and it was
treated with recombinant human GH (rhGH) for the next 4 years, without improvement.
At the age of 8 years she was diagnosed with bilateral sensorineural hearing loss.At
the age of 10 she was diagnosticated with posterior subcapsular cataract, probably
related to chronic steroid treatment. The patient 2 (P2) is a ten years old female.
From four months of age she suffered from recurrent fever, associated from the age
of 11 months to painful cutaneous lesions. Laboratory assessment showed elevated serum
inflammatory markers, mild anaemia, hypogammaglobulinemia and reduced levels of B-cells.
Growing up, she showed failure to thrive, developmental delay, facial dysmorphisms,
brittle, microcephaly, hepato-splenomegaly and swelling of the right ankle. At the
age of two she was diagnosticated with sensorineural hearing loss and bilateral cataract.
At the age of 5 she started therapy with rhGH for GHD.
Results: Suspecting Chronic Infantile Neurologic Cutaneous and Articular (CINCA) syndrome,
even though negativity of molecular analysis of CIAS1, they started treatment with
anti-IL1 (Anakinra) at the age of 9 (P1) and 2 (P2). Due to the partial response,
P1 shifted to anti-TNFa therapy (Etanercept) at the age of 11 with significant improvement.
P2 showed nonresponse to Anakinra so she shifted to Etanercept after four months.
Whole exome sequencing was performed resulting in two mutation of TNRT1: P1 c.608G>A
(p.Arg203Lys), c.1246A>G (p.Lys416Glu); P2 c.938delT (p.Leu313fs), c.1246A>G (p.Lys416Glu).During
the 9 years follow-up the patients underwent six-month clinical and laboratory assessment,
showing normalization of inflammatory index and resolution of recurrent fever and
associated symptoms.
Conclusion: To date, 34 patients with TRNT1 mutations related disease have been reported,
presenting significant clinical heterogeneity. In this study we extend the cohort
of patients and we report a new mutation (c.938delT).It was recently reported that
treatment with TNF inhibitors has been efficacious in four patients, including three
patients treated with Etanercept for 3 years.We report the longest follow-up in these
patients treated with Etanercept, confirming efficacy and safety of that treatment.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2087 Does colchicine really cause leukopenia?
Erdal Sag1, Yagmur Bayindir2, Aydin Adiguzel2, Selcan Demir1, Yelda Bilginer1, Selin
Aytac3, Seza Ozen1
1Division of Pediatric Rheumatology; 2Department of Pediatrics, Faculty of Medicine,
Hacettepe University, Ankara, Turkey; 3Division of Pediatric Hematology, Department
of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
Correspondence: Seza Ozen
Introduction: FMF is the most common monogenic autoinflammatory disease and colchicine
has been used as the drug of choice for the treatment since 1972. It is a safe drug
when it is used in the suggested dosage however it is associated with certain side
effects. Some case reports suggest that colchicine can cause leukopenia even with
the lower doses.
Objectives: In this study, we aimed to investigate the bone marrow side effects of
colchicine in patients who are treated with normal routine dose (0.5-2mg/day) for
FMF.
Methods: 213 consecutive pediatric FMF patients between July-September 2018 who were
followed at Hacettepe University Department of Pediatric Rheumatology and treated
with colchicine for at least 6 months were included in this study. Clinical characteristics,
demographics, and laboratory findings were reviewed retrospectively from medical charts
and electronic records of the patients. In patients with leukopenia, the time interval
from the treatment onset and time interval to full recovery were also recorded.
Patients were diagnosed as FMF according to Yalcinkaya-Ozen criteria, and the treatment
started as 0.5 mg/day <5 years, 1 mg/day 5-10 years and 1.5 mg/day >10 years old.
Max colchicine dose was 2 mg/day. Patients were followed at 2ndweek of treatment for
acute side effects of colchicine, at 3 months and then every 6 months. GraphPad 6.0
was used to evaluate the statistical analysis. Proportions, medians, minimum and maximum
values were used where appropriate to present the descriptive analyses.
Results: 213 pediatric FMF patients were included to the study group of whom 52.3%
of them were female. The mean age at the disease onset and the start of the colchicine
was 5.74±4.07 years. The median follow-up duration was 70 months ranged from 8 months
to 16.9 years.175 (82.2%) of the patients had recurrent fever, 165 (77.5%) of them
had abdominal pain, 89 (42%) of them had arthritis and 17 of them (8%) had chest pain
at the time of diagnosis.
Twenty-three (10.8%) out of 213 FMF patients had leukopenia during the colchicine
treatment. Among these 23 patients, 1 of them had moderate lymphopenia (500-1000/mm3),
2 had moderate neutropenia (500-1000/mm3), 7 had mild neutropenia (1000-1500/mm3)
and 2 patients had both mild lymphopenia and neutropenia. The median interval between
the onset of the treatment and the leukopenia onset was 63 months (range 3-179 months).
At the time of leukopenia onset, median colchicine doses per weight (0.026 vs 0.027
mg/kg/day p:0.96) were comparable in patients with and without leukopenia. There were
no other significant differences in terms of demographics, clinical features, mutation
types and colchicine formulations. Lymphocyte count (1760.87±512.34 vs 2264.89±924.04;
p<0.001) PMNL count (1673.91±574.63 vs 4172.34±3074.77; p<0.001) and platelet count
(249304±42568 vs 282399±77571; p<0.001) were also lower in this group as expected.
Colchicine doses were lowered due to this adverse event. In all patients, leukopenia
was transient and completely resolved in median 146.0 (IQR 70.5-192) days. There was
no increased rate of infections observed in these patients with leukopenia compared
to other patients.
Conclusion: Colchicine caused leukopenia in 10.8% of the patients in our cohort however
only 3 patients had moderate cytopenia and none of them had severe leukopenia. All
of the cases were fully reversible after dose adjustment and there were no clinical
consequences.Leukocyte counts should be assessed every 6 months in patients on colchicine.
Disclosure of Interest
None Declared
P2088 Mycophenolate mofetil (MMF) in defined and undefined interferonopathies
Carmela Gerarda Luana Raffaele, Gianmarco Moneta, Silvia Federici, Manuela Pardeo,
Claudia Bracaglia, Fabrizio De Benedetti, Antonella Insalaco
Division of Rheumatology, IRCCS, Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Carmela Gerarda Luana Raffaele
Introduction: Type I interferonopathies are genetic disorders characterized by an
up-regulation of type I interferon (IFN) activity. An increased expression of type
I IFN regulated genes, IFN signature (IS), is described in these conditions. They
are characterized by autoinflammation and varying degrees of autoimmunity or immunodeficiency.
Some patients with a phenotype strongly suggestive for type I interferonopathy with
a high IS, do not show any mutations in known type I interpheronopaties related genes,
being classified as undefined
Objectives: To evaluate the effect of mycophenolate mofetil (MMF) in patients with
defined and undefined type I interferonopathy
Methods: 7 patients with type I interferonopathy followed at a Pediatric Rheumatology
center, were included. Leucocyte (WBC) and platelet count, hemoglobin (Hb), CRP, ESR,
serum amyloid A (SAA), autoantibodies, complement levels and IS, were assessed before
and after 5-7 months of MMF treatment (600 mg/m2 BID). IS was determined by qPCR (high
scores >1.42)
Results: Patient 1 and 2 presented respectively with SAVI and Aicardi-Goutieres syndrome.
The others were classified as undefined. In patient 1(table), treated with JAK1/2
inhibitor, MMF was followed by decrease of inflammatory markers and resolution of
lung involvement; in patient 2 to an increase in Hb and normalization of inflammatory
markers. Among patients with an undefined phenotype the addition of MMF to low dose
prednisone led to complete resolution of inflammation. A reduction of the antinuclear
antibodies titre was observed in patients 2, 3 and 7 and a normalization of complement
level in patients 3, 4 and 7. Patient 5 had normal inflammatory markers already before
the beginning of MMF possibly due to previously administered immunosuppressive treatment.
Despite all patients presented a significant improvement of clinical picture after
5 months of MMF treatment, the IS decreased only in 4/7 patients while it remain stable
or increased in the others
Conclusion: Our data suggest that mycophenolate mofetil might be an effective therapy
in patients with type I interferonopathy leading to improvement of clinical and laboratory
features thus allowing a glucocorticoid sparing
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P2088).
See text for description
Pt 1
Pt 2
Pt 3
Pt 4
Pt 5
Pt 6
Pt 7
Disease
SAVI (lung and skin involvement, systemic inflammation)
Aicardi Goutieres (neurological involvement, rash, fever)
Undefined (epilepsy, arthritis,skin involvement)
Undefined
(recurrent fever, hypertransaminasemia, hemophagocytic lymphohistiocytosis)
Undefined
(hemiplegia)
Undefined
(epilepsy, arthritis,skin involvement)
Undefined (recurrent fever, lymphadenopathy, hypogammaglobulinemia
Clinical improvment after MMF
Resolution of lung involvement
Resolution of fever and rash
Resolution of rash, arthritis, improvement of seizures
Resolution of fever, inflammation and hypertransaminasemia
Improvement of motility
Resolution of arthritis and skin involvement
Resolution of fever and limphadenopathy
Gender
F
F
M
M
M
F
M
Age at onset (yrs)
3 (days)
2
4
7
4
6
16
WBC/ mmc3*
16 /7,4
8,0/8,4
9,8/8,5
1,7/8,4
4,4/8,2
4,4/5,2
6,6/5,9
Hb g/dl *
7,7/8,9
8,5/12,3
12,9/12,8
9,7/13
12,1/10,7
12/12,9
11,5/15,1
PLT/mmc3 *
950 /766
680/320
194/181
56/161
358/421
381/390
218/323
ESR (mm) *
44/40
49/9
38/10
7/6
2/5
24/6
3/3
CRP (mg/dl) *
1,22/0,73
3,13/0,06
5,55/0,32
<0,05/<0,05
<0,05/<0,05
1,15/<0,05
8,34/0,98
SAA (mg/dl)*
95,8/3,62
5,37/2,82
188/8,11
-/1,89
<0,84/-
4,19-0,78
/
C3 (90-180mg/dl)*
154/134
122/108
81/92
83/118
203/170
127/108
53/133
C4 (10-40 mg/dl)*
22/22
10/24
6/8
16/27
38/28
24/14
15/41
Antinuclear antibody*
Absent
1:2560/1:160
1:10.240/1:1280
Absent
Absent
1: 2560 /1:320
Absent
ENA*
pANCA:40/1:20
Absent
Anti dsDNA 1:1280/1: 160
Absent
Absent
Anti dsDNA 1:320/1:40
Absent
IFN signature*
43,2/18,3
42,6/79,8
54,73/64,6
8,66/18,19
40,6/5,95
171,5/13,12
14,34/2,24
* Lab value pre/post MMF therapy
P2089 Successful IL-17 targeted therapy in a patient with severe Blau syndrome and
novel NOD2 mutation
Nikolaus Rieber1, Maximilian Steinhauser1, Matthias Klopfer2, Sabine Pietzsch3, Peter
Strotmann1, Harald Engelhardt3, Uta Behrends1, Rainer Berendes3, Stefan Burdach1
1Department of Pediatrics, Kinderklinik Muenchen Schwabing, München-Klinik Schwabing
und Klinikum rechts der Isar, Technical University of Munich; 2Department of Ophthalmology,
Technical University of Munich, Munich; 3Kinderklinik St. Marien Landshut , Landshut,
Germany
Correspondence: Nikolaus Rieber
Introduction: Blau syndrome is a monogenic disease resulting from mutations in the
pattern recognition receptor NOD2, and is phenotypically characterized by the classical
triad of granulomatous polyarthritis, dermatitis and uveitis. However, extra-triad
symptoms have increasingly been reported including, but not limited to, vasculitis,
granulomatous glomerular and interstitial nephritis, interstitial lung disease, arterial
hypertension, pericarditis, and hepatic granulomata.1 Therapy of Blau syndrome is
challenging with following medications being reported with varying responses: steroids,
methotrexate, TNF-blocker, Il-1 and IL-6 targeted therapies.
Objectives: To describe the case of a Blau syndrome patient refractory to conventional
therapies benefiting from IL-17 targeted therapy.
Results: The female patient of African origin presented at the age of six months with
recurrent high fever episodes for days to weeks, polyarthritis, erythematous and ichthyosiform
skin manifestations, severe panuveitis, granulomatous liver disease, kidney disease
with tubulopathy and severe arterial hypertension. Laboratory evaluation revealed
highly elevated inflammation parameters (C-reactive protein (CRP), erythrocyte sedimentation
rate (ESR), Serum Amyloid A (SAA)). Liver biopsy showed granulomatous liver disease.
Broad infectious disease work-up including tuberculosis was negative. The family history
was unremarkable regarding inflammatory or immunological diseases. The suspicion of
Blau syndrome was made and genetic analyses revealed a novel de novo mutation in the
NOD2 Gene (c.[1807C>A]; Histidin603> Asparagin) confirming the diagnosis Blau syndrome.
The patient was consecutively treated with each high doses of steroids, IL-1 receptor
antagonist (anakinra up to 10mg/kg/d) and anti-TNF antibodies (allergic reaction to
3rd dose of infliximab, adalimumab up to 5mg/kg weekly) in addition to maintenance
doses of steroids, none of which with sustained success. Therefore a hitherto novel
therapeutic approach was initiated with an anti-IL-6 therapy (tocilizumab; up to 20mg/kg
every 2 weeks) which yielded a good, yet only contemporary response for up to 6 months.
As significant amounts of IL-17 have been identified in granuloma biopsies of Blau
syndrome patients² we decided to start a novel therapy targeting the Il-23 / IL-17
pathway. We first used the anti- IL-12 / IL-23 antibody ustekinumab (up to 6mg/kg
every 3 weeks) which led to striking clinical and laboratory response for up to 6
months but then lost effectiveness. Therefore we switched to the anti-IL-17A antibody
secukinumab (up to 17mg/kg every 4 weeks) leading to substantial therapeutic response
again. The patient has now been successfully treated with this therapy for 10 months
together with a maintenance dose of prednisolone (0,2 mg/kg/d), electrolyte substitutions
due to her tubulopathy and anti-hypertensive therapy. No substantial side effects
have been observed so far. Further observation is needed for long term evaluation
of the anti-IL-17 therapy response in this single patient.
Conclusion: This case report might encourage the use and report of high-dose IL-17
targeted therapies in further refractory Blau syndrome patients. The repeated secondary
loss of effectiveness towards anti-IL-6 antibody tocilizumab and anti- IL-12 / IL-23
antibody ustekinumab after several months of successful treatment might be related
to anti-drug antibody formation or the specific pathophysiology of Blau syndrome.
1 Wouters et al., Pediatric Rheumatology 2014 ² Jannsen et al., J Allergy Clin Immunol
2012
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2090 Recurrent fevers associated with neurodevelopmental disorders and their treatment
with anakinra
Tina M. Romeo, Amanda K. Ombrello, Karyl Barron, Anne Jones, Seth Berger, Ann C. Smith,
Daniel L. Kastner, Deborah L. Stone
National Institues of Health/NHGRI, Bethesda, United States
Correspondence: Tina M. Romeo
Introduction: Rubenstein-Taybi syndrome, a multiple congenital anomaly syndrome characterized
by intellectual disability and dysmorphic facial features, is usually associated with
mutations in the transcriptional coactivator CREB-binding protein.1 Mutations in the
transcriptional factor, DEAF1, have been associated with DEAF1-associated neurodevelopmental
disorder (DAND), characterized by intellectual disability, speech impairment and motor
delay.2We describe the presence of a recurrent fever syndrome in a child with Rubenstein-Taybi
syndrome and another with DAND.
We evaluated a child with Rubenstein-Taybi syndrome with recurrent fevers associated
with grunting.During a severe flare, he had been found to have small pericardial and
pleural effusions. He did not respond to colchicine and was treated frequently with
prednisone. A second child was diagnosed with DAND and recurrent fevers that exacerbated
his seizure disorder. Both children had increased inflammatory markers at the time
of their fevers.
Objectives: To find a steroid-sparing treatment for these children.
Methods:Both children were treated with anakinra at the first sign of symptoms related
to a fever flare.
Results: Both children responded rapidly with improvement in fevers, inflammatory
markers, and other associated symptoms (grunting, poor appetite, diarrhea, and behavioral
issues).
Conclusion: Anakinra may be effective in treating fevers and inflammation in children
with syndromes caused by mutations in genes for transcription factors or activators.
These children have dysregulation of multiple genes, including some plausibly involved
in the innate immune system.
Disclosure of Interest
None Declared
P2091 Hematopoietic stem cell transplantation (HSCT) successfully curedtwo patients
with PSTPIP1-associated autoinflammatory diseases (PAMI)
Alexandra Laberko1, Daria Yukhacheva1, Irina Shipitsina2, Maria Dunaykina2, Anna Kozlova1,
Vasilii Burlakov1, Irina Mersiyanova3, Yulia Rodina1, Elena Raykina3, Dmitrii Balashov2,
Larisa Shelikhova2, Anna Shcherbina1
1Immunology; 2Hematopoietic Stem Cell Transplantation; 3Laboratory of Molecular Biology,
National Medical Research Center of Hematology, Oncology and Immunology named after
D. Rogachev, Moscow, Moscow, Russian Federation
Correspondence: Anna Shcherbina
Introduction: HSCT isan accepted curative treatment for diseases caused by genetic
defects of immune system. Yet, it’s not as widely used in autoinflammatory syndromes
since some of them affect not only hematopoietic, but also other cell types. PAMI
caused by certain mutations of PSTPIP1 gene andmanifests mainly withhematologic abnormalities
(that can be life-threatening) and autoinflammation with or without purulent features.PAMI
treatment is challenging as IL-1 inhibitors can alleviate the inflammatory symptoms
but not hematologic features.Hence HSCT seems a logical treatment optionin PAMI.
Objectives: To describe treatment results of two PAMI patients.
Methods: The girl born in 2005 (P1) and the boy born in 2016 (P2) from unrelated families
were diagnosed with PAMI based on detection of p.E250K mutation ofPSTPIP1. TCR alfa/beta/CD19
depletion of the transplant and myeloablative preparative regimen with treosulfan
36-42g/m2, fludarabin 150mg/m2, thiotepa 10mg/kg were used forHSCT. Pre- and post-transplant
immunosuppression in P1 consisted of tocilizumab 10mg/kg day -1, abatacept 10mg/kg
days -1, +7, +14, +28 and bortezomib 1,3mg/m2 days -5, -2, +2, +5, in P2 thymoglobulin
5mg/kg and abatacept 10mg/kg days -1, +7, +28, both received rituximab 100mg/m2 day
-1.
Results: Both patients had high inflammatory activity, fever episodes and cytopenia
from the first year of life. P1was treated withIVIG, mycophenolate mofetil andrapamicin,
with partialeffect, but later developedmyelodisplastic syndrome. P2 was treated with
infliximab with partial effect, yet developed severe vasculitis and hemophagocytic
lymphohistiocytosis and received treatment according to the HLH2004 protocol. Allogenic
HSCT from matched unrelated donor in P1 andhaploidentical related donor in P2was performed
at the age of 12 years (P1) and 18 months (P2). There were no severe posttransplant
complications in both patients. Currently the patients are15 (P1) and 9 (P2) months
after HSCT. Both patients have predominantly donor chimerism, good immune function,
no inflammatory activity or other signs of PAMI.
Conclusion: PAMI syndrome can be successfully treated with HSCT. Indications for HSCT
in other autoinflammatory syndromes have to be yet evaluated.
Disclosure of Interest
None Declared
P2092 Response to JAK inhibition in two children with haploinsufficiency of A20 (HA20)
caused by truncating mutations in the ZNF4 domain
Deborah L. Stone, Amanda K. Ombrello, Karyl Barron, Tina Romeo, Natalia Sampaio Moura,
Ivona Aksentijevich, Daniel L. Kastner
National Institutes of Health, U.S., Bethesda, United States
Correspondence: Deborah L. Stone
Introduction: Haploinsufficiency of A20(HA20) is an early onset autoinflammatory syndrome.
The A20(TNFAIP3) protein is an important inhibitor of the NFκB signaling pathway,
and individuals with HA20 frequently have increased inflammatory markers, fevers,
oral and genital ulcers, and inflammation of the joints and eyes.1A20 has also been
found to be a critical hepatoprotective factor 2 , and some individuals have presented
with liver inflammation and fibrosis. Most mutations in A20 occur in the ovarian tumor
(OTU) domain, but we follow two patients with heterozygous, de novo ZnF4 domain mutations,
Thr604Argfs*93 and Leu626Valfs*45. The teenage girl with Thr604Argfs*93 had frequent
and severe oral, genital and perirectal ulcers that required her to take frequent
courses of prednisone and did not respond to etanercept, adalimumab or anakinra.The
younger child with Leu626Valfs*45 had chronically elevated transaminases, decreased
platelet count, increased prothrombin time and stage 3 liver fibrosis.
Objectives: To find an effective treatment for individuals with HA20 who have not
responded to anti-IL1 and anti-TNF therapy or who have severe disease with liver involvement.
Methods: Because A20 was found to act as a regulator of STAT13, JAK inhibition was
proposed as a treatment. Gene expression testing of interferon related genes was performed
before and after treatment. Tofacitinib was prescribed at a dose of 5 mg twice daily
for the older girl and 2.5 mg twice daily for the younger one.
Results: Gene expression testing of interferon related genes showed upregulation in
both girls before treatment. The older girl was started on tofacitinib and noted a
great improvement with many fewer oral ulcers even when her dose of tofacitinib was
reduced to once daily. Repeat gene expression testing post-initiation of therapy showed
a reduction in expression of interferon related genes. After approximately 3 months
of taking tofacitinib, the younger girl’s liver fibroscan (transient elastography)
measurement had decreased from 13.5 Kpa, suggestive of advanced liver disease, to
8.7 Kpa (normal ≤7 Kpa). Her transaminases appeared to be slowly decreasing with a
progressive increase in her platelet count.
Conclusion: Treatment with JAK inhibitors has benefited two children with HA20 who
have truncating mutations in the Zn4 domain, demonstrating that HA20 is an interferonopathy
in these patients. Further research may determine whether these results are generalizable
to other individuals with HA20. Gene expression testing and treatment with JAK inhibitors
should be considered in patients with HA20.
1
Zhou Q, Wang H, Schwartz DM, Stoffels M, Park YH, Zhang Y, et al. Loss-of-function
mutations in TNAIP3 leading to A20 haploinsufficiency cause an early-onset autoinflammatory
disease. Nat Genet 2016 Jan; 48(1):67-73. PMID 26642243
2 Catrysse L, Farhang Ghahremani M, Vereecke L, Youssef SA, McGuire C, Sze M, et al.
A20 prevents chronic liver inflammation and cancer by protecting hepatocytes from
death. Cell Death Dis 2016 Jun; 7(6): e2250. PMID 27253414
3 De Wilde K, Martens A, Lambrecht S, Jacques P, Drennan MB, Debusschere K, et al.
Ann Rheum Dis 2017 Mar; 76(3): 585-592. PMID 27551052
Disclosure of Interest
None Declared
P2093 Squalene synthase inhibitors to regulate the inflammation in mevalonate kinase
deficiency
Annalisa Marcuzzi1, Elisa Piscianz1, Erica Valencic2, Alessandra Tesser2, Andrea Taddio1,2,
Alberto Tommasini2
1University of Trieste; 2IRCCS Burlo Garofolo Trieste, Trieste, Italy
Correspondence: Alessandra Tesser
Introduction: Mevalonate Kinase Deficiency (MKD) is a rare inborn disease belonging
to the family of periodic fever syndromes. MKD phenotype is characterized by multiorgan
inflammation, which may involve the brain in the most severe cases. Anti-IL-1 therapies
can contrast almost completely systemic inflammation, but it is uncertain whether
they can prevent neural inflammation. Since it is believed that shortage of mevalonate
derived isoprenoids plays a major role in inflammation, biochemical treatments modulating
the mevalonate pathway may contribute to improve the cure of the disease.
Objectives: We hypothesize that repurposing of the squalene synthase inhibitor Lapaquistat
could represent a promising therapeutic approach by increasing the accumulation of
squalene isoprenoids with antinflammatory properties.
Methods: MKD shows different degrees of disease severity due to the residual mevalonate
kinase (MK) activity, ranging from autoinflammatory hyper immunoglobulinemia D and
periodic fever syndrome, with a 1-8% residual MK activity, to mevalonic aciduria in
which MK activity is undetectable.
To mimic the spectrum of the biochemical defect of the mevalonate pathway, a consolidated
MKD-model was used to test the anti-inflammatory potential of the Lapaquistat. Briefly,
a murine monocyte/macrophage cell line was treated with increasing concentration of
alendronate (25/50/100 μM) to obtain a biochemical block of the mevalonate pathway.
At the same time, cells were stimulated with different concentration of Lapaquistat
(10/25/50 μM). After 24 hours, cells were treated with bacterial stimuli (lipopolysaccharide)
to mimic a generic inflammatory stimulus.
Cell viability, programmed cell death, morphology and cytokine release were the experimental
readouts.
Cell viability was measured by means of impedance assay: the system allows to quantify
cell proliferation, changes in morphology and the quality of cell adhesion to the
plastic wells. These data were confirmed by flow cytometric programmed cell death
assays. Cells morphology was assessed by electronic microscopy, and in particular
the evaluation was focused to discriminate the mitochondrial and membranes size and
shape.
Finally, after stimulation, culture supernatants were collected to analyse the cytokine
concentration by means of Multiplex Assay, with particular reference to IL-1β, IL-6
and TNF-α.
Results: Lapaquistat was able to preserve the cellular morphology in MKD-cellular
model, as assesses by impedance analysis. However, treatment with Lapaquistat didn’t
reduce LPS-induced apoptosis.
As for the cytokine profile, as expected, the production of inflammatory cytokines
IL-1β, IL-6 and TNF-α significantly increased following treatment with LPS in cells
treated with alendronate in a dose-dependent manner. At low doses of alendronate,
Lapaquistat was able to reduce the release of these cytokines, contrasting inflammation,
with a significative effect on IL-6.
The morphological-qualitative analysis showed that Lapaquistat was able to preserve
the membranes, to reactivate the correct process of mitophagy and to prevent the formation
of toxic lipid aggregates, but only at lower concentrations of alendronate.
Conclusion: Based on these results, we could hypothesize an efficacy of Lapaquistat
as a complementary treatment in MKD, to be added to currently available antinflammatory
treatments to improve the control of inflammation. Moreover, it is possible that Lapaquistat
alone could have a sufficient antinflammatory effects in subjects with milder MK defect.
However, further studies in animal models are needed to evaluate whether the benefits
of increasing pre-squalene isoprenoids overcame the costs of a reduction of post-squalene
sterols in vivo, which might affect in other ways the cell function.
Disclosure of Interest
None Declared
P2094 IL1Β blockade by canakinumab leads into remission recurrent pericarditis associated
with the MEFV variant P.GLU148GLN (E148 Q)
Maria Tsinti1, Maria Zamanakou2, Vasiliki Dermentzoglou1, Elena Tsitsami1
1Pediatric Rheumatology Unit, First Department of Pediatrics, School Of Medicine,
University Of Athens, Children’s Hospital “Aghia Sofia”, Greece, Athens; 2CeMIA, Larissa,
Greece
Correspondence: Maria Tsinti
Introduction: Increasing evidence suggests that idiopathic Recurrent Pericarditis
(RP) results from inflammasome activation. The autoinflammatory (AIF) origin is strongly
supported by the efficacy of treatments typically applied in Familial Mediterrenean
Fever (FMF) and other AIF diseases; colchicine and IL1 blockade. RP is met in TRAPS
patients and represents the rarest manifestation of polyserositis of FMF. A minority
of FMF patients suffer from RP as the sole manifestation. The effecticeness of treatment
of RP refractory to colchicine with IL1 blockade by anakinra has been shown in control
trials. The efficacy of IL1β blockade by canakinumab in RP has been scarcely described.
Objectives: To indicate the effectiveness of canakinumab in treating RPin a patient
carrying the E148 Q MEFV variant, along with other AIF genes variants.
Methods: Case presentation
Results: A 12-year-old overweight girl was hospitalized for 15 days with fever; 39,5oC-2
spikes daily, myalgias, arthralgias, headache, hepatosplenoomegaly and pericarditis
(chest pain, dyspnea, tachypnea ST elevation in ECGand moderate pericardial effusion
on US; cardiomegaly& bilateral pleuritic effusion on X-Ray. Laboratory findings revealed
leukocytosis-WBC=14400/uL, neu 80%, mild anemia-Hb=8,5 g/dl, elevation of acute phase
reactants-CRP=184 mg/l, SAA=900 mg/l, ESR=85mm/hr, ferritin=558μg/L fibrinogen=445mg%,
d-dimmers= 29μg/ml), mildly elevated γGT, normal cardiac enzymes and abnormal clotting
studies (PT=19,2 sec, APTT=32,4 sec, INR=1,7). Infections were excluded and medical
history was negative for drug administration, recurrent fevers or rheumatic disease
manifestations. Serology revealed absent Antinuclear Autoandibodies, normal C3&C4
and elevated IgA . Ibuprofen was ineffective. Prednisolone (PDN) 60 mg daily was administered
with immediate response. Two months later during steroid tapering pericarditis recurred
with similar manifestations. PDN dose was increased to max. Colchicine 2 mg/d was
initiated. Analysis for monogenic AIF diseases by a custom NGS protocol including
25 genes (mean coverage >92%) was performed. Common polymorphisms-UCSC Common SNPs-
with no reported disease associations in the ClinVar database were excluded. Pathogenicity
of variations was predicted by bioinformnatic analysis using SIFT and PolyPhen tools,
in comparison to their European frequency (ExAc database). Detected mutations were
cross-referenced with the International Society for Systemic AIF Disease (Infevers)
and ClinVAr databases.The E148Q Variant of Uncertain Significance-VOUS-on the MEFV
gene, along with a benign variant; p.Ala313Thr and a VOUS; p.Gly192Val of the TMEM172
gene and a VOUS; p.Ala313Gly of the PLCG2 gene were detected (reported according to
the HGVS and the guidelines for the genetic diagnosis of hereditary recurrent fevers).
E148Q as the only MEFV variant cannot support the diagnosis of FMF, due to its high
frequency in the general population; however it has been detected in patients with
typical FMF phenotype as the sole variant. Thus, RP was considered a manifestation
of FMF in this patient. A 2nd relapse of pericarditis occurred in 2 months during
PDN tapering. Colchicine was increased to 3 mg/d and PDN to 30 mg/d. After 3 months
while on 7,5 mg PDN pericarditis relapsed with milder manifestations. PDN was increased
to 15 mg, canakinumab, 150 mg, monthly was initiated and colchicine dose was adjusted
to 2 mg/d. In 3 months steroids were interrupted. The disease remains into remission
for 8 months under canakinumab.
Conclusion: ConclusionIL-1β blockade by canakinumab is effective and safe in recurrent
pericarditis associated with polymorphisms in AIF genes.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2095 Anakinra treatment in recurrent pericarditis: single center experience
Zeynep Toker Dincer, Osman Corbali, Serdal Ugurlu, Huri Ozdogan
Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty,
University of Istanbul - Cerrahpasa, Istanbul, Turkey
Correspondence: Serdal Ugurlu
Introduction: Recurrent pericarditis (RP), however the etiology is unknown in the
majority, may be observed in autoinflammatory diseases such as familial Mediterranean
fever (FMF) and tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS).
Colchicine has long been used to treat pericarditis related to FMF as well as patients
with idiopathic recurrent pericarditis (IRP) (1). Alternative treatments have been
reported for cases with colchicine resistant RP.
Objectives: The aim is to present our data regarding anakinra treatment in recurrent
pericarditis either related to FMF or idiopathic, who are resistant to colchicine.
Methods: Patients who had recieved anakinra with a diagnosis of recurrent pericarditis
either idiopathic or secondary to FMF followed in our autoinflammatory disease center
between 2014-2018 are evaluated retrospectively. From patients’ files, demographic
and clinical features, response to other treatment approaches such as NSAID, corticosteroid,
colchicine, were evaluated. All patients have been genetically screened for monogenic
autoinflammatory diseases (MEFV, TRAPS, MVK, NLRP3, NOD2). Patients who had at least
3 attacks were administered anakinra 100 mg/day. Therapeutic efficacy, as well as
side effect profile of anakinra is also assessed.
Results: There were 5 patients (3 male and 2 female) with the diagnosis of RP, 1 was
related to FMF and 4 were idiopathic. The mean age of the group was 28±8 (range 20-40).
All patients diagnosed with IRP were negative for autoinflammatory genetic screening,
while a MEFV variant (K695R het.) was detected in the FMF patient. Median duration
of follow-up was 30 months (range 11-129). In table 1, demographic and clinical features
are given. The median number of recurrence was 6 before anakinra treatment. No episode
of pericarditis was observed in any of the patients after the initiation of anakinra.
The response to anakinra persisted even after the dose was reduced to 100 mg/alternate
day in 3 patients, however in 2, recurrence of pericarditis was observed and anakinra
was escalated to initial dose. It was possible to discontinue corticosteroid treatment
in all patients. Currently all patients continue anakinra treatment. No side effect
including injection site reaction, has been observed by now.
Conclusion: Anakinra seems to be a safe and effective treatment approach for colchicine
resistant recurrent pericarditis. However recurrence may occur during dose tapering.
Reference
1) Adler Y, et al. Colchicine treatment for recurrent pericarditis. A decade of experience.
Circulation. 1998 2;97(21):2183-5.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P2095).
Demographic features and treatment response during anakinra therapy
Patient ID #
Age
Sex
Diagnosis
Duration of pericarditisfollow-up (mo)
Prior medications
Number of recurrences before anakinra
Anakinra treatment duration (mo)
Time to corticosteroid discontinuation (mo)
Number of recurrences after daily dose of anakinra
1*
23
M
IRP
129
Colchicine, NSAIDs, CS, HCQ
6
52
9
No
2
32
F
IRP
128
Colchicine, NSAIDs
7
4
NA
No
3*
40
F
IRP
21
Colchicine, CS
6
8
1
No
4
20
M
IRP
11
Colchicine, CS
3
8
2
No
5
25
M
FMF
30
Colchicine, CS
5
15
1
No
F: Female, M: Male, CS: Corticosteroid, HCQ: Hydroxychloroquine, NA: Not applicable
*Dose tapering was unsuccessful in these patients
Immunedysregulation
P2096 Inaugural hemophagocytic syndrome in autoimmune diseases: a case series
Laura Damian1, Manuela Sfichi2, Mihaela Lupse3, Simona Cocu4, Laura Urian5, Cristina
Pamfil6, Mihnea Zdrenghea5, Ina Kacso7, Simona Rednic6, Anca Bojan5
1Rheumatology; 2Immunology, Emergency Clinical County Hospital Cluj; 3Infectious Diseases;
4Intensive Care; 5Hematology; 6Rheumatology; 7Nephrology, “Iuliu Hatieganu” University
of Medicine Cluj, Cluj-Napoca, Romania
Correspondence: Laura Damian
Introduction: Hemophagocytic syndrome, lymphohistiocytosis or macrophage activation
syndrome (MAS) is a severe, potentially lethal disease with unspecific features often
mimicking sepsis. It may be triggered by infections or by the autoimmune disease itself.
Objectives: To describea series of MAS cases heralding systemic autoimmune diseases.
Methods: We retrospectively reviewed the patients’ records and charts in our tertiary
referral units, in the last 5 years. The MAS cases in patients with a previously known
autoimmune diagnosis were excluded. MAS was diagnosed according to the HLH-2004 criteria.
Genetic tests were not performed.
Results: MAS was found to herald systemic diseases in 8 cases (7F, 1M, median age
46.2 years). The autoimmune diseases were: systemic lupus erythematosus (3 cases-
all with anti-Ro+ and no anti-dsDNA, in 2 overlap with Sjogren’s syndrome), inflammatory
idiopathic myopathy (2 cases), seronegative rheumatoid arthritis, systemic pyoderma
gangrenosum and polyarteritis nodosa (1 case each). In all cases, prolonged fever
and cytopenia in at least 2 lines were the presenting symptoms. Three cases required
intensive care and life support; plasma exchange was employed in a case of thrombotic
microangiopathy and immunoglobulins (1 g/kg) were given in the other two cases. Hiperferritinemia
was noted in all cases, with large variations from 510 IU to over 10000 UI. Low NK
counts and/or percentage (by flow cytometry BD FACS) were found in 5 of the 6 cases
tested.
Conclusion: MAS may reveal the presence of autoimmune diseases, even when infectious
triggers are proven. Clinical awareness, a great index of suspicion and a fast multidisciplinary
approach in a referral center improve the prognosis.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P2096).
See text for description
No
S
Age
Trigger
Disease
Therapy
Outcome
Observations
1.
F
72
Resp. Virus
IIM
life support (ICU); MP pulses; cyclosporine; immunoglobulins
survival
ARF; hypoC4
Atypical rash
2.
F
56
Acute cholecystitis
PG
Life support (ICU); immunoglobulins; MP, CyA
survival
3.
F
58
viral
RA
MP, CyA, MTX
survival
4.
F
46
?
SLE/SSj (Ro52)
MP, CyA
survival
Evolved to Systemic sclerosis
5.
F
49
Q fever
SLE/SSj (Ro52)
cryoglobulinemia
Life support (ICU); plasma exchange; MP, CyA
survival
TMHA; hypoC3, C4
6.
M
23
?
PAN
MP, CyA
survival
7.
F
25
?
SLE
MP, CyA
survival
8.
F
57
Resp. virus
inflammatory idiopathic myopathy
MP pulses; CyA, then Aza
survival
Atypical rash
Legend: ARF- acute respiratory failure, Aza- azathioprine, CyA- cyclosporin A,ICU-
intensive care unit, IIM= inflammatory idiopathic myopathy, MP- methylprednisolone,
PAN- polyarteritis nodosa, PG- pyoderma gangrenosum (systemic), RA-rheumatoid arthritis,
SLE- systemic lupus erythematosus, SjS- Sjogren’s syndrome, TMHA- thrombotic microangiopathy
P2097 Assessing the mutation detection rate and genotype-phenotype correlation with
a large haemato-immunological NGS panel: crossing the borders among different subspecialties
Alice Grossi1, Maurizio Miano2, Stefano Volpi3, Roberta Caorsi3, Francesca Fioredda2,
Marina Lanciotti2, Enrico Capelli2, Carlo Dufour2, Marco Gattorno3, Isabella Ceccherini1
1UOC Genetica Medica; 2UOC Ematologia; 3Clinica Pediatrica Reumatologia e UOSD Centro
Malattie Autoinfiammatorie-Immunodeficienze, IRCCS Istituto Giannina Gaslini, Genova,
Italy
Correspondence: Alice Grossi
Introduction: Next Generation Sequencing (NGS) has driven the rapid increase in the
number of recognizable inborn errors of immune system development and/or function often
hampered by the wide heterogeneity of the many genetically diverse but phenotypically
overlapping diseases. NGS has also led to the discovery of new genes implicated in
well-defined biological pathways, revisiting frequencies and broadening their phenotypic
spectrum.
Objectives: Identification of the genetic causes of already known and unknown immune-mediated
diseases with immunedysregulation; improvement of our knowledge about clinically overlapping
phenotypes through the genetic characterization of the corresponding patients; optimization
of the diagnostic work-up in order to administer disease specific treatments to patients.
Methods: A total of 150 patients, selected based on a clinical history highly evocative
for immune-dysregulation (peripheral and/or central cytopenia and/or lymphoprolipheration
and/or autoimmunity or autoinflammation) and/or immunodeficiency were submitted to
3 custom gene panels progressively larger and sequenced through the Ion Personal Genome
Machine (PGM™) System. Based on the clinical phenotype, frequency and impact on the
protein, variants were selected and validate by standard Sanger sequencing.
Results: Table 1 reports technical results for the 3 gene sets. The mutation detection
rates for these panels were 2/30 (6%), 15/51 (29%), and 16/69 (23%), respectively, for
a total of 35 pathogenic variants that correlate with the respective clinical phenotypes.
The patients could be classified in: ALPS/ALPS-like (97, 26 of whichdiagnosed), cytopenia
(33, 4 diagnosed), undefined autoinfiammatory (12, 2 diagnosed) and suspected immunodeficiency
(8, 1 diagnosed). Moreover, variants of unknown significance (VUS) in potentially
causative genes were also found in additional 14 patients (6/30; 4/51; 4/69). A number
of variants, either pathogenic, likely pathogenic, or VUS have been detected in some
cases at genes unexpected on the basis of the phenotypes, among which PRKCD, PIK3CD,
IL7R, NCF1, TNFRSF13C, CASP8, thus confirming wide heterogeneity in the phenotypic
spectrum associated with diseases sharing haemato-immune-rheumatological features.
Conversely, several clinically similar cases did not reveal any relevant mutation,
thus reflecting a genetic heterogeneity that is far from being disclosed yet.
Conclusion: The NGS approach has demonstrated excellent performances in the 1) evaluation
of large genes and mutation detection, 2) overall timeliness of the gene panels, relying
on continuous literature updates, and 3) identification of unexpected phenotypes for
well-defined monogenic disease and definition of different disease clinical entities
characterized by overlapping phenotypes. By contrast, due to the remarkable variability
in clinical presentations, defining the appropriate list of genes for a given phenotype
represents one key difficulty in the design of these panels. In the near future we
will have to focus on the functional study of the many variants, especially VUS, that
have emerged in a massive study like ours.
Disclosure of Interest
None Declared
Table 1 (abstract P2097).
See text for description
GENE PANEL 1
GENE PANEL 2
GENE PANEL 3
Library_capture technology
Ampliseq_ThermoFisher
Haloplex HS_Agilent
Haloplex_Agilent
#genes
58
146
315
Target size
209,54 kbp
341,073 kpb
769,995 kpb
Target bases analyzable (coverage)
197,35kbp (94,18%)
337,24kbp (98,88%)
750,99kbp (97,53%)
#patients analyzed
30
51
69
Mean total variant called/filtered
127/4
641/14
1413/25
P2098 Vitamin D status & its therapeutic role in pediatric patients with idiopathic
nephrotic syndrome
Dina E. Sallam
Paediatric, Ain Shams University hospital, Cairo, Egypt
Introduction: Idiopathic nephrotic syndrome (INS) is the most common form of childhood
nephrotic syndrome, the hallmark of the diseases still remains unknown, however; strong
evidence suggests that it has an immune pathogenesis involving T-cells and its released
cytokines including IFN-g. Vitamin D is a multifunctional hormone that exerts its
biological activities mainly through the vitamin D receptor (VDR) and has an anti-inflammatory
and immunomodulatory effect on many immunological disorders.
Objectives: This study aimed at detecting the changes in serum level of vitamin D
in children with idiopathic steroid sensitive nephrotic syndrome at diagnosis, early
remission and at full remission together with studying the effect of vitamin D intake
and other factors on achieving early remission and studying serum level of interferon
gamma (IFN-g) as a marker of immunoregulatory effect of vitamin D.
Methods: This study included twenty five newly diagnosed children with idiopathic
steroid sensitive nephrotic syndrome and was randomly categorized into two groups;
both received oral prednisolone at diagnosed; meanwhile, only group 2 received vitamin
D injection. Vitamin D statuses were detected at initial diagnosis, early remission
and at full remission together with the serum level of IFN -g.Follow up was made over
a period of 28 days.
Results: Study results revealed a deficiency of 25 (OH) D3 in our patients with INS,
which improved markedly with remission especially if combined with vitamin D injection,
while serum levels of 1, 25 (OH)2 D3 were normal from the start. Serum levels of IFN-g
were at lower levels which increased with remission; meanwhile its level did not increase
significantly in vitamin D supplemented group. Dyslipidemia improved with vitamin
D injection. Interestingly, the most determinant factor for achieving early remission
was the younger of our patients at diagnosis.
Conclusion: deficiency of 25 (OH) D3 is common among children with INS and improves
with remission which emphasizes the effect of proteinuria and loss of vitamin D binding
protein on serum level of 25 (OH) D3. On the other hand, active vitamin D (1, 25 (OH)2
D3) does not seem to be affected. Vitamin D has no significant effect on serum IFN-g.
Both vitamin D and IFN-g do not appear to have significant role in the immunopathogenesis
of nephrotic syndrome. Screening for vitamin D deficiency in children with INS and
administration of therapeutic doses of vitamin D will help remission. Vitamin D supplementation
has a protective lowering effect on serum cholesterol.
Disclosure of Interest
None Declared
P2099 Immune reconstitution in autoinflammatory CANDLE like syndrome due to SAMD9L
mutation
Analia G. Seminario1, María S. Caldirola1, Ileana Moreira1, Valeria Regairaz1, Marco
Gattorno2, Raphaela Goldbach-Mansky3, Liliana Bezrodnik1
1Immunology, Centro de Inmunología Clínica Dra Bezrodnik, Buenos Aires, Argentina;
2Rheumatology, IRCCS Istituto Giannina Gaslini, Genova, Italy; 3Translational Autoinflammatory
Disease Studies, NIH/NIAID/LCID, Bethesda, United States
Correspondence: Analia G. Seminario
Introduction: Autoinflammatory diseases are inborn errors of the innate immune system.
They present with uncontrolled systemic and organ specific inflammation, like infections,
that generally associate inflammation of the skin and others organs since neonatal
period and raised inflammatory markers in blood. Some may not have fever. In recent
years, new mutations were discovered, as causes of primary immunodeficiencies. SAMD9L
expression is high in B and NK lymphocytes, moderate in T cells, monocytes, neutrophils,
lung and muscle and low in skin, liver, heart and kidney tissues. Missense mutation
in SAMD9L can cause, an Early-Onset Immune- Dysregulation Syndrome of Neutrophilic
Panniculitis, Interstitial Lung Disease and Cytopenias.
Objectives: Report clinical case and immune reconstitution 3 years after bone marrow
transplant in a patient with severe neonatal autoinflammatory syndrome due to SAMD9L
mutation, with innate and adaptive immune compromise.
Methods: Retrospective analysis of a clinical history and immune reconstitution in
a patient with a new primary disease of immune dysregulation.
Results: 3 years old girl, with chronic and generalized pustulosis since birth. At
2 months, persists with severe skin ulcers, no fever but high levels of CRP:78.5 mg/dl
and ERS:68 mm3/h. In the immunological lab: hypogammaglobulinemia and almost absent
B cell counts. Because of that she began treatment with intravenous gammaglobulin
and corticosteroid, in spite of it she presented several skin exacerbations. So anti-TNF
α (0.8 mg/dose weekly) treatment was added. She could improve skin lesions and almost
normalized CRP but at fifth dose, she presented low platelets, white cells count and
visceromegaly with respiratory failure because of Pneumocity Jiroveci and skin erythema
and adenopathy at BCG site, needing mechanical ventilation, antibiotic, corticosteroid,
cyclosporine and tuberculostatics drug because: positive Mycobacterium bovis in blood.
After this treatment she presented partial response with marrow aplasia and she received
canakinumab (ant IL-1β) 1 mg/kg/dose. No mutation in ADA2, TNFRSF1A, CECR1 and NLRP3
was found. Given the severe compromise, new studies were performed: Altered score
for interferonopathies and mutation in SAMD9L protein was found by WES. Two months
later, she was clinically stable. In 2016 she received unrelated HSCT (10/10). Nowadays
she presents clinically well, no infections, only has mild rash in skin. No cytopenias,
normal immunoglobulins, with B cell engraftment 15% (18,3 %B memory cells, 10,3% post
switched memory cells and 3,2 % B transitional cells) Cd4 naïve T cells: 29,8% - 169
mm3, Normal NK compartment and T cells proliferations and normalized serum proinflammatory
cytokines, with good evolution up to today and stopped GvHD treatment, only continue
with weekly subcutaneous gammaglobulin
Conclusion: Severe autoinflammatory syndrome represent a challenge for clinical immunologists.
HSCT was a curative treatment for our patient, who presented with a severe neonatal
autoinflammation due to an immunodeficiency that affect innate and adaptive immune
response
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2100 FASL gene mutation in a child with autoimmune lymphoproliferative syndrome
Madhubala Sharma1, Amit Rawat1, Deepti Suri1, Vignesh Pandiarajan1, Koon W. Chan2,
Yu L. Lau2, Surjit Singh1
1Allergy amd Immunology Department, Post Graduate Institute of Medical Education and
Research, Chandigarh, India; 2Department of Pediatrics and Adolescent Medicine, Queen
Mary Hospital, Hong Kong, Hong Kong
Correspondence: Madhubala Sharma
Introduction: Autoimmune lymphoproliferative syndrome (ALPS) is characterized by immune
dysregulation due to a defect in lymphocyte apoptosis. The clinical manifestations
may be noted in multiple family members and include lymphadenopathy, splenomegaly,
increased risk of lymphoma, and autoimmune disease, which typically involves hematopoietic
cell lines manifesting as multilineage cytopenias. Since the disease was first characterized
in the early 1990s, there have been many advances in the diagnosis and management
of this syndrome. The inherited genetic defect of many ALPS patients has involved
(FAS) pathway signaling proteins.
Objectives: To demonstrate genetic variation in a case of autoimmune lymphoproliferative
syndrome.
Methods: This case describes a 22-month-old female symptomatic from 2.5 months of
life. She had severe pallor, received a blood transfusion (TORCH infections panel-
negative). At 5.5 months she had anemia and ecchymoses over extremities and splenomegaly,
which Improved with oral prednisolone, however, she developed relapse during tapering
of oral prednisolone doses with cervical and axillary lymphadenopathy, hepatosplenomegaly-
spleen 6 cm below left costal margin.
There was no significant family history. Her elder male sibling is 9 years old, he
is alive and healthy.
Results: Following Investigations were made for her at 2.5 months and at 22 months:
I. 2.5 months
1. Hemoglobin- 3.3 g/dl, white cell counts- 39,600/cu.mm, differentials- P14 L58 M26
E12, platelet counts- 40,000/cu.mm, reticulocyte counts- 11.6%, LDH values- 306 IU,
peripheral smear- anemia, thrombocytopenia with lymphocytosis
2. Bone marrow- erythroid hyperplasia with increased lymphocytes
3. CD3 cell counts- 13,376/cu.mm, CD4 cell counts- 10,883/cu.mm, CD8 cell counts-
7,332/cu.mm, B cells- 6000/cu.mm, Double negative T cells- 23.9%
II. 22 months
IgG- >2509 mg% (310-1380)
IgA- 266 mg% (50-220)
IgM- 285 mg% (40-229)
Direct Coombs test- positive for C3d
Double negative T cells- 7.6% of all CD3+TCRαβ+ cells
Antinuclear antibody- negative
Antiphospholipid antibodies- negative
Flow cytometric Annexin V assay: effective apoptosis in the case was 9.8% (REDUCED)
compared to 41.2% in control
Sequencing of the FAS ligand gene identified a homozygous nonsense mutation in exon
1, c.343C>T, p.R115X. Father and mother both are heterozygous carrier the same mutation.
Conclusion: FASL gene mutations account for < 5% of all ALPS patients. The identification
of a nonsense mutation in the FASL gene confirms the diagnosis. However, serum FASL
levels could not be estimated in the child or the parents.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2101 Characteristics of the immunological status in patients with systemic and articular
form of juvenile idiopathic arthritis
Anna Y. Spivakovskaya, Yuri Spivakovskiy, Yuri Chernenkov
Depertment of Hospitality Pediatrics, Saratov State Medical University, Saratov, Russian
Federation
Correspondence: Anna Y. Spivakovskaya
Introduction: Juvenile idiopathic arthritis (JIA) brings together a diverse group
of chronic joint diseases. JIA is one of the most serious and potentially disabling
pathologies in pediatric rheumatology. The high frequency of occurrence, the tendency
to the progression of the pathological process, the possibility of systemic manifestations
with the involvement of internal organs, dictates the need for a more thorough and
comprehensive examination of patient's data. Identification of the features of the
immunological reaction in patients with various forms of the course of JIA has not
lost its relevance.
Objectives: To compare changes in cytokine (IL-1β, IL-6, INF-γ, IL-4) and chemokine
(MCP-1) profiles in patients with systemic and articular JIA.
Methods: The study involved 96 patients, ranging in age from 1,1 years to 16,11 years
(mean age 9,8 ± 4,2 years). A group of children with a verified diagnosis of JIA consisted
of 76 patients with a medicamentally supported inactive disease stage and a remission
stage. Of these, 20 patients with the systemic variant of the disease and 56 children
with the articular form of JIA (30 patients with oligoarticular and 26 with the polyarticular
variant of JIA). The comparison group consisted of relatively healthy children (n
= 20). The concentration of interleukins and chemokine in the serum of patients was
determined by enzyme immunoassay (ELISA) using ready-made commercial detection kits
- IL-1β, IL-4, IL-6, INF-γ and chemokine MCP-1 from the company “Vector-Best” (Novosibirsk,
Russia). The study was performed on a “Lazurite” automated immunoassay analyzer (Dynex
Technologies Inc., USA).
Results: The main changes in cytokine status in the examined patients were associated
with an increase in serum concentrations of IL-1β, IL-6 and INF-γ in relation to the
change in these parameters in volunteers from the comparison group. The serum IL-1β
concentration in the articular form of the disease was 1,1-1,7 times higher than in
patients with systemic JIA. The level of IL-6 in systemic arthritis was 1,2-1,6 times
higher than in the articular form of JIA. If the concentration of INF-γ in oligoarthritis
was only 1,3 times higher than in the control group, then in polyarthritis and systemic
arthritis it was 2,6-2,7 times higher, respectively. The course of JIA characterized
an increase in the level of chemokine MCP-1 in all variants of the disease by an average
of 1,5-1,9 times relative to the comparison group. Changes in the level of MCP-1 correlated
with the concentration of IL-1β and IL-6 (r = 0,6; p <0,05) in polyarthritis and with
IL-6 (r = 0,5; p <0,05) in systemic version of JIA.
Conclusion: The revealed fluctuations in immunological parameters in various variants
of JIA did not go beyond the general trends of the current pathological process. At
the same time, a number of features have been established that characterize various
forms of JIA. Investigation of the MСP-1 chemokine reaction makes it possible to increase
the informativeness of the JIA verification algorithm.
Disclosure of Interest
None Declared
Unusual or unsolved case reports
P2102 Early onset Behcets disease in an Indian family: is it related to A20 haploinsufficiency?
Vignesh Pandiarajan, Deepti Suri, Amit Rawat, Anju Gupta, Surjit Singh
Allergy Immunology Unit, Pediatrics, Postgraduate Institute of Medical Education and
Research, Chandigarh, India
Correspondence: Vignesh Pandiarajan
Introduction: A20 haploinsufficiency due to defect in TNFAIP3 has been recently described
as a monogenic cause for early-onset Behcets disease. Characteristic features include
presence of recurrent oral, genital and gastrointestinal ulcerations, fever, and presence
of multiple autoantibodies.
Objectives: To describe a child with early-onset Behcets disease who was identified
to have a defect in TNFAIP3
Methods: A 6-year-old girl was symptomatic since 6 months of age in form of recurrent
oral ulcers, fever, and genital ulcers. She had elevation in erythrocyte sedimentation
rate (ESR) (40 mm at 60 min) and C-reactive protein (CRP) (32 mg/L). HLA B51 and HLA
B27 were positive by polymerase chain reaction (PCR). Oral ulcers had shown a partial
response to colchicine therapy. She developed abdominal pain and gastrointestinal
bleeding at the age of 4 years. Colonoscopy revealed increased vascularity in terminal
ileum and biopsy revealed non-specific inflammation. Azathioprine was used to control
the bowel symptoms. She developed headache and blurring of vision at age of 5.5 years
and fundus revealed papilloedema. MRI Brain revealed features of type 2 Arnold Chiari
malformation. Antinuclear antibodies and anti-neutrophil cytoplasmic antibodies were
negative by indirect immunofluorescence. Her younger brother had recurrent oral ulcerations
from the age of 8 months.
Results: Genomic DNA was extracted and was subjected to Next Generation Sequencing
using an exome panel for known autoinflammatory disorders. A heterozygous missense
variation in exon 7 of the
TNFAIP3
gene (c.1504C>T; p.Arg502Trp) was detected. The variant has not been reported in the
1000 genomes database and in silico predictions are possibly damaging by PolyPhen-2
(HumDiv), and damaging by SIFT, LRT and Mutation Taster2. The mutation is validated
later by Sanger sequencing.
Conclusion: We describe a case of early-onset Behcets Disease from an Indian family
probably related to a novel heterozygous TNFAIP3 defect, however, functional validation
of the genotype is warranted to conclusively prove the association. Identification
of underlying genetic defect could pave way for future development of targeted therapies
for abrogation of inflammation.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2103 Two types of systemic amyloidosis in a single patient
Riccardo Papa1, Janet A. Gilbertson2, Nigel Rendell2, Ashutosh D. Wechalekar2, Julian
D. Gillmore2, Philip N. Hawkins2, Helen J. Lachmann2
1Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy;
2National Amyloidosis Centre, University College London Medical School, Royal Free
Hospital Campus, London, United Kingdom
Correspondence: Riccardo Papa
Introduction: The systemic amyloidoses are a group of rare diseases, in which extracellular
deposition of a variety of proteins in an abnormal fibrillar confirmation results
in life-threatening organ dysfunction. Acquired and hereditary amyloidoses differ
in their precursor proteins and predilection for specific organ involvement. Two types
of fibril have been reported in a single organ, and can complicate the same disease,
but two separate types of systemic amyloidosis have not previously been described
in a single patient.
Results: We report a woman of Sudanese origin who presented aged 31 with dysuria and
haematuria. She was found to have an estimated Glomerular Filtration Rate of 38 ml/min
and no proteinuria, and a renal biopsy demonstrated AA amyloid deposition. An I123
labelled SAP scan demonstrated a small amount of amyloid confined to the kidneys.
She had no overt underlying inflammatory disease, an infectious diseases work up,
including blood borne viruses, was negative and serial measurement of serum amyloid
A protein showed no significant elevation with a median of 5 mg/L. Retrospective molecular
analysis of the MEFV and TNFRSF1A genes, underlying Familial Mediterranean Fever and
the Tumor Necrosis Factor Receptor Associated Periodic Syndrome, revealed the heterozygosity
for MEFV E148Q and TNFRSF1A P46L common sequence variants of unknown significance.
Interpretation of the significance polymorphisms in two fever genes remains contentious
but given her persistently normal acute phase reactants they were felt to be of no
clinical relevance. Homozygosis for SAA1.1 allele of the SAA1 gene is a recognised
risk factor for AA amyloidosis, but testing showed she was heterozygous. Management
was blood pressure control only, and her inflammatory markers and renal function remained
stable until she was lost to follow up 3 years later.
Thirteen years after her renal biopsy she represented in end stage renal failure with
a history of weight loss, deranged liver function tests and marked easy bleeding.
Further investigation demonstrated well controlled C reactive and serum amyloid A
proteins, and an IgG lambda M-band with no serum free light chain bias. A bone marrow
demonstrated 7% neoplastic plasma cells and was complicated by a retroperitoneal bleed.
An SAP scan now showed a large amyloid load with amyloid deposition in the liver and
spleen obscuring the kidneys.Review of the bone marrow and a duodenal biopsy demonstrated
amyloid deposition which was AL (lambda) type by both immunohistochemistry and proteomic
analysis after laser dissection and mass spectroscopy. Review of the original biopsy
confirmed AA type amyloid by both immunohistochemistry and proteomics. Six-cycle chemotherapy
for AL amyloidosis was administered with complete clonal response. She remained on
dialysis and died four years later of a cerebrovascular accident.
Conclusion: This is the first reported case of two types of amyloidosis developing
consecutively in a single individual. The underlying inflammatory driver of her AA
amyloidosis was never identified and given that she had migrated some years earlier
from Africa, previous chronic infection that has resolved or responded to non-disclosed
prior treatment was thought to be the most likely cause. Whether the subsequent development
of AL amyloidosis was pure chance remains unclear. Theoretically chronic inflammation/infection
may drive generation of oligoclonal bands with the potential for monoclonal breakthrough.
Whether her AA amyloid deposits played a role by providing a template for deposition
of subsequent AL amyloidosis derived from an entirely separate precursor protein is
also unknown although this theoretically possible and has been shown in reverse in
mice models.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2104 MAFB not seems to regulate serum C1Q concentration in humans
Riccardo Papa1, Annalisa Madeo2, Stefano Volpi1, Roberta Caorsi1, Giancarlo Barbano3,
Marina Botto4, Andrea Superti-Furga5, Marco Gattorno1, Maja Di Rocco2, Paolo Picco1
1Clinica Pediatrica e Reumatologia; 2Malattie Rare; 3Nefrologia e Trapianto di Rene,
IRCCS Istituto Giannina Gaslini, Genova, Italy; 4Faculty of Medicine, Imperial College
London, London, United Kingdom; 5Division of Genetic Medicine, Centre Hospitalier
Universitaire Vaudois, Lausanne, Switzerland
Correspondence: Riccardo Papa
Introduction: MafB-deficient mice develop systemic lupus erythematous-like autoimmune
disease by inhibited C1q production and efferocytosis. MafB-deficient humans develop
multicentric carpotarsal osteolysis syndrome (MCTO), frequently followed by progressive
nephropathy.
Objectives: To investigate a possible role of C1q deficiency in patients with MCTO.
Results: Three patients with MCTO were enrolled (table 1). The patient A presented
recurrent urinary tract infections since 18 months of life for a third-degree vesicoureteral
reflux. Despite correction surgery, he displayed proteinuria after one year, and kidney
biopsy did not revealed significant lesions. After two years, he displayed bilateral
tarsal malformations requiring orthopedic surgery. At the age of 6, a pathological
fracture of the right wrist occurred, and local X-ray revealed osteolysis of carpal
bones. The patient B was treated with intra-articular steroid injection and subcutaneous
methotrexate for one year without benefit because of a suspected juvenile idiopathic
arthritis of the right wrist. After one year, he developed proteinuria and kidney
biopsy revealed focal segmental glomerular lesions with tubular fibrosis and renal
vasa sub-intimal delamination. C3 and C4 positive mesangial deposits were also present.
The patient C was sent to our observation for a suspected juvenile idiopathic arthritis
of the right wrist. No inflammatory signs were present at the ultrasound examination.
Sanger sequencing of the MAFB gene revealed in all the patients a novel heterozygous
mutation. Although specific variants have not been reported before, the nature and
position of the variants associated with the clinical features of the patients strongly
argued in favor of their pathogenic role. The serum C1q concentration was normal in
all the patients.
Conclusion: MCTO-associated progressive nephropathy is an orphan disease with dramatic
impact on the patient life who usually require kidney transplantation in the adulthood.
For that reason, despite ACE-inhibitor could reduce progression of kidney dysfunction,
retarding the onset of end state kidney disease, other treatments should be used to
permit a sufficient lifelong kidney function in patients with the well-known structural
kidney damage related to MafB-deficiency. Furthermore, a slight proteinuria reduction
in a patient with MCTO treated with cyclosporine has been reported. However, despite
further studies are necessary to exclude a role of complement system in the progressive
nephropathy of patients with MCTO, our study seems to exclude a MafB-dependent regulation
of complement component C1q production in humans.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P2104).
Main features of three patients with multicentric carpotarsal osteolysis syndrome
Patient A
Patient B
Patient C
Age (years); gender; country of origin
14; M; Croatia
16; M; Italy
11; F; Russia
MAFB mutation
c.184A>G, p.Thr62Ala
c.172A>G, p.Thr58Ala
c.208T>C, p.Ser70Pro
Bone lesions onset (age; years)
5
8
8
Presentation
Bilateral
Monolateral
Monolateral
Site
Tarsus
Carpus
Carpus
Current state (except carpotarsal joints)
Elbows and knees contractures
Knees contractures
None
Nephropathy onset (age; years)
3
9
None
Current state
Proteinuria (720mg/24h)
Proteinuria (1.3g/24h)
Normal kidney function
Serum C1q concentration
174 mg/l
312 mg/l
176 mg/l
P2105 Sibship with uveitis and sensorineural hearing loss
Pallavi Pimpale Chavan1, Mayur Morekar2, Raju P. Khubchandani1
1Section of Pediatric Rheumatology, SRCC Children’s Hospital; 2Consultant Eye Surgeon,
Bombay Hospital & Medical Research Centre, Mumbai, India
Correspondence: Pallavi Pimpale Chavan
Introduction: We hope to use this forum to guide us in the diagnosis for this family.
Objectives: We describe a family from India with three siblings having uveitis and
sensorineural hearing loss.
Methods: A 16 years male born of a non consanguineous marriage, sixth by birth order
was referred to us by an ophthalmologist for bilateral anterior non granulomatous
uveitis with band shaped keratopathy. There was no history of any constitutional symptoms
or apparent hearing loss.
On further enquiry and on reviewing records, there was a significant history of other
two female siblings suffering with uveitis and gradually progressive sensorineural
hearing loss while other 3 siblings (2 females and 1 male) were well.
Results: On examination, he had conjunctival congestion with no syndromic features.
Systemic examination was normal. His complete blood picture, erythrocyte sedimentation
rate, urine routine, urine for beta 2 microglobulin, mantoux test and chest X ray
were all normal. Due to a positive family history of hearing loss with uveitis, his
Brainstem Evoked Response Audiometry (BERA) was done which was suggestive of mild
sensorineural hearing loss.
He was started on topical steroids along with oral methotrexate (10.7mg/m2). Gradually
his topical steroids were tapered and stopped while oral methotrexate (9.7mg/m2) was
continued. His repeat BERA after a year has not shown any further deterioration and
no other systems or organs have been involved.
Conclusion: Literature search for this unique sibship with uveitis and sensorineural
hearing loss pointed us towards tubulointerstitial nephritis, uveitis, hearing loss
and vestibular failure (TINU) with atypical Cogan's overlap syndrome (Brogan.K et
al) but our three siblings screened negative for renal disease. We are awaiting further
genetic analysis. (Courtesy – Dr Daniel Kastner and Dr Ivona Aksentijevich)
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2106 An unsolved case including granulomatous panuveitis from India
Pallavi Pimpale Chavan1, Mihir Kothari2, Raju P. Khubchandani1
1Section of Pediatric Rheumatology, Jaslok Hospital and Research Centre; 2Pediatric
Ophthalmologist, Jyotirmay eye clinic for children and binocular vision laboratory,
Mumbai, India
Correspondence: Pallavi Pimpale Chavan
Introduction: We hope to use this forum to guide us in the diagnosis and management
of this child.
Objectives: We describe a child from India, who presented with bilateral congenital
glaucoma, recurrent granulomatous uveitis with episodes of fever, drowsiness, rash
and arthritis.
Methods: A 5.6 years old male born of a second degree consanguineous marriage presented
at birth with watery eyes and was diagnosed with bilateral congenital glaucoma at
2 months of age. Since 8 months of age, he had episodes of fever with recurrent granulomatous
uveitis and ‘boil’ like rash on his face since 1 year of age. Gradually the frequency
of fever spikes increased to 2-3 per month with drowsiness and increase in rash. At
2 years of age, he developed swelling of the right knee.
There is a notable family history of vertically transmitted sensorineural deafness
in paternal grandfather, mother and elder sibling with arthritis in mother and maternal
uncle.
Results: When he presented to us, on examination, he had failure to thrive, delayed
milestones, poor vision, hearing loss, erysipelas like rash on the face and limbs
with hepatosplenomegaly and arthritis of the right knee. His investigations were suggestive
of anaemia (5.1 - 9.4 g/dl), normal leucocyte counts with monocytosis (max 13%), intermittent
thrombocytopenia(30000/cmm) with raisedESR (14-124mm/hr) and CRP(13-368 mg/l). He
had hypertriglyceridemia with mild ferritin elevation and (1:40) 1+ ANA.
His Immunoglobulin profile, Bone marrow, skin and conjunctival biopsy were all normal.
Computed Tomography (CT) brain didnot show any intracranial calcification. Mutation
studies were sent for BLAU and CAPS, which were negative. His interferon signals were
negative.
To date he has received oral corticosteroids, methotrexate, colchicine and thalidomide
(as canakinumab and anakinra are not available in our country). After starting thalidomide,
in the last 10 months his frequency of fever, rash, arthritis and uveitis has reduced.
He is regularly taking topical drugs and following up with the ophthalmologist and
has eventually developed cataract, retinal detachment, left eye corneal decompensation,
pthisis bulbi (all sequelae of the panuveitis).We propose to start adalimumab for
him.
Conclusion: We have achieved quiescence of disease in this child but do not have a
diagnosis and are awaiting further genetic analysis. (Courtesy – Dr Daniel Kastner
and Dr Ivona Aksentijevich)
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2107 An unsolved case: is this a Candle-like syndrome?
Alessia Pin1, Alessandra Tesser2, Flavio Faletra2, Alberto Tommasini2, Serena Pastore2,
Andrea Taddio1,2
1Department of Medicine, Surgery and Health Sciences, University of Trieste, Italy;
2Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy, Trieste,
Italy
Correspondence: Alessia Pin
Introduction: Chronic Atypical Neutrophilic Dermatosis with Lipodystrophy and Elevated
Temperature (CANDLE) syndrome is a complex autoinflammatory disorders arising from
inborn defects in immunoproteasome. Several genes can be involved and cases with digenic
inheritance have been described. However, many cases remain without the identification
of a specific genetic defect. A positive interferon signature is typically found in
patients and may serve as a diagnostic clue.
Objectives: To describe clinical and genetic features in a girl with CANDLE and in
her relatives with a variety of different rheumatologic complaints.
Methods: We performed Whole Exome Sequencing (WES) on 10 family members. Moreover,
we assessed RNA-seq on three sample from the proband, collected during acute phases
of disease (samples positive to class I interferon signature (IS)) (1), and her parents.
Results of RNA sequencing (RNA-seq) were compared with specimens from healthy controls.
Differentially expressed genes (DEGs) were filtered by fold change > 2 and padj <
0.05. DEGs enrichment were performed using different R packages, such as pathfindR.
Results: We describe the case of a 20 years old girl with clinical and biological
data supportive of CANDLE syndrome. At the age of 3 years, she started presenting
a clinical picture reminiscent of amyopathic dermatomyositis, with skin rash, lipodystrophy,
subcutaneous panniculitis nodules, and more recently with chilblains, skin ulcerations,
polyarticular arthritis and alopecia.
Her pedigree includes several relatives with rheumatic disorders, but none has a clinical
picture as complex and severe as our patient.
This girl was found to have a strongly positive class I IS in peripheral blood cells.
After several unsuccessful therapeutic attempts with antirheumatic drugs and biologics,
the girl showed a dramatic clinical response to the JAK inhibitors tofacitinbib.
IS resulted positive also in 4 of her relatives, three of whom presented also rheumatologic
symptoms. Conversely, one uncle of the girl was affected with rheumatologic symptoms
but had negative IS. The pedigree may suggest a complex pattern of inheritance, likely
with a major dominant disorder, whose expression can be modulated by multigenic and/or
environmental factors.
WES failed to detect significant genetic variants in proteasome components. However,
RNA-seq revealed a profile of differentially expressed IFN-regulated genes similar
to that reported by Anja Brehm et al. in subjects with CANDLE/PRAAS (2).
Conclusion: Our results suggest that our family may present a multigenic form of CANDLE,
with a complete clinical picture only in the proband, whilst other relatives may only
present partial or incomplete forms of the disease.
1.Rice GI, et al. Assessment of Type I Interferon Signaling in Pediatric Inflammatory
Disease. J Clin Immunol. 2017 Feb;37(2):123-132. doi: 10.1007/s10875-016-0359-1. Epub
2016 Dec 9.
2.Brehm A, et al. Additive loss-of- function proteasome subunit mutations in patients
with CANDLE/PRAAS promote type I IFN production. J Clin Invest. 2016 Feb;126(2):795.
doi: 10.1172/JCI86020. Epub 2016 Feb 1.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2108 A case of sting-associated vasculopathy with onset in infancy (SAVI) without
skin involvement
Carmela Gerarda Luana Raffaele, Virginia Messia, Manuela Pardeo, Camilla Celani, Silvia
Federici, Gianmarco Moneta, Ivan Caiello, Claudia Bracaglia, Fabrizio De Benedetti,
Antonella Insalaco
Division of Rheumatology, IRCCS, Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Carmela Gerarda Luana Raffaele
Introduction: STING-associated vasculopathy with onset in infancy (SAVI) is a newly
described type I interferonopathy caused by autosomal dominant gain-of-function mutations
in Transmembrane Protein 173 (TMEM173) gene. It is characterized by early-onset systemic
inflammation with increased levels of acute phase reactants, severe cutaneous vasculopathy
leading to extensive tissue loss and severe interstitial lung disease (ILD)
Objectives: to describe an atypical clinical phenotype
Methods: A 4 year-old young girl presented since the first months of life with recurrent
fevers, arthralgia, persistent cough and failure to thrive (below the 5th percentiles).
She never showed skin rash. At the age of 3, she was admitted to our hospital for
persistent fever and arthritis of left knee and right ankle. She started ibuprofen
without any benefit. Laboratory tests showed persistently elevated CRP and serum amyloid
A levels, persistent microcytic anemia and increased IgG levels. Highly positive antinuclear
antibody (title 1:640, homogeneous pattern) with positive p-ANCA was detected. Immunological
and cytogenetic studies performed on bone marrow were normal. Both sweat and genetic
test for cystic fibrosis were negative. She started low-dose glucocorticoids with
incomplete response, persistent cough and polyarthritis in small joints. Chest X-ray
and CT scan showed a severe interstitial lung disease (ILD) with bronchiectasis and
small nodules. Extensive investigations for bacteria, virus and fungi and cytological
tests on blood and bronchoalveolar lavage were negative. A lung biopsy revealed desquamative
interstitial pneumonia. High-dose methylprednisolone, subcutaneous methotrexate and
rituximab were started. Whole blood from patient and healthy donors (HD) (n = 10)
were collected into PAXgene tubes. The type I IFN signature was defined by the expression
levels of six IFN-regulated genes (IFI27, IFI44L, IFIT1, ISG15, RSAD2, SIGLEC1), measured
by quantitative polymerase chain reaction (qPCR). As previously described by Rice
GI, the median fold change of each IFN-induced gene, when compared with the median
of the combined HD, was used to calculate the type I IFN score. The mean type IFN
score of the HD plus two SD was calculated; we considered as positive a type IFN score
higher of 1,42
Results: Because of a persistent inflammatory state, ILD and polyarthritis, an autoinflammatory
syndrome with lung involvement was suspected (COPA and SAVI Syndromes) The sequencing
of coatomer associated protein subunit alpha (COPα) gene showed no mutations while
the molecular analysis of the TMEM173 gene by NGS showed the presence of c.463G>A
(p.Val155Met) variant in heterozygotic status. Whole-blood gene expression studies
demonstrated increased IFN signature (182,2), consistent with the values reported
in SAVI patients and in other interferonopathies already described. Elevated levels
of CXCL-10 (>1000 pg/ml) were also found
Conclusion: The clinical picture of SAVI syndrome is characterized by early-onset
(in the first month of life) cutaneous vasculitis, recurrent fevers, ILD, and systemic
inflammation. Our patient never developed skin rash unlike the cases described in
literature. Therefore, the lack of typical skin lesions should not exclude this clinical
suspicion since the respiratory and systemic inflammatory components of the disease
may predominate. In the context of early age of onset, ILD, failure to thrive and
recurrent fevers, SAVI must be considered as a differential diagnosis. A better understanding
of the genotype–phenotype correlation is needed to improve SAVI management and prognosis.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2109 A boy with severe phenotype of immune deficiency and relapsing hyperinflammationcured
with a hematopoietic stemcell transplantation
Kim Ramme1, Yenan Bryceson2, Mikael Sundin1, Sofie Vonlanthen3, Anna Carin Horne4
1Pediatric Hemathology, Karolinska Hospital; 2Department of Medicine, Karolinska Institutet;
3Molecular Biology; 4Department of Paediatric Rheumatology, Karolinska Hospital, Stockholm,
Sweden
Correspondence: Kim Ramme
Introduction: Patients with a clinical picture of immune deficiency combined with
severe inflammation present significant challenges in diagnosis and treatment.
Objectives: Description of the phenotype and treatment of a patient with immune deficiency
combined with severe hyperinflammation.
Methods: We have investigated a boy of non-consanguineous parents of Middle East origin,
with extended immunologic and genetic studies..
Results: The boy was born after an uncomplicated pregnancy at 36+6 wks.At two wks
of age he developed problems moving his right leg. Osteomyelitis was suspected but
never confirmed. At admission he had an unspecific skin rash, pancytopenia and very
high inflammatory markers He then developed periodic fever, near-fatal episodes of
enterocolitis and reoccurent macrophage activation syndrome (MAS). The boy also suffered
different suspected and confirmed infections (Enterococcus coli and Enterococcus faecalis)
requiring broad-spectrum antibiotics and ICU admission.The immunological work-up initially
showed very high levels ofIL-18 (55,000) but normal levels of IFN-gamma. It also showed
showed initially low peripheral blood T- and B-cell as well as NK-cell numbers. T-cells
and NK-cells were gradually improving when the hyperinflammation was under control,
however the B-cells remained low.Both the CD4+ and CD8+ lymphocytes showed a normal
response to stimulation with mitogen and superantigen with FASCIA. Clinical features
suggested hemophagocytic lymphohistiocytosis (HLH) or NLRC4 which led to a rapid examination
of functional studies and the most common genes for these syndromes, which were absent.
Whole genome sequencing was performed and analyzed for genes linked to primary immune
deficiencies and autoinflammatory conditions, but no genetic alterations linked to
the phenotype were found. Treating the reoccuring infections and the hyperinflammation
was a balancing act. Supportive care included regular transfusions of erythrocytes
and platelelts as well as total parenteral nutrition.Steroid pulses were initially
given to reduce hyperinflammation, followed by peroral dexamethasone and then high-dose
Anakinra(10 mg/kg/day).As the dose was lowered hyperinflammation reoccured. Unfortunately
neutropenia, a side effect of Anakinra, developed. This was controlled by the addition
of colony stimuli factor. The hyperinflammation slowly improved (over months), although
an infection triggered a further life-threatning relapse. Due to his severe phenotype
a hematopoietic stem cell transplantation (HSCT) was considered necessary, with cord
blood as the stem cell source. His condition was initially stable with a complete
donor-chimerism, but he later developed a severe thrombocytopenia secondary to immune
suppression. Consequently, the immune suppression was stopped at approximately eight
months following transplantation, with a marked improvement of the thrombocytes. Unfortunately
however he then developed suspected severe GVHD of the skin and a myopathy. This is
currently being treated with methotrexate and Etanercept.
Conclusion: During recent years the progress in immunological phenotyping and genetic
investigations have improved tremendously, requiring close collaboration between physicians,
clinical immunologists and molecular biologists. However, there are still patients
where a specific genetic diagnosis cannot be established, making the choice of treatment
difficult. In this case a boy with a severe phenotype of immune deficiency and relapsing
hyperinflammation was cured with an HSCT.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2110 Two genes and one phenotype: same therapy?
Silvia Ricci1, Ilaria Pagnini1, Elena Sieni2, Chiara Azzari1, Martina Cortimiglia1,
Giusi Mangone1, Lorenzo Lodi1, Elisa Calistri1
1Pediatric Immunology, AOU Meyer- University of Florence, Florence, Italy; 2Paediatric
Haematology/Oncology, AOU Meyer- University of Florence, Florence, Italy
Correspondence: Silvia Ricci
Introduction: We report two cases of 2-years old twins with periodic fever. They were
born at 36 weeks of gestational age after pregnancy with donor oocytes in-vitro fertilization
(IVF). The patient came to our attention at 1 year of life due to recurrent episodes
characterized by high fever (39-40°C) for 3-4 days, associated with bilateral cervical
lymphadenopathy, diarrhea, not constantly morbilliform rash. Laboratory findings,
during these episodes, included leukocytosis, thrombocytopenia, anemia, and elevated
C-reactive protein. Our patients were generally well between attacks. Regarding their
past clinical history: at first months of life they underwent to intervention foranal
fistula, discovered on neonatal period. They suffered also from recurrent wheezing
since the introduction in the nursery. They presented optimal growth and good psychomotor
development.
Results: We performed immunological workup that evidenced elevated levels of immunoglobulin
D (P1: 150 mg/L and P2 250mg/L, normal values 5-120mg/L) and serum amyloid A (P1 124
mg/L and P2 89 mg/L; normal values < 6.4 mg/L), normal immune-phenotyping, with normal
lymphocyte T and NK function. We performed analysis of the MVK gene and we identified
two known1missense compound heterozygous mutations: c.803T > C (p.I268T) and c.1129G
> A (p.V377I). In particular, p.I268Tis described in homozygosity in a patient who
died at 4.5 months of age. Moreover, other authors, demonstrated in fibroblast-derived
lysates of patients with the same mutation, markedly reduced or absent mevalonate
kinase activity and in vitro studies they demonstrated dramatically reduced enzyme
activity of the mutant protein. These data indicate that the p.I268T mutation markedly
affects enzyme stability and activity2-4. In 2016, the same genotype p.V377I /p.I268T
was described in 25 patients of a cohort of 114 patients (21%) from the Eurofever
Register5. The study demonstrated statistically significance between patients with
p.V377I/p.I268T versus all other genotypes for amyloidosis developing (p 0.049).
At the same time, for the history of perinatal anal fistula and recurrent inflammatory
attacks, despite no complete criteria for HLH (Hemophagocytic lymphohistiocytosis),
knowns FHL (Familial Hemophagocytic Lymphohistiocytosis) genes and SH2D1A and XIAP
genes were sequenced and a known hemizygous mutation c.1408A>T (p.T470S) was revealed
on XIAP gene (chromosome X). Evidently, it was no possible to demonstrate hereditary
of this mutation, because maternal DNA was not available. This mutation is a known
missense mutation with very low frequency (reported with frequency <1% in HGMD) and
previously reported as causative of XLP26(X-linked lymphoproliferative disease 2)
and very early onset Crohn’s disease (VEOIBD)7. Cytofluorimetric and western blotting
analysis showed good expression of XIAP protein in our patients. No others functional
analysis was performed, until now. After initial treatment with nonsteroidal anti-inflammatory
drugs and steroids given during attacks, therapy was switched to colchicine without
clinical success.
Conclusion: On the basis of frequent association between their MVK genotype and amyloidosis
(16% of patients)5, and persistent high levels of serum amyloid A (mean values: P1
261mg/L and P2 120mg/L) we decide to start with IL-1 inhibitor (Anakinra) that based
on limited literature data, appeared to improve symptoms and could induce complete
remission in patients with MKD. Moreover, studies are ongoing to test the response
to IL-1 inhibitor in lymphoproliferative disease. The coexistence of mutations of
different autoinflammatory syndromes in our patients has been reported very rarely,
and its implications are not totally clear, but they include atypical clinical manifestations
with a variable response to treatment.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2111 Autoinflammatory phenotype as a mask of oncological pathology
Evgeny Fedorov, Svetlana Salugina
Nassonova Research Institute of Rheumatology, Moscow, Russian Federation
Correspondence: Svetlana Salugina
Introduction: The interest of the professional community in auto-inflammatory diseases
(AID) is growing worldwide. Diagnosis of AID began to be made more often. It must
be remembered that AID is a diagnosis of exclusion of other conditions with a similar
clinical picture, including oncological pathology.
Objectives: To present the observation of oncological disease in a child with suspected
AID.
Methods: Clinicalcase of a 5-year-old girl who entered the Federalrheumatological
center in April 2018 to exclude AID. Complaints at admission were periodic fever 38.5
lasting 6-7 days, abdominal pain, increased posterior cervical lymph nodes, sometimes
tonsillitis attacks, arthralgia, weakness, fatigue. Patient was examined according
to the standard program of the patient with systemic juvenile arthritis (soJIA). Infectious
diseases were excluded. X-ray examination and radioisotope skeleton scintigraphy,
bone marrow biopsy, molecular genetic analysis using automatic sequencing for mutations
in the NLRP3 and TNFRSF1A genes in hot points were performed.
Results: The family history of AID is not burdened. The patient is sick from 4 years
(from February 2017). In the onset of disease - febrile fever, pain in the cervical
spine, cervical lymphadenopathy. After 2 months arthralgia of the knee, synovitis
of the hip, claudication appeared. On examination, it was an increase of acute phase
markers, anemia. At the initial examination infections, tuberculosis were excluded,
on abdominal CT - an increase in para-aortic lymph nodes, radioisotope scintigraphy
of the skeleton without pathologicalfeatures. According to bone marrow biopsy, there
is no data for hematologic disease. Diagnosis: soJIA. Treatment: NSAIDs, against the
background of which the pain in the joints stopped. From the 5th month of the disease
was in the form of monthly febrile fevers, lasting 6-7 days, accompanied by hyperemia
of the pharynx and raid on the tonsils, spotty rashes, enlarged cervical lymph nodes,
abdominal pain, pain in the knee. ESR 59 mm/h, Hb-96 g /l, CRP-43.8 mg/l, WBC-7.3х109/l
. During hospitalization in the rheumatological center in April 2018 there were febrile
fever, weight loss, intoxication (weakness, lethargy, moodiness), generalized lymphadenopathy,
liver enlargement, arthritis of the left hip joint, Hb 92 g /l, ESR 48 mm/h, CRP 30
mg/l. There were no pathogenic mutations in the NLRP3 and TNFRSF1A genes. On the X-ray
of the pelvis and scintigraphy - multiple lesions in the bones. Sent for re-examination
by an oncologist. The increase in the level of the tumor marker of a neuron-specific
enolase detected during additional examination, the results of the femur biopsy confirmed
the diagnosis: low differentiated neuroblastoma without primary focus, 4 stages with
multiple lesions in bones and para-aortic lymph nodes
Conclusion: The diagnosis of AID should be considered only after the exclusion of
other, more common and severe pathologies. In clinical practice physicians who areworking
withpts with an auto-inflammatory phenotype should be aware of possibility of oncological
disease.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2112 Coexistence of familial Mediterranean fever with celiac disease in armenian
patient (case report)
Hasmik Sargsyan
Pediatrics N2, Yerevan State Medical University, Yerevan, Armenia
Introduction: Familial Mediterranean Fever (FMF) is autosome-recessive inherited disorder,
particularly frequent around the Mediterranean basin. FMF shows a marked ethnic distribution;
it is most frequently observed in Armenian, Jewish, Turkish and Arabic communities.
In general, FMF is characterized by recurrent episodes of fever, associated with serositis.
Celiac disease (CD) known as gluten enteropathy is immune-mediated inflammatory disease
of the small intestine caused by gluten sensitivity in genetically predisposed people.
The most common symptoms of CD are chronic diarrhea, anorexia, weight loss, abdominal
distention and pain. However, both of the diseases share some common clinical features
and sometimes, both of the diseases are associated with many inflammatory and autoimmune
diseases. It is necessary to mention, that there are some cases of FMF with CD in
the literature.
Objectives: We present FMF patient coexistence of CD. Despite the high level of FMF
in Armenia, this is the first case of these two disorders.
Methods: Clinical and laboratory findings are presented.
Results: 14 years old boy admitted to the “Arabkir” Medical Center with complains
of: fever, recurrent abdominal pain, chest pain, arthritis of knee and ankle, sometimes
nausea, vomiting, irregular stool. Manifestation of disease began from the four years
old. The attack was 3-5 times per month each lasting typically for 3-4 days. There
is a family history of FMF: sister and brother have FMF (with M694V/M694V mutation).
Physical examination revealed M-46, P-168, BMI-16,31, paleness, low muscular tone,
enlargement of the spleen.Some investigations as a IgA, IgM, IgG, C3, C4, ASLO, RF,
PT, serological tests for viral or bacterial infections were negative, kidney and
liver tests also without any abnormalities. The inflammation markers were positive
(CRP 176.11(N<5mg/dl), ESR 25mm/h, ferritin 101.27(30-300ng/ml). Chest X-ray revealed
exudates in the costophrenic angle from the two sites, EchoCG – aseptic pericarditis,
ultrasound of abdomen – splenomegaly and fluid in abdomen. The vitaminD were checked.
Specific markers of CD (T-TG IgA 92.6(N<10), HLA DQ2, HLA DQ8, EMA IgA) was positive.
Duodenum biopsy was revealed Marsh Type III. Genetic investigation of MEFV discovered
M694V/M694V mutation. We established the diagnosis of FMF and CD at the same time
rule out other diseases (endocrine, autoimmune, ets.). It was started the treatment
with colchicine 1mg/day and gluten-free diet.
Conclusion: This is a family case of FMF, one of the member has a CD.It is necessary
to continue investigations the siblings in the field of CD. Not excluded, that should
be revealed some factors which can confirm familial form of CD in this family. However,
for the understanding relationship between CD and FMF should be further studies with
more patients for a providing precise interpretation.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2113 Inflammation arising on combined genetic background characterized by simultaneous
occurrence of NOD2 and IFNGR1 mutations
Anna Sediva1, Zuzana Parackova1, Markéta Bloomfield1, Adam Klocperk1, Irena Zentsova1,
Michael Svaton2, Eva Froňková2
1Department of Immunology; 2Department of Pediatric Hematooncology, Motolm University
Hospital, 2nd School of Medicine, Charles University, Prague, Czech Republic, Prague,
Czech Republic
Correspondence: Anna Sediva
Introduction: New technologies such as NGS enable elucidation of genetic cause in
patients with primary immunodeficiencies with complex, atypical or ambiguous presentation.
Here we present a patient with a complicated clinical picture characterized by severe
bcgitis in the neonatal and infant age, followed later by manifestations of autoinflammation
characterized by generalized skin lesions, lymphoproliferation, recurrent erythema
nodosum, joint involvement and bone lesions.
Objectives: NGS and testing of immune function in an effort to precise diagnosis and
set personalized therapy.
Methods: NGS was performed by Illumina-based technology, functional assays included
complex immune profiling, analysis of signalling pathways and cytokine response after
stimulation by IFNg (due to IFNGR1) and muramyl dipeptide (MDP) (in a context with
NOD2 mutation). To verify the effect of the therapy functional tests were repeated
after initiation of Methotrexate treatment.
Results: In the patient, mutations in IFNGR1 and NOD2/CARD15 genes were detected simultaneously
bearing an increased susceptibility to mycobacterial infections and NOD2 associated
Blau syndrom. The patient’s cellular phenotype correlated with known features of partial
IFNGR1 deficiency, a marked overexpression of surface IFNGR1, decreased IFNγ-induced
STAT1 phosphorylation, overproduction of IFNγ by T cells upon stimulation, significantly
decreased IL-12p70 production by PBMCs upon IFNγ and LPS co-stimulation and a reduction
of expresion of STAT1-inducible genes, CXCL10 and IRF1. The functional property of
the NOD2 mutation indicated an enhanced basal NFκB activation, MAPK phosphorylation
and expression of transcription factors c-Jun and c-Fos. The stimulation with MDP
resulted in further increase of NFκB activation, but only minimal increase in MAPK
phosphorylation.
Interestingly, treatment with methotrexate alone almost completely resolved the inflammatory
symptoms. This was paralleled with suppression of untreated and MDP-induced NFκB activation,
MAPK activation and MDP-induced and simultaneous IFNγ and MDP-induced production of
cytokines.
Conclusion: We present here the patient with a dominant autoinflammatory phenotype
consistent with NOD2 related Blau syndrome, influenced by a simultaneous immune deficiency
based on IFNGR1 mutation. Based on the results of functional testing we hypothesize
that both mutations exhibit certain mutual alteration. While the NOD2-derived proinflammatory
bias may decrease the susceptibility to mycobacterial infections associated with IFNGR1
deficiency, the strongly Th1-polarized immune system may accentuate the inflammatory
responses via IFNγ-driven priming of NOD2-mutated cells, reflecting in the patient’s
severe granulomatous disease. We also show significat effect of methotrexate chosen
to influence granulomatous inflammation in a situation when antiTNF treatment could
not be used due to an increased susceptibility to Mycobacteria.
Disclosure of Interest
None Declared
P2114 Relapsing-remitting systemic and neurological symptoms in Griscelli disease
Alessandra Tozzo1, Nicoletta Milani1, Gianluca Marucci2, Luisa Chiapparini3, Alessandra
Erbetta3, Elena Sieni4, Nardo Nardocci1
1Neuropsichiatria Infantile; 2Anatomia Patologica; 3UOC Neuroradiologia, Fondazione
IRCCS Istituto Neurologico Besta; 4Oncoematologia Pediatrica, Azienda Ospedaliero-Universitaria
A.Meyer, Milano, Italy
Correspondence: Alessandra Tozzo
Introduction: We present the case of a 3 years old Romanian healthy boy who developed
a relapsing-remitting multifocal encephalomyelopathy and episodic pancytopenia, hepatosplenomegaly
and fever.
Objectives: Our patient had a physiological and a remote pathological anamnesis mute
up to 3 years of age.
He was the first-born of non consanguineus parents.
He appeared as an healthy child with very light hairand skin. After some day of a
flu-like syndrome,he showed systemic symptoms (fever, pancytopenia, hepatosplenomegaly)
and then developed neurological symptoms consisting of focal epilepsy, cerebellar
signs, right hemiparesis.
Systemic and neurological symptoms were responsive to steroids.
After a short period of well being, he had two more episodes of worsening of neurological
symptoms. A few months later, during steroid and antiepileptic therapy, he developeda
rightnon-convulsive status epilepticusand then a contralateral one.
Methods: Neurological symptoms werein temporal correlation with the appearance ofmultifocal
extensive lesions of the white matter in brain andcervical cord, with enhancement.
The CSF investigations showed a mild protein elevation. Brain biopsy was compatible
with non-specific findings suggestive of inflammatory pathology. We made further investigations
in order to exclude infective, metabolic, autoimmune or autoinflammatory diseases
. The strong diagnostic suspicion in the context of pathologies that could secondarily
be associated with hemophagocytic lymphohistiocytosis induced a deepening in specific
immunodeficiencies.
Results: We identified a mutation in Rab27a in homozygosity responsible for the type
II Griscelli syndrome.
Conclusion: Griscelli Syndrome Type 2 (GS-2) is caused by mutations in RAB27A gene
and is associated with immunological dysfunction without primary neurological impairment.
The cytotoxic defect caused by RAB27A mutations is responsible for triggering the
hemophagocytic syndrome characterized by acute onset of uncontrolled T-lymphocyte
and macrophage activation. Neurological symptoms in GS-2 may be due to infiltration
of brain by the activated hematopoietic cells (1). A relapsing- remitting course is
not typical for GS-2. We can’t demonstrate a sure hemophagocytic syndrome (ferritin
was always normal) but we had episodic pancytopenia, hepatosplenomegaly and fever
responsive to steroid. Unfortunately, although the genetic defect was identified,
the child's general condition was too compromised to carry out a stem cell transplant
and medical therapy proved ineffective; after a long period of medicaltreatment the
patient died. This case showes the importance to not avoid to consider rare conditions
even with atypical manifestations.
Reference
(1) Intractable Rare Dis Res. 2017 Feb; 6(1): 76–79. “Griscelli syndrome subtype 2
with hemophagocytic lympho-histiocytosis: A case report and review of literature”.
Priyanka Minocha, Richa Choudhary, Anika Agrawal, Sadasivan Sitaraman
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2115 Deficiency of adenosine deaminase 2: the importance of a diagnosis before irreversible
damage
Elena Tronconi1, Francesca Conti1, Duccio M. Cordelli2, Stefano Volpi3, Marco Gattorno3,
Andrea Pession1, Angela Miniaci1
1Department of Pediatrics; 2Child Neurology and Psychiatry Unit, Pediatric Department,
Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna; 3Clinica Pediatria
e Reumatologia, Istituto Giannina Gaslini, Genova, Italy
Correspondence: Elena Tronconi
Introduction: We present the case of a 15 years old girl who was admitted to our hospital
for acute lower limb flaccid paralysis.
Results: Physical examination revealed marked and diffuse livedo reticularis. Neurologic
exam showed peripheral deficit of the VII cranial nerve, motor activity at lower limbs
was absent with sensitive deficit. She underwent a brain and spinal magnetic resonance
imaging (MRI) showing multiple areas of signal abnormalities (T2 hyperintensity) in
both thalamus and basal ganglia, small area in the spinal cord at C2-C3, at D10-D11
and L1 levels; these images were related to vascular damage. Blood exams showed high
blood counts and high inflammatory markers (PCR 16.76 mg/dl). Coagulation was normal,
antiphospholipid and antinuclear antibodies were negative, immunological work-up showed
normal immunoglobulins level, T and B phenotype. She started intravenous steroid and
received high dose intravenous immunoglobulin in 4 days. The constellation of findings
led to clinical suspicion for adenosine deaminase 2 (ADA2) deficiency (DADA2), which
was confirmed by low plasma ADA2 activity. For the presence of microhematuria, worsening
proteinuria and hypertension, vascular ultrasound was performed with no evidence of
renal artery stenosis. She underwent renal biopsy negative for glomerulonephritis,
renal vasculitis and amyloidosis. Following the diagnosis of DADA2, she was initiated
on etanercept 50 mg once weekly and she was able to switch from intravenous to oral
prednisone and to start its tapering with normalization of inflammatory markers and
improvement of skin rash. She underwent an intensive daily rehabilitation training
with improvement in the trunk stability but without recovery of the leg paralysis.
The girl is the second of 3 children, born from consanguineous parents (first grade
cousin) of Italian origin. By the age of 1 she started suffering from fever, arthritis,
pericarditis with elevation of inflammatory markers and was diagnosed with systemic
juvenile idiopathic arthritis (sJIA). At that time, she already presented livedo reticularis
and chronic disease anemia. She was treated with short term oral steroid first and
later with methotrexate with remission of fever and articular symptoms. She presented
speech delay. At the age of 2 presented a convulsive crisis. Polysomnography and brain
MRI were negative. One year later she presented a convulsive status epilepticus, brain
MRI was repeated and resulted negative. She was started on topiramate with no further
crisis, treatment was stopped 2 years later. When she was 9, she was admitted for
pancytopenia and she was diagnosed of Leishmania infection. The two siblings of the
girl were tested for plasma ADA2 activity and both resulted deficient. The boy is
a 12 years old boy with mild development delay and a previous diagnosis of sJIA at
the age of 5. He was treated with steroid and Methotrexate with remission. The older
sister is now 19 years old and she had an episode of erythema nodosum. Genetic testing
of all the family members is still pending. In 2014, two independent groups, Zhou
et al. and Navon-Elkan et al., described the first 34 patients with disease-associated
mutations in ADA2. During the past 4 years, over 170 new patients of many ancestries
have been reported in the literature showing a highly variable phenotype.
Conclusion: Given the important morbidity, especially in consanguineous families,
a high index of suspicion is needed for early diagnosis and precocious intervention,
before persistent neurologic damage has been established. Our report describes for
the first time a new neurological presentation as acute transverse myelitis in a patient
with DADA2.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2116 The case study of undifferentiated autoinflammatory disease treated with anakinra
Marina Visnevska1, Anija Meiere1, Zane Davidsone1, Ruta Santere2, Valda Stanevica1
1Rīga Stradiņš University; 2Children's Clinical University Hospital, Riga, Latvia
Correspondence: Marina Visnevska
Introduction: Patients with symptoms commonly found in autoinflammatory disorders
may not fit a specific diagnosis, either because their clinical phenotype is nondiagnostic
or genetic tests are negative. The term undifferentiated systemic autoinflammatory
disorder (uSAID) has been used to describe such cases (Harrison et al., 2016). Recognizing
uSAID requires a high degree of clinical suspicion and remains a diagnosis of exclusion
with suboptimal treatment.
Objectives: To report an unsolved case of uSAID with successful anti-IL-1 treatment.
Methods: We report a case of a 10-year-old boy, presented in Children’s Clinical University
Hospital in Riga, Latvia in December 2013 with fever lasting for 3 weeks and knee
joint pain.
The boy was born full term from physiological pregnancy and had no family history
of autoinflammatory disease or consanguinity. In medical history he had surgical treatment
of cryptorchidism, frequent pneumonia, bronchitis episodes and asthma diagnosis in
later childhood. At the age of 7 he experienced an episode of bloody diarrhoea. Since
the age of 8 he had recurrent acute otitis media.
In December 2013, while in hospital, ultrasound showed bilateral suprapatellar bursitis.
Temperature elevations were not observed. The patient was treated as reactive arthritis
with NSAIDs. In January 2014 he developed recurrent episodes with fever up to 40°C
every 3-4 days. Laboratory tests showed CRP 10 mg/L, ESR 73 mm/h, negative autoimmune
profile and normal results of bone marrow biopsy (BMBx). The examinations and clinical
findings suggested systemic JIA (> 1 joint involved, fever > 2 weeks, hepatosplenomegaly).
Fever and knee joint pain disappeared at first with pulse corticosteroid (CS) treatment.
Until July 2016, he received treatment with 6 CS pulses, low-dose oral CS daily and
methotrexate (MTX).However, with CS dose reduction subfebrility and erythema nodosum-like
(EN-like) lesions appeared periodically. Skin biopsy showed non-specific changes.
During July and August 2017, the boy had febrile temperature every other day when
CS were not given and experienced aphthous stomatitis (possibly MTX-related). The
patient became CS dependent. He had recurrent elevated temperature, fatigue, headache,
abdominal pain, EN-like lesions.Secondary osteoporosis with vertebral compression
fractures was diagnosed. Repeated skin biopsy showed undifferentiated panniculitis.
Weber-Christian disease was excluded. Laboratory tests showed Serum Amyloid A 138
mg/L (N <6.4).The diagnosis of Still’s disease was reconsidered. Genetic tests for
50 autoinflammatory genes and NOD2 gene were negative. Urinalysis showed normal mevalonic
acid level. Treatment with Azathioprine 2 mg/kg and Plaquenil 200 mg once daily was
started without significant response. In December he had a fever with CRP 99 mg/L,
without signs of infection and CRP normalization without a/b therapy, with an episode
of EN-like eruptions with non-specific panniculitis in histologic examination. BMBx
remained normal. Cyclosporin A 3 mg/kg was initiated and condition improved slightly.
In May 2018 Anakinra 100 mg/day was started, with good response: no recurrent episodes
of fever, inflammatory marker values normalized, EN-like lesions appeared periodically.
Results: The boy presented with uSAID, with a time of 4 years to diagnosis, with the
initial diagnosis of systemic JIA. The results of genetic testing were negative. The
disease was only partially controlled by or unresponsive to DMARDs and steroid treatment.
Good response was achieved with IL-1 blocker.
Conclusion: 1. USAID should be considered in the differential diagnostics of systemic
JIA.
2. Genetic testing must be performed in patients presented with a range of nonspecific
autoinflammatory symptoms.
3. We conclude that Anakinra seems a feasible treatment option for uSAID.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2117 Etanercept in the treatment of familial Mediterranean fever: a case report
Yeli̇z Zahi̇roglu
Rheumatology, Health Sciences University, Samsun Education and Research Hospital,
ılkadım, Turkey
Introduction: Familial Mediterranean Fever (FMF) is an autoinflammatory disease characterized
by recurrent fever,peritonitis,pleuritis or arthritis attacks.The main treatment of
FMF is daily oral colchicine treatment. There is strong evidence that colchicine inhibits
both acute inflammatory attacks of FMF and systemic amyloidosis.We aimed to report
the response of a 2-year-old patient with colchicine-resistant FMF to the treatment
of Etanercept.
Objectives: A two-year-old girl complained of recurrent fever one year ago. R202Q
heterozygote positivity was determined in the gene analysis and colchicine 0.5mg /
day was started with the diagnosis of FMF. Although the patient received this treatment
regularly, she had fever and abdominal pain attacks for the last 4 months and her
attacks started to increase day by day. She lost appetite and weight loss. The older
brother had FMF in his family history. Physical Examination: height: 89,5cm, weight:
11,5kg, Fever: 38 degrees, abdominal sensitivity was present, there was no arthritis
and rash. In laboratory tests; Sedimentation: 31mm/ h, C-reactive protein: 65mg /
L, Fibrinogen: 4.27g / L. The patient was treated with colchicine 1mg / day, ibuprofen
200mg / day and prednisolone 5mg / day. Four weeks later, the patient complained of
abdominal pain, fever, loss of appetite and weight loss. The frequency of attacks
was not decreased.
Methods: The patient who was treated with subcutaneous Etanercept at 0.8mg / kg /
week with the diagnosis of colchicine-resistant FMF, had no abdominal attacks and
fever episodes.
Results: After 6 weeks there was no attack and sedimentation, CRP and fibrinogen levels
decreased to normal limits.
Conclusion: There are no more alternatives for patients who do not respond to colchicine
or cannot tolerate the drug.Considering cytokine patterns; Anti -TNF agents may be
an alternative in the treatment of FMF.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
New monogenic diseases
P2118 A case of neonatal-onset proteasome-associated autoinflammation and immunodeficiency
disease resembling but distinct from Nakajo-Nishimura syndrome
Noriko Kinjo1, Satoru Hamada1, Koichi Nakanishi1, Hiroyuki Mishima2, Akira Kinoshita2,
Koh-Ichiro Yoshiura2, Tsunehiro Mizushima3, Jun Hamazaki4, Shigeo Murata4, Hiroaki
Hemmi5, Tsuneyasu Kaisho5, Nobuo Kanazawa6
1Department of Pediatrics, University of the Ryukyus., Nishihara-cho, Okinawa; 2Department
of Human Genetics, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki; 3Picobiology
Institute, Graduate School of Life Science, University of Hyogo; 4Laboratory of Protein
Metabolism, Graduate School of Pharmaceutical Sciences, University of Tokyo, Tokyo;
5Department of Immunology, Institute for Advanced Medicine, Wakayama Medical University;
6Department of Dermatology, Wakayama Medical University, Wakayama, Japan
Correspondence: Noriko Kinjo
Introduction: We report a Japanese boy with a distinct neonatal-onset autoinflammatory
phenotype. Exudative erythemas developed on his face and extremities 2 weeks after
birth. At 1 month of age, the patient developed fever with elevated serum C-reactive
protein and hepatic amino transferase levels. A febrile convulsion with basal ganglia
calcification appeared at 4 months. At 7 months of age, severe pulmonary arterial
hypertension was diagnosed. He periodically developed erythema and myositis with elevated
serum creatine kinase level. Anti-nuclear antibodies were negative. His symptoms were
improved with corticosteroid but recurred periodically. Portal hypertension with hepatosplenomegaly
was diagnosed at 6 years of age. Although Nakajo-Nishimura syndrome (NNS) was suspected,
lipomuscular atrophy has never been developed. This case was once reported in 8thISSAID,
but we additionally present the case with the recent disease course and new findings,
especially the aspects of immunodeficiency.
Objectives: To identify the responsive gene mutation(s) in this patient and to clarify
his phenotypic difference from NNS.
Methods: Sequencing a panel of genes causing known autoinflammatory syndromes and
whole exome sequencing of the patient and his parents were performed using the next
generation sequencer. Expression of proteasomeal subunits and ubiquitinated protein
was analyzed by western blotting and immunostaining. Proteasomal activities were also
analyzed. Serum TREC/KREC levels were analyzed by qRT-PCR.
Results: No significant mutation had been detected in a panel of genes causing autoinflammatory
syndromes including PSMB8, while whole exome sequencing of the patient and his parents
identified a novel de novo heterozygous PSMB9 mutation in the patient. Among proteasome-associated
genes, a rare polymorphism in PSMD9 has additionally been detected in the patient
and his father. By analysis of the patient-derived cells, disrupted assembly and maturation
of the immunoproteasome similar to NNS, but relatively intact catalytic activities
without apparent accumulation of ubiquitinated proteins in contrast to NNS, were observed.
Blood analysis showed not only increase of monocytes but also decrease of B cells.
A TREC level as well as a KREC level decrease significantly. Notably, serum IgG levels
were decreased (less than 500 mg/dL) and IgG supplementation was required every week
and efficient as treatment. These facts suggest that humoral immunity was severely
impaired.
Conclusion: Thus, our case manifested not only autoinflammation but also immunodeficiency,
which is resembling but distinct from NNS. This implicates a novel category of autoinflammatory
disease, which we may propose proteasome-associated autoinflammation and immunodeficiency
disease (PRAID).
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2119 Proteasome-associated autoinflammatory syndrome 2 (PRAAS2) in a five months
oldboy
Anna Kozlova, Ekaterina Viktorova, Viktoria Zaharova, Dmitriy Konovalov, Aleksandra
Terentieva, Vasiliy Burlakov, Elena Raikina, Natalia Kuzmenko, Julia Rodina, Alexsey
Maschan, Anna Shcherbina
Immunology, National Medical Research Center of Pediatric Hematology, Oncology and
Immunology named after Dmitry Rogachev , Moscow, Russian Federation
Correspondence: Anna Kozlova
Introduction: PRAAS2 is a monogenic autoinflammatory syndrome caused by autosomal
dominant mutations in POMP gene. It was first reported in 2018 as a disorder with
early onset severe inflammatory neutrophilic dermatitis, autoimmunity and variable
immunodeficiency. Only 3 patients have been reported to date
Objectives: To describe a case ofPRAAS2 ina 5-months-old Russian boy
Methods: Genetic defect was identified by whole exome sequencing (TruSeq DNA Exome
kit, Illumina). Mutation was confirmed by Sanger sequencing in the patient, was absent
in both parents
Results: Five-months old boy from healthy non-consanguineous parents was referred
to our Center due to the multisystem inflammatory condition.Since the first days of
life the patient suffered from vasculitis-like rash with centralnecrosis, recurrent
fever, hepatosplenomegaly, thrombocytopenia, high inflammatory markers (leukocytosis,
elevated CRP, hypergammaglobylinemia). Skin biopsy revealed non-specific changes including
dermal fibrosis, subepidermal and perivascular chronic inflammatory, mostly histiocytic,
infiltration. Later he developedbilateral pneumonia, purulent otitis, enterocolitis.
Upon admission to our Center he also fulfilled criteria forhemophagocytic lymphohystiocytosis.The
patient was treated with broad-spectrum antimicrobials, high-dose steroids,tocilizumab
and anakinra, with resolution of cytopenia, but otherwise no effect. The patient’s
conditiondeteriorated rapidly, he developed hepatitis with coagulopathy, intracranial
and lunghemorrhage, respiratory failureand died from progressive multiorgan failure.
Heterozygous de novo c.335delT, p.I112fs mutation in POMP gene was identified post
mortem.This mutation was not previously reported andpredicted to be deleterious
Conclusion: Heterozygous mutations in the same position334-335 was previously described
in patient with less severe course ofPRAAS2.Severity of the disease varies in the
few patients described, even within the same family.Steroids, IL6 and IL1-blocking
anti-cytokine agents were not successful in our patient. Treatment strategy for PRAAS2
is yet to be elucidated
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2120 A case of novel identified proteasome-related autoinflammation and immunodeficiency
syndrome caused by PSMB9 mutation
Hidenori Ohnishi1, Shinsuke Kataoka2, Hideki Muramatsu2, Emi Kadoi3, Nobuo Kanazawa4,
Satoshi Okada5, Yoshitaka Honda6, Kazushi Izawa6, Ryuta Nishikomori6, Takeshi Taketani7,
Jun Hamazaki8, Shigeo Murata8, Yoshiyuki Takahashi2, Toshiyuki Fukao9
1Pediatrics, Graduate School of Medicine, Gifu University, Gifu; 2Pediatrics, Nagoya
University Graduate School of Medicine, Nagoya; 3Pediatrics, Gifu City Hospital, Gifu;
4Dermatology, Wakayama Medical University, Wakayama; 5Pediatrics, Hiroshima University
Graduate School of Biomedical & Health Sciences, Hiroshima; 6Pediatrics, Kyoto University
Hospital, Kyoto; 7Pediatrics, Shimane University Faculty of Medicine, Izumo; 8Laboratory
of Protein Metabolism, Graduate School of Pharmaceutical Science, University of Tokyo,
Tokyo; 9Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
Correspondence: Hidenori Ohnishi
Introduction: Recently, type I interferonopathy was categorized with autoinflammatory
syndrome. Several responsible genes of type I interferonopathy including not only
the 7 causative genes of Aicardi-Goutieres syndrome but also TMEM173(STING) and the
genes associated with proteasome such as PSMB8had been reported. Additionally, patients
with heterozygous truncated mutation of POMPhad both type I interferonopathy and combined
immunodeficiency. More recently, it was shown that the model mice with STING-gain-of-function
mutation had combined innate and adaptive immunodeficiency and virus-induced pulmonary
fibrosis. In this situation, we found a patient with a mutation of PSMB9 (also called
β1i), which is the major component of immunoproteasome.
Objectives: In this study, we present the clinical symptoms and the results of in
vitro analysis of a novel identified patient who showed the very early onset severe
inflammatory phenotype caused by PSMB9mutation in Japan.
Methods: The patient is one-month-old male infant. He showed the characteristic phenotypes
which included severe skin eruption like chilblain, myositis, hepatitis, pneumonia,
pulmonary hypertension, pancytopenia, the increase of inflammatory reactants, the
elevated serum ferritin, the increase of protein concentration of the central spinal
fluid (CSF), and intracranial calcification. The detailed immunological patterns were
evaluated and the gene panel including the known autoinflammatory syndrome was analyzed
using next-generation gene sequencer. The trio-based whole exome sequence was also
performed as the additional analysis. His dermal fibroblast was established, and the
immunoproteasome activity, immunoproteasome assembly analyzed by western blotting
of fractionated protein and the cytokine production level were analyzed. The reporter
gene activity was analyzed using the dual-luciferase reporter assay system.
Results: By the ex vivo analysis using the patient’s peripheral blood, several abnormal
patterns were detected. In the lymphocyte subset analysis, CD8, γδT and NK cells were
decreased. NK cell activity was also decreased. IFN-α was increased in his serum and
CSF. IFN signature of his peripheral blood was also enhanced. Interestingly, in his
serum polyoma virus was detected continuously. The gene panel analysis revealed the
de novo mutation of PSMB9. This mutation was located on the dimer interface between
PSMB9 proteins in the complex structure of immunoproteasome. No other known pathogenic
gene was identified by whole exome analysis. Furthermore, the retain of premature
form of PSMB9 protein, the accumulation of UMP1 and the decreased activity of IFN-γ
induced 20S proteasome were shown using his dermal fibroblast. The decrease of production
level of IL-6 from TNF-α stimulated his fibroblast was shown. The decreased NF-κB
reporter gene activity was shown in the PSMB9mutation transfected HEK293T cells.
Conclusion: The identified genotype is same with the previously reported mutation
in 8th ISSAID by Kinjo N et al. and their clinical phenotypes were quite similar.
Thus, we hypothesized that this PSMB9mutation caused the early onset immunodeficiency
leading the virus infection and this might trigger the type I interferonopathy. We
proposed that this disease is designated as “Proteasome-associated autoinflammation
and immunodeficiency disease (PRAID)” including POMP and PSMB9 mutation-related diseases.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2121 ‘Non-self’ mutation: double-stranded RNA elicits antiviral pathogenic response
in a drosophila model of expanded CAG repeat neurodegenerative diseases
Rob Richards1, Saumya Samaraweera1, Andrew Scott1, Dani Webber1, David Harvey1, Olivia
Mecinger1, Louise O'Keefe1, Jen Cropley2, Paul Young2, Joshua Ho2, Cath Suter2
1Molecular and Biomedical Sciences, The University of Adelaide, Adelaide; 2Victor
Chang Cardiac Research Institute, Sydney, Australia
Correspondence: Rob Richards
Introduction: Inflammation is activated prior to symptoms in neurodegenerative diseases,
providing a plausible pathogenic mechanism. Indeed genetic and pharmacological ablation
studies in animal models of several neurodegenerative diseases demonstrate that inflammation
is required for pathology.
Objectives: However, while there is growing evidence that inflammation-mediated pathology
may be the common mechanism underlying neurodegenerative diseases, including those
due to dominantly inherited expanded repeats, the proximal causal agent is unknown.
Methods: We have utilized Drosophila genetics to explore the ability of various forms
of expanded repeat RNA to cause pathology and genetically dissect the responsible
pathway.
Results: Expanded CAG.CUG repeat double stranded RNA causes inflammation-mediated
pathology when expressed in Drosophila. Repeat dsRNA is recognised by Dicer2 as a
foreign or ‘non-self’ molecule triggering both antiviral RNA and RNAi pathways. Neither
of the RNAi pathway cofactors R2D2 nor loquacious are necessary, indicating antiviral
activation. RNA modification enables avoidance of recognition as ‘non-self’ by the
innate inflammatory surveillance system. Human ADAR1 edits RNA conferring ‘self’ status
and when co-expressed with expanded CAG.CUG dsRNA in Drosophila the pathology is lost.
Cricket Paralysis Virus protein CrPV-1A is a known antagonist of Argonaute2 in Drosophila
antiviral defence. CrPV-1A co-expression also rescues pathogenesis, confirming anti-viral-RNA
response.
Conclusion: Repeat expansion mutation therefore confers ‘non-self’ recognition of
endogenous RNA, thereby providing a proximal, autoinflammatory trigger for expanded
repeat neurodegenerative diseases.
Disclosure of Interest
None Declared
I have a possible gene or a strange phenotype. Looking for a second case
P2122 A family with SAVI-like vasculopathy, arthritis and cold-induced inflammatory
urticarial rash
Ester Conversano1, Elisa Piscianz1, Erica Valencic2, Alessandra Tesser2, Alberto Tommasini2,
Serena Pastore2, Valentina Moressa3, Alessia Omenetti4, Bianca Lattanzi4, Giulia Gortani2,
Andrea Taddio1,5
1University of Trieste; 2Institute for Maternal and Child Health IRCCS Burlo Garofolo;
3University of Trieste, Department of Medicine, Surgery and Health Sciences, Trieste;
4Pediatric Division, Ospedali Riuniti ‘Salesi Children’s Hospital’, Ancona, Italy,
Ancona; 5Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy,
Trieste, Italy
Correspondence: Ester Conversano
Introduction: Awareness of autoinflammatory disorders is allowing the detection of
families with phenotypes reminiscent of known monogenic defects but lacking genetic
confirmation. We describe three patients from a family of Italian ancestry with autoinflammatory
phenotype. Exome sequencing didn’t allow the detection of any mutation in genes associated
with autoinflammatory syndromes but held complex results supportive of a possible
digenic disorder.
Objectives: Describe clinical and genetic features of the family, and to hypothesize
treatments targeted to mechanisms likely involved in the disease pathogenesis.
Methods: Whole exome sequencing was performed in patient 1, 2, 3 and mother of patient
1. Mutations found were analysed by Sanger sequencing. IFN signature and flow-cytometric
assessment of TBK1 phosphorylation was analysed in all the family.
Results: Patient (pt) 1, a 2 years old girl, presented urticarial rash since 2 months
of age, sometimes aggravated by cold. No history of recurrent fever or abnormal physical
and neurological development was reported. Pt 2, her 40 years old father, presented
analogues cutaneous lesion associated by sporadic episodes of polyarthritis starting
later in childhood compared to his daughter, sometimes treated with prednisone with
partial remission of symptoms. Pt 3, the 42 years old uncle, presented episodic fever
of unknown origin associated to polyarthritis and urticarial starting during childhood.
Corticosteroid therapy did not prevent a severe progression of the disease characterized
by cutaneous ulcers and small articulation deforming polyarthritis evolving to erosion
of the nasal bridge, deformity of hands and fingers, auto amputation of toes. All
three patients present evidence of baseline systemic inflammation with elevations
of the erythrocyte sedimentation rate and C-reactive protein. A twin brother and the
mother were completely asymptomatic. Whole exome sequencing was performed in pt 1,
2, 3 and mother of pt 1. Two mutations in two candidate genes were found in pt 1,
2 and 3: ZC3H12D and MB21D1. The first is a new heterozygous c.C564A variation in
the ZC3H12D gene (stop-gain mutation), coding for a Zn-finger protein involved in
the IL-6 mRNA degradation. The second one is a heterozygous c.A948G variation in the
MB21D1 gene, encoding the cytosolic DNA sensor cGAS, one of the main trigger of type
I interferon (IFN) production. This variant is already described but no frequency
data are reported and is predicted as damaging by different bioinformatic tools. These
two mutations were afterwards analysed in twin brother of patient 1 by Sanger sequencing,
revealing the presence of only the heterozygous c.C564A variation in ZC3H12D. None
of the two mutation were found in mother. Except for mother, all components of the
family showed an intermediate interferon signature, suggesting a possible involvement
of the type I IFN inflammation. Despite the role of the two candidate genes, and the
result of IFN signature, the flow-cytometric assessment of the TBK1 kinase phosphorylation
didn’t reveal a significant increase of the IFN pathway activation, even after LPS
stimulation.
Conclusion: This family shows a clinical phenotype of variable severity, not definitely
explained by genetic mutation found. The fact that the uncle phenotype is similar
to SAVI syndrome is coherent with the possible involvement of dysregulated cGAS pathway
in the pathogenesis of inflammation. Further analysis are required to clarify the
role of candidate genes to provide a suitable pharmacological approach.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
Table 1 (abstract P2122).
Summary of family members: age, sex, results of exome sequencing (mutations) and functional
assays
Patient
Age
Sex
Mutation
State of mutations
Interferon Signature
Lymphocyte pTBK1 LPS (NS)
Monocyte pTBK1 LPS (NS)
1
2
F
ZC3H12D:c.C564A
MB21D1:c.A948G
Het
Intermediate
3.8(3.9)
1.7(1)
2
42
M
ZC3H12D:c.C564A
MB21D1:c.A948G
Het
Intermediate
3.7(4.7)
3.2(2.7)
3
40
M
ZC3H12D:c.C564A
MB21D1:c.A948G
Het
Intermediate
-
-
Twin brother
pt1
2
M
ZC3H12D:c.C564A
Het
Intermediate
4.2(3.4)
1.2(0.9)
Mother
pt1
37
F
-
-
Negative
6.7(3.7)
4(1.4)
P2123 New ATM variants and a rare association of juvenile idiopathic arthritis and
ataxia-telangiectasia: coincidence or relationship?
Nastasia Kifer1, Todor Arsov2,3, Mario Sestan1, Marijan Frkovic1, Carola G. Vinuesa2,3,
Marija Jelusic1
1Department of Paediatrics, Division of Rheumatology and Immunology, University Hospital
Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia; 2Centre for
Personalised Imuunology (CPI), Australian National University, Canberra, Australia;
3China-Australia Centre for Personalised Immunology (CACPI), Australian National University;
Renji Hospital, Jiao Tong University, Shanghai, China
Correspondence: Nastasia Kifer
Introduction: Ataxia-telangiectasia (A-T) is an autosomal recessive disorder caused
by biallelic pathogenic variants in ATM (ataxia telangiectasia mutated) gene. A-T
has a variable presentation, including cerebellar ataxia, telangiectasia, gradually
developing cerebellar degeneration, immunodeficiency, predilection for cancer occurrence
and radiation sensitivity. Juvenile idiopathic arthritis (JIA) is an autoimmune disorder,
believed to be of a polygenic nature, encompassing all arthritis of unknown aetiology
occurring in children under the age of 16.
Objectives: We present a patient diagnosed with a rare association of JIA and A-T
which with identified two likely pathogenic ATM variants.
Methods: We obtained all patient’s records from the Department of Paediatrics, UHC
Zagreb. Genomic analysis was done using singleton whole exome sequencing (WES).
Results: Our patient is a male with suspected ataxia telangiectasia and JIA. His older
sister suffers from cerebral palsy (due to complications of premature birth). He was
diagnosed with ataxia at 3 years of age. Brain MRI performed at the age of 15 years
revealed pontocerebellar hypoplasia and laboratory testing showed selective IgA deficiency,
decrease in proportion of lymphocytes and progressive elevation of alpha fetoprotein
concentration. Genetic testing excluded Friedrich ataxia and spinocerebellar ataxia.
Cytogenetics analysis detected mosaic translocation (7;14) suggestive of chromosomal
instability. These findings were clinically suggestive of A-T.
Regarding the JIA, the patient first noticed swelling of the fifth finger of the right
foot at 13 years of age. Two years later the metacarpophalangeal joint of the thumb
of his left hand started to swell and finally his left knee. MRI revealed chronic
effusion, oedema and a popliteal cyst in the left knee. MRI of the right foot detected
erosive changes followed with the expansion of the soft tissue and bone. Ultrasound
of hands, left knee and feet confirmed chronic inflammatory changes. Based on these
features the patient was diagnosed with JIA and treated with nonsteroidal anti-inflammatory
drugs (NSAIDs). Due to the chronic character of JIA and having in mind the concomitant
disease, low doses of methotrexate were initiated alongside NSAIDs, after which a
stable improvement followed.
Genomic analysis using WES identified two likely pathogenic ATM variants: NM_000051.3
(ATM_v001): c.8305T>C, p.(W2769R) and c.5293C>T, p.(Q1765Ter) confirming the A-T diagnosis.
Analysis of the familial segregation of the identified variants is underway to ascertain
the phase of the variants and identify heterozygous relatives at increased risk of
cancer.
Conclusion: To the best of our knowledge, this is the second reported case of an association
between JIA and typical A-T in the literature. A compelling phenomenon is that the
only prior described case was identified in the same geographical region. Further
analysis of these case with the rare association between A-T and JIA may help us explore
and understand the possible role of the ATM gene in development of JIA.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2124 A case of drug-induced undifferentiated connective tissue disease in a 2 years
old girl as a manifestation of munchausen syndrome by proxy
Tetiana Kovalchuk
Department of Pediatrics # 2, Ivan Horbachevsky Teropil State Medical University,
Ternopil, Ukraine
Introduction: Munchausen syndrome by proxy (MSBP) is a mental health problem in which
a caregiver makes up or causes an illness or injury in a person under his or her care,
such as a child. Because vulnerable people are the victims, MSBP is a form of child
abuse.
Objectives: The purpose of the study was to analyze the case of undifferentiated connective
tissue disease and probable autoinflammatory disease as a manifestation of MSBP.
Methods: A 2-years-old girl was referred to Pediatric Hospital for symptoms of increase
in body temperature to 39-40º C, recurrent lower back pain, lethargy, general weakness.
A baby was from the first pregnancy. The second pregnancy of the mother ended in premature
stillbirth of the twins under unknown circumstances.
Results: Physical examination confirmed daily episodes of resistant to antipyretics
febrile fever which were accompanied by severe lower back pain and hepatosplenomegaly.
Anemia, leukocytosis, high rates of ESR (up to 149 mm/hour), C-reactive protein (up
to 267,9 mg/l) and procalcitonin (up to 269,5 ng/ml) were recorded. Slightly increased
Ig M and circulating immune complexes were noted in the serum of blood without violations
of the cellular immunity. CT of abdomen just confirmed hepatosplenomegaly and mesenterial
limfadenopathy. No other lymph nodes have been enlarged. Results of trepanobiopsy
allowed to exclude the diagnosis of leukemia. A girl received antibiotics of different
groups, nonsteroidal anti-inflammatory drugs and detoxification therapy in relation
to an intoxication syndrome of unknown etiology. 6 weeks later were arose positive
alarm symptoms, and appendectomy was performed. Catarrhal appendicitis was diagnosed
postoperatively. Further daily episodes of high fever up to 39-40°C and lower back
pain were observed with symptoms of transient synovitis of the right hip joint. Undifferentiated
connective tissue disease and utoinflammatory disease were suspected. A short-term
effect of pulse corticosteroid therapy with methylprednisolone was noted. Methotrexate
therapy was not accompanied by an improvement of girl’s condition. The results of
immunohistochemical study of the skin and kidneys confirmed mesangial proliferative
glomerulonephritis with a weak tubule-interstitial component and secondary microvasculitis.
In dynamics, oliguria, erythrocyturia, and unstable edema of the face and pubic area
were increased on the background of normal rates of urea and creatinine in the blood
serum. Methotrexate was replaced by cyclophosphamide. Episodes of hyperthermia last
5-6 days, after the normal body temperature is noted 1-2 days. Given the lack of positive
dynamics, cyclophosphamide has been discontinued. Negotiations with European clinics
for genetical diagnosis of autoinflammatory disease in this girl were conducted. Three
months colchicine therapy didn’t produce any positive effect. After 9 months from
the debut of disease a group of doctors documented urinary catheter tie with thread
that was the reason of blocked urine flow. During the search policemen seized a blank
ampoule of pyrogenal from the mother. Pyrogenal is an immunomodulator which contains
the bacterial lipopolysaccharide and enhances the functional activity of the cellular
and humoral immune response (produced by the Russian Federation only). Side effects
of the drug are dose-dependent and accompanied by high fever, lower back pain, and
extremely increased inflammatory blood parameters. From the moment of mother isolation
from the child, girl’s condition has improved, all symptoms of the disease have disappeared
till now.
Conclusion: The diagnostic search for recidive fever is extremely difficult even for
a highly qualified doctor. In the search for rare diseases accompanied by a persistent
fever, a doctor should always remember about MSBP.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
T. Kovalchuk Conflict with: noneShareholder of: none,Grant / Research Support from:
none,Consultant for: none,Employee of: none,Paid Instructor at: none,Speaker Bureau
of:none
P2125 Severe large vessels vasculitis with toe gangrene in a young child
Caterina Matucci Cerinic, Roberta Caorsi, Stefano Volpi, Silvia Rosina, Riccardo Papa,
Paolo Pietro Picco, Angelo Ravelli, Marco Gattorno
Clinica Pediatrica e Reumatologica, Istituto Giannina Gaslini, Genova, Italy
Correspondence: Caterina Matucci Cerinic
Introduction: Takayasu arteritis is a granulomatous large vessel vasculitis involving
mainly the aorta and its major branches. It is rare in childhood, with only few anecdotal
cases in the first years of life reported in the literature.
Objectives: To describe, in a 2-year-old boy, a peculiar clinical phenotype characterized
by systemic inflammation, sialoadenitis and large vessels vasculitis, complicated
by digital ischemia.
Results: A 23 month-old boy was admitted for persistent fever associated with cervical
and submandibular swelling, with no response to antibiotics. The minor salivary gland
and lymph-node biopsies showed a chronic sclerosing sialoadenitis and a reactive follicular
hyperplasia, respectively. The laboratory work up showed a neutrophilic leukocytosis
and elevation of acute phase reactants. A broad work-up for infectious diseases was
negative, as chest x-ray, whole body STIR-MRI and bone marrow evaluation. Abdominal
US identified a slight splenomegaly. All the immunologic investigations were negative
except for a B CD20 lymphocyte expansion and an elevation of plasmatic IgG4. The double
negative T lymphocytes were negative, as the FAS-mediated apoptosis test. A 41-gene
NGS panel for autoinflammatory diseases was negative.
The patient was treated with i.v. metilprednisolone (2 mg/kg), with prompt clinical
response and resolution of acute phase reactants, but reappearance at tapering. In
light of the non-specific clinical and immunological findings and the age of the patient,
treatment with Mophetil Mycophenolate (600 mg/mq twice a day) was started with good
response. After 3 months, the patient started to complain with pain of the right foot
and after few days presented with cyanosis of the anterior part of the right foot
and an ulcer of the first toe, associated to severe systemic hypertension and elevation
of acute phase reactants. The Doppler US revealed a reduced patency of the common
iliac arteries, with a wall thickening of the common right iliac artery, a discontinuous
aspect of the femoral and posterior tibial right arteries and of the subrenal abdominal
aorta.
The angioCT and angioMRI showed a thickening of the abdominal aorta, the common right
iliac artery, and the distal part of the brachial right artery.
Full dose iloprost, heparine and metylprednisolone pulses were started, together with
cyclophosphamide (4 mg/kg/day) with quick amelioration of the pain; however, the ischemia
evolved to the entire first toe and the third phalanx of the third and fourth toe.
In the hypothesis of a large vessel vasculitis, treatment with rituximab (375 mg/m2
x 4 weeks) was added, with complete control of systemic inflammation and without a
further evolution of the ischemia. When the clinical picture was stabilized, the patient
underwent the amputation of the first toe and of the third phalanges of the third
and fourth toe.
When the maximal cumulative dose of cyclophosphamide was reached (200 mg/kg) , the
patient was switched to azathioprine (3 mg/kg) and the steroids progressively tapered,
with good control of the disease.
Conclusion: In this case, we present a large vessels vasculitis similar to Takayasu
arteritis associated to toe gangrene, that is an atypical manifestation of large vessels
vasculitis, in a young child.
The peculiar clinical picture and the age at diseases onset may suggest a monogenic
origin. Whole exome sequencing is actually in progress in the patient and the parents.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2126 Is this disease related to NLRP3 or MEFV or both?
Ayşenur Paç Kısaarslan1, Nihal Şahin1, Sümeyra Özdemir Çiçek1, Afig Berdeli2, Zübeyde
Gündüz3, Hakan Poyrazoğlu1, Ruhan Düşünsel1
1Pediatric Rheumatology, Erciyes University School of Medicine, Kayseri; 2Molecular
Genetic, Ege University Faculty of Medicine, İzmir; 3Pediatric Rheumatology, Acıbadem
University School Of Medicine, Kayseri, Turkey
Correspondence: Ayşenur Paç Kısaarslan
Introduction: Cryopyrin-associated periodic syndrome (CAPS) is a broad definition
for a group of auto-inflammatory disorders caused by activating mutations in the NLRP3 gene.
CAPS involved three disorderscharacterized by blood neutrophilia, fever and tissue-specific
inflammation in the skin, joints and conjunctiva. Thus far, more than 200 mutations
in the NLRP3 gene associated with CAPS have been documented in the INFEVER database.
Objectives: We presented a patient carried both NLRP3 and MEFV mutations.
Methods: Eight year-old female patient was admitted our rheumatology clinic with fever,
vomiting, and abdominal pain attacks lasting 4 days for 2 years. An aphthous stomatitis,
rash, conjoctivitis, and arthritis were not accompained. The attack ferquency was
4 times in last 6 months. Acute phase rectactans were very high in attack periods.
There was consaguinity, but no family history.
On the attack period, the patient was reevaluated. There werenopathologic sings of
infectious and rheumatologic diseases. High level of white blood cell(WBC), C-reactive
protein(CRP), and eritrocyte sedimantation rate(ESR) were detected. Blood and urine
cultures were negative. Genetic sample for autoinflammatory diseases was sent , colchicine
1 mg/d was started. After 20 days, she was admitted withfever, arthritis, systolic
murmur, high CRPESR and antistreptolysin-O. An ecocardiographic evaluation showed
mitral valve regurgitation. Patient was diagnosed acute rheumatic fever, and started
steroid, enalapril, and furosemid treatments. While patient on steroid treatment,
all complaints was regressed, and decreased levels of CRP,ESR (APR) . After steroidstopped,
attacks of arthritis repeated accompanied by high APR. Complaints of abdominal pain
and vomiting decreased on this period. Autoinflammatory disease panel was analysed
on NLRP3,NLRC4, IL1RN, PSMB8, TNFRSF1A, MVK, PSTPIP1, MEFV, NOD2, PLCG2, NLRP1, CARD8,
NLRP12, CARD14, CECR1, TNFRSF11A, TMEM173, TNFAIP3, LACC1, OTULIN, IL23R, TREX1, IL12RB1,
PRF1, DNASE1, UNC13D, STX11, STXBP2, USP43, RIPK1 genes.
Results: As the result, p.Ile313Val(c.937A>G) (Heterozygos)on NLRP3 gene,p.Pro369Ser(c.1105C>T)
(Heterozygos) on exon 3, andp.Arg408Gln (c.1223G>A) (Heterozygos) on exon 3 mutations
on MEFV gene were detected. Patient still receivesmaximum dose colchicine, nonsteroidal
antiinflammatory drug, and enalapril treatments. Her ophthalmologic and hearing examinations
were normal.
Conclusion: The Ile313Val mutation is determined as “symptomatic for MAGIC Syndrome”
in infevers database.Mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome
is a disease that fulfilled criteria for diagnosis of Behcet's disease (BD) and relapsing
polychondritis (RP).Our patient had not oral or genital aphthae and polychondritis.We
do not know whether our patients clinical findings related to NLRP3 or MEFV mutations
or both.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2127 M1184V mutation in NLRP1: is that polymorphism or pathogenic mutation?
Nihal Sahin1, Sumeyra O. Cicek1, Afig Berdeli2, Aysenur P. Kisaarslan1, Zubeyde Gündüz3,
Muammer H. Poyrazoglu1, Ruhan Düşünsel1
1Pediatric Rheumatology, Erciyes University Faculty of Medicine, Kayseri; 2Molecular
Genetics, Ege University Faculty of Medicine, Izmir; 3Pediatric Rheumatology, Acıbadem
Hospital, Kayseri, Turkey
Correspondence: Nihal Sahin
Introduction: Monogenic autoinflammatory disorders are a heterogeneous group of conditions
characterized by innate immune dysregulation that typically present in early childhood
with fever, rashes, and disease-specific patterns of organ inflammation. The genetic
mutations leading to autoinflammatory phenotypes affect pathways the innate immune
responses. Nuclear localization leucine-rich-repeat protein 1 (NLRP1) play role regulator
of the innate immune system. The NLRP1 inflammasome promotes caspase-1, resulting
in IL-1β secretion.
Objectives: We present a patient with a periodic fever who was detected the NLRP1
gene mutation.
Methods: The genetic analysis was performed at Ege University, Department of Molecular
Genetics. The informed consent form for the publication was obtained from patient
and her parents.
Results: A 7-year-old girl was admitted with recurrent fever to our rheumatology clinic.
Her complaints firstly started in 4-year-old and recurred with a monthly. There were
enuresis and dysuria in some of the fever periods and she was treated as urinary tract
infection. But there were no positive urine cultures at any time. Urinary ultrasonography
and renal cortical scintigraphy were normal. In 5-year-old, tonsillectomy and adenoidectomy
were performed because of presented tonsillitis in fever attacks and repeated after
two years. After these surgeries, the fever was not present in 3 months. But then
periodic fever was present again. She had pneumonia at once. In apart of these fever
periods, she had the normal physical examination findings. Any rash, arthritis, lymphadenitis,
and periorbital edema were not detected. There was no complaint of abdominal pain,
diarrhea or myalgia in attacks. She has no remarkable family history. In laboratory
examinations in fever attacks, complete blood count and urine analysis were normal,
CRP, ESR and serum amyloid A were increased, throat culture was negative. Level of
immunoglobulin G, A, M, E was normal but immunoglobulin D was increased. The increased
AFRs was seen in the attack-free period also. We considered that she had an autoinflammatory
disease and gave colchicine. After colchicine treatment, AFRs normalized, but the
fever attacks continued. The comprehensive genetic panel was performed for autoinflammatory
diseases. This genetic panel included NLRP3, NLRC4, IL1RN, PSMB8, TNFRSF1A, MVK, PSTPIP1,
MEFV, NOD2, PLCG2, NLRP1, CARD8, NLRP12, CARD14, CECR1, TNFRSF11A, TMEM173, TNFAIP3,
LACC1, OTULIN, IL23R, TREX1, IL12RB1, PRF1, DNASE1, UNC13D, STX11, STXBP2, USP43,
RIPK1. M1184V mutation was detected in the NLRP1 gene.
Conclusion: M1184V is a polymorphism in NLRP1. In one study was shown that M1184V
exhibited caspase-1 activation and IL-1β secretion. However, this polymorphism was
presented in 25% of the population without causing any pathological manifestation.
Therefore, we do not know whether M1184V mutation is polymorphism or a pathogenic
mutation.
Disclosure of Interest
None Declared
P2128 Periodic fever syndrome with novel TRNT1 variant - possible cause of TRNT1 deficiency
or just an incidental finding?
Mario Sestan1, Todor Arsov2,3, Nastasia Kifer1, Marijan Frkovic1, Carola G. Vinuesa2,3,
Marija Jelusic1
1Department of Paediatrics, University Hospital Centre Zagreb, University of Zagreb
School of Medicine, Zagreb, Croatia; 2Centre for Personalised Imuunology (CPI), Australian
National University, Canberra, Australia; 3China-Australia Centre for Personalised
Immunology (CACPI), Australian National University, Canberra, Australia; Renji Hospital,
Jiao Tong University, Shanghai, China
Correspondence: Mario Sestan
Introduction: Biallelic pathogenic variants in TRNT1 gene, coding for the enzyme transfer
RNA nucleotidyltransferase 1, cause TRNT1 deficiency with various clinical manifestations
of autoinflammation, autoimmunity and immunodeficiency, including the syndrome of
congenital sideroblastic anaemia with immunodeficiency, periodic fevers and developmental
delay (SIFD).
Objectives: Authors present a case of a child with recurrent fevers and epilepsy with
de novo heterozygous mutation in TRNT1 gene of uncertain role in disease pathogenesis,
successfully treated with TNFα inhibitor.
Methods: Retrospective analysis of patient medical data and genomic testing using
whole exome sequencing (WES).
Results: Three months old female infant was referred to our Department with right-sided
hemiconvulsions and dysrhythmic EEG changes treated with valproic acid. Subsequently,
she had seizures on several occasions successfully treated with diazepam. Since 11
months of age, the child has had periodic protracted febrile episodes. Seven months
after the onset of fever, she developed intermittent erythema accompanied with swelling
of both hands, feet, knees and face. Subsequently, episodes of fever recurred in an
irregular rhythm. The patient has been showing signs of progressive fatigue and severe
facial erythema unrelated to febrility. Her physical exam was unremarkable apart from
occasional facial erythema. Laboratory findings were normal, except for the long-lasting
microcytic anemia (the lowest hemoglobin was 85 g/L) and elevated C-reactive protein
and erythrocyte sedimentation rate during the febrile episodes. Comprehensive laboratory,
microbiological and immunological examination failed to establish underlying diagnosis.
Bone marrow examinations were normal. The frequent and prolonged febrile episodes
were successfully treated with short-term methylprednisolone, however this treatment
failed to prevent the occurrence of new episodes. To ameliorate fevers, TNFα inhibitor
(etanercept) was consequently introduced in therapy at 5 years of age. Over the four
month period after the initiation of TNFα inhibitor, the child had no further febrile
episodes or seizures and there was an improvement in appetite and general condition.
It is planned to reduce the dose of antiepileptics.
Genomic testing using trio WES identified a de novo heterozygous TRNT1 variant, NM_182916.2
(TRNT1_v001): c.448C>T, p.(R150C), predicted to be pathogenic with high CADD score.
Previous cases of TRNT1 deficiency have been described with bialellic TRNT1 pathogenic
variants and analyses are underway to elucidate whether this finding could establish
the underlying diagnosis. At present we hypothesize that this could be a case of unidentified
second intronic TRNT1 variant or that this TRNT1 variant could have a dominant negative
effect. In this respect, it should be noted that in our patient we have identified
some but not other features of SIFD.
Conclusion: Clinical manifestations associated with TRNT1 deficiency have a broad
spectrum with significant clinical heterogeneity, which makes it difficult for rapid
clinical recognition. Although the WES is as a powerful tool for the diagnosis of
clinically unrecognized genetic conditions, there are still unresolved cases that
pose a challenge in routine clinical practice.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared
P2129 A novel autoinflammatory and lymphoproliferative syndrome associated with PIM1
mutations
Giovanna Ferrara1, Silvio Polizzi2, Erica Valencic3, Annalisa Chiocchietti4, Josef
Vuch3, Alessia Pin1, Elisa Piscianz1, Diego Vozzi3, Serena Pastore3, Paola Tomietto5,
Andrea Taddio3, Flavio Faletra3, Umberto Dianzani4, Alberto Tommasini3
1University of Trieste, Trieste; 2Meyer Children's Hospital, Firenze; 3IRCCS Burlo
Garofolo, Trieste; 4Universita’ del Piemonte Orientale, Novara; 5Azienda Sanitaria
Universitaria Integrata Trieste, Cattinara Teaching Hospital, Trieste, Italy
Correspondence: Andrea Taddio
Introduction: Whole exome sequencing (WES) can allow genetic diagnosis in subjects
with long lasting clinical stories not supportive of any well defined disorder.
A 35-year-old man was referred to ophthalmologist’s evaluation for blurry vision in
his left eye. The fundus examination showed choroidal lesions in both eyes. His past
medical history was relevant for recurrent episodes of fever and skin rashes, inflammatory
lesions of the osteoarticular-muscular system, one episode of aseptic meningitis,
an intracranial granuloma and two episodes of anterior uveitis. In adulthood, his
medical history included episodes of fever with urticaria and subcutaneous nodules.
The histological examination of two skin lesions showed a reactive angioendotheliomatosis
and a leukocytoclastic vasculitis. Spleen biopsy revealed the finding of non-caseating
granulomas. Brain TC founded multiple lytic and sclerotic skull lesions. He was diagnosed
with atypical sarcoidosis and started oral steroid and methotrexate.
Laboratory data showed persistent elevated erythrocyte sedimentation rate, strong
positive C-reactive protein, polyclonal gammopathy and elevated serum amyloid A levels.
Objectives: To describe functional and genetic data supporting the role of PIM1 mutation
in a man with early onset multisystemic inflammation and lymphoproliferation.
Methods: WES analysis was performed to search for a monogenic cause underlying the
disease. Flow-cytometry was carried out to evaluate Pim1 expression, BAD phosphorylation
(target of Pim1 kinase) and the effect of PIM inhibitor (PIM447) on cell viability.
RNAseq was performed on primary fibroblasts from the patient and from healthy donors.
The mutated gene was cloned in a vector to perform further functional studies.
Results: WES analysis revealed the de novo heterozygous missense variation c.C1132A
(p.H378N) in PIM1 gene, never described in on-line database and predicted as damaging.
Preliminary functional investigations showed that expression of Pim1 in patient’s
fibroblasts was comparable to those of healthy controls while phosphorylation of BAD
protein was higher in cells from the patient. Moreover, cell from the patient displayed
a lower sensitivity to PIM447. RNAseq showed an altered expression profile in genes
involved in the extracellular matrix organization. Our data revealed an increased
expression of some collagen and matrix metalloproteinases genes, which are related
to invasion and migration processes, already known to be impaired in several cancer
types, and a decreased expression in genes responsible for anti-tumorigenic activity.
Conclusion:
PIM1 is an oncogene that encodes a protein kinase and, indeed, somatic gain of function
mutations can be found in cancers. Also preliminary data obtained from our patient
suggest a gain of function effect of the p.H378N variant.
The lymphoproliferation may be sustained by the anti-apoptotic action of phosphorylated
BAD. Recent data correlated hyperactive Pim1 in tumors with high degree of inflammatory
infiltration accompanied by IL6 expression. A role of this cytokine also in our patient
was coherent with a good clinical response to a treatment with IL-6 inhibitor.
Although these results are supportive of a role of mutated Pim1 in the observed phenotype,
we cannot still claim that this is causative of a novel syndrome. The detection of
further cases and functional studies on cells transfected with mutated PIM1 will help
shedding more light on this disorder.
Consent for publication has been obtained from patient
Yes
Disclosure of Interest
None Declared