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RELA haploinsufficiency is a recently described autoinflammatory condition presenting with intermittent fevers and mucocutaneous ulcerations. The RELA gene encodes the p65 protein, one of five NF-κB family transcription factors. As RELA is an essential regulator of mucosal homeostasis, haploinsufficiency leads to decreased NF-κB signaling which promotes TNF-driven mucosal apoptosis with impaired epithelial recovery. Thus far, only eight cases have been reported in the literature. Here, we report four families with three novel and one previously described pathogenic variant in RELA. These four families included 23 affected individuals for which genetic testing was available in 16. Almost half of these patients had been previously diagnosed with more common rheumatologic entities (such as Behcet’s Disease; BD) prior to the discovery of their pathogenic RELA variants. The most common clinical features were orogenital ulcers, rash, joint inflammation, and fever. The least common were conjunctivitis and recurrent infections. Clinical variability was remarkable even among familial cases, and incomplete penetrance was observed. Patients in our series were treated with a variety of medications, and benefit was observed with glucocorticoids, colchicine, and TNF inhibitors. Altogether, our work adds to the current literature and doubles the number of reported cases with RELA-Associated Inflammatory Disease (RAID). It reaffirms the central importance of the NF-κB pathway in immunity and inflammation, as well as the important regulatory role of RELA in mucosal homeostasis. RELA associated inflammatory disease should be considered in all patients with BD, particularly those with early onset and/or with a strong family history.

Background Monogenic autoinflammatory diseases (AID) are caused by mutations in innate immune genes. The effects of these mutations on allergic inflammation are unknown. Objectives We investigated allergic, immunological and clinical phenotypes in FMF (familial Mediterranean fever), CAPS (cryopyrin-associated periodic syndrome), TRAPS (tumour necrosis factor receptor-associated periodic syndrome), HIDS (hyper-IgD syndrome), PAPA (pyogenic arthritis, pyoderma gangrenosum and acne), DADA2 (deficiency of adenosine deaminase 2), HA20 (haploinsufficiency of A20), CANDLE (chronic atypical neutrophilic dermatosis, lipodystrophy, elevated temperature) and SAVI (STING-associated vasculopathy of infancy). Methods In this cross-sectional study, clinical data were assessed in 425 patients with AID using questionnaires and chart reviews. Comparator data were obtained from public databases. Peripheral blood mononuclear cells obtained from 55 patients were stimulated and CD4+ cytokine production assessed. Results Clinical laboratory features of Type 2 immunity were elevated in CAPS but reduced in most AID, particularly DADA2. Physician-diagnosed allergic diseases were prevalent in multiple AID, including CAPS and DADA2. T helper 2 (Th2) cells were expanded in CAPS, TRAPS and HIDS; Th9 cells were expanded in HA20. Conclusions CAPS is characterised by an enhanced Type 2 signature, whereas FMF and CANDLE are associated with reduced Type 2 responses. DADA2 is associated with reduced Type 2 responses but a high rate of physician-diagnosed allergy. Therefore, NLRP3-driven autoinflammation may promote Type 2 immunity, whereas AID like DADA2 may manifest clinical phenotypes that masquerade as allergic disorders. Further investigations are needed to determine the contribution of autoinflammation to allergic clinical and immunological phenotypes, to improve the treatment of patients with AID.

The deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessively inherited disease that has undergone extensive phenotypic expansion since being first described in patients with fevers, recurrent strokes, livedo racemosa, and polyarteritis nodosa in 2014. It is now recognized that patients may develop multisystem disease that spans multiple medical subspecialties. Here, we describe the findings from a large single center longitudinal cohort of 60 patients, the broad phenotypic presentation, as well as highlight the cohort’s experience with hematopoietic cell transplantation and COVID-19. Disease manifestations could be separated into three major phenotypes: inflammatory/vascular, immune dysregulatory, and hematologic, however, most patients presented with significant overlap between these three phenotype groups. The cardinal features of the inflammatory/vascular group included cutaneous manifestations and stroke. Evidence of immune dysregulation was commonly observed, including hypogammaglobulinemia, absent to low class-switched memory B cells, and inadequate response to vaccination. Despite these findings, infectious complications were exceedingly rare in this cohort. Hematologic findings including pure red cell aplasia (PRCA), immune-mediated neutropenia, and pancytopenia were observed in half of patients. We significantly extended our experience using anti-TNF agents, with no strokes observed in 2026 patient months on TNF inhibitors. Meanwhile, hematologic and immune features had a more varied response to anti-TNF therapy. Six patients received a total of 10 allogeneic hematopoietic cell transplant (HCT) procedures, with secondary graft failure necessitating repeat HCTs in three patients, as well as unplanned donor cell infusions to avoid graft rejection. All transplanted patients had been on anti-TNF agents prior to HCT and received varying degrees of reduced-intensity or non-myeloablative conditioning. All transplanted patients are still alive and have discontinued anti-TNF therapy. The long-term follow up afforded by this large single-center study underscores the clinical heterogeneity of DADA2 and the potential for phenotypes to evolve in any individual patient.

BACKGROUND: Deficiency of adenosine deaminase 2 (DADA2) is an autoinflammatory disease caused by deleterious ADA2 variants. The frequency of these variants in the general population, and hence the expected disease prevalence, remain unknown. OBJECTIVE: We aim to characterize the functional impact and carrier frequency of ADA2 variants. METHODS: We performed functional studies and in silico analysis on 163 ADA2 variants, including DADA2-associated variants and population variants identified in the Genome Aggregation Database (gnomAD). We estimated the carrier rate using the aggregate frequency of deleterious variants. RESULTS: Functional studies of ADA2 variants revealed that 77/85 (91%) of DADA2-associated variants reduced ADA2 enzymatic function by > 75%. Analysis of 100 ADA2 variants in gnomAD showed a full spectrum of impact on ADA2 function, rather than a dichotomy of benign versus deleterious variants. We found several in silico algorithms that effectively predicted the impact of ADA2 variants with high sensitivity and specificity, and confirmed a correlation between the residual function of ADA2 variants in vitro and the plasma ADA2 activity of individuals carrying these variants (n = 45; r = 0.649; p < 0.0001). Using < 25% residual enzymatic activity as the cut-off to define potential pathogenicity, integration of our results with gnomAD population data revealed an estimated carrier frequency of at least 1 in 236 individuals, corresponding to an expected DADA2 disease prevalence of ~1 in 222,000 individuals. CONCLUSION: Functional annotation guides the interpretation of ADA2 variants to create a framework that enables estimation of DADA2 carrier frequency and disease prevalence.

The anti-inflammatory protein A20, encoded by TNFAIP3 , is a ubiquitin-modifying enzyme that targets proinflammatory molecules, including those upstream of the transcription factor nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB). Patients with heterozygous loss-of-function TNFAIP3 mutations develop haploinsufficiency of A20 (HA20), a systemic autoinflammatory disease that can cause severe end-organ pathology.1–3 No available medication directly targets NF-κB signalling; thus, treatment decisions are based on clinical experience. Mild cases are treated with disease-modifying antirheumatic drugs, whereas severe cases are treated with systemic corticosteroids and biological agents, including tumour necrosis factor (TNF)-α and IL-1 receptor (IL-1R) blockade.1 2 We report that a type I interferon (IFN) signature, or elevation of IFN-stimulated genes (ISGs), correlates with disease activity and predicts response to janus kinase (JAK) inhibition in HA20. A cohort of 12 patients with HA20 is followed at the NIH Clinical Center. All patients were diagnosed by Sanger sequencing, and increased NF-κB activity was confirmed with luciferase assay.2 Five patients had disease that was treatment-refractory or caused end-organ pathology. P1 was a 15-year-old female with p.T604Rfs*93 and severe gastrointestinal ulcerations refractory to TNF-α and IL-1R inhibition. P2–P4 were members of the same extended family with p.F224Sfs*4, aged 28, 32 and 61 years. All three had incomplete responses to TNF-α and IL-1R blockade; P2 had retinal vasculopathy and neuroinflammation, whereas P3 had membranous nephropathy. …

Stratification of patients with autoinflammatory phenotypes by interferon (IFN) score suggests a new group of IFN mediated autoinflammatory diseases with overlapping clinical phenotypes A Almeida de Jesus, Z Deng, S Brooks, H Kim, G Montealegre, D Chapelle, Y Liu, B Marrero, L Malle, M O’Brien, W Goodspeed, Y Huang, P Hashkes, G Nasrullayeva, MT Terreri, C Silva, B Arabshahi, K O’Neill, M Punaro, L Moorthy, A Reinhardt, V Lilleby, J Niemela, S Rosenzweig, T Fleisher, R Goldbach-Mansky

Background Two thirds of the 1700 patients seen at our NIH clinic for autoinflammatory diseases do not have a genetic diagnosis. Whole exome sequencing permits analysis of most of the protein coding regions of the human genome. Methods With the use of whole exome sequencing and candidate gene screening, we identified five children from four unrelated families, who had unexplained autoinflammatory disease and shared mutations in one common gene. One family from Saudi Arabia was consanguineous with two affected daughters. The second family of mixed Czech and British background had one affected boy. The third and fourth families were of mixed European ancestry from the United States and each family had one affected daughter. We performed additional experiments in patients samples including flow cytometry, immunophenotyping, cytokine profiling, mitochondria related function and ribosomal assembly assays. Protein function was studied with morpholino knockdowns in zebrafish embryos. Results All patients carried missense recessive mutations in one common gene, the TRNT1 (tRNA Nucleotidyl Transferase, CCA-Adding, 1), on chromosome 3. The two affected Saudi Arabian sisters were homozygous for a p. H215R missense mutation, while the other three children were compound heterozygous for a missense mutation, p. I223T or p. R99W, and one shared mutation p. D163V. The p. H215R mutation was not found in any public database neither in 1061 Arab control DNA samples. From the three Caucasian mutations, the p. R99W was novel whereas the p. I223T and p. D163V were found at a very low allele frequency ( Preliminary data from cytokine analysis in two patients have shown elevated levels of the proinflammatory cytokines interleukin 6 and type 1interferon, suggesting possible therapeutic targets. Knockdown of the zebrafish TRNT1 homologue caused hydrocephaly, defects in tail development, anaemia and a reduction in the number of hair cells present in the lateral line, that has function resembling human inner ear. Conclusion The CCA-adding TRNT1 enzyme catalyses the addition of the CCA terminus to the 3 prime end of all tRNAs precursors, a step that is essential for tRNA aminoacylation and protein synthesis. The discovery that missense mutations in this essential and ubiquitiously expressed gene cause a newly defined periodic fever syndrome, will allow further understanding of mechanisms underlying inflammation.

Interferon gamma receptor-2 (IFNγR2) deficiency is characterized by increased susceptibility to nontuberculous mycobacteria and intracellular pathogens. We report successful HLA-identical bone marrow transplantation (BMT) of a patient with this defect. A Qatari male born to consanguineous parents presented with a CMV positive urine culture, while blood and urine mycobacterial cultures were initially negative. Bacille-Calmette-Guerin (BCG) vaccine was not administered due to a history of IFN-γ R2 deficiency in his deceased older sister. The patient was found to have the same defect. Parents initially refused BMT. He received prophylactic azithromycin but developed disseminated Mycobacterium avium complex (MAC) infection requiring an aggressive regimen including amikacin, azithromycin, ethambutol, linezolid, rifampin and moxifloxacin. CMV infection was treated with ganciclovir, foscarnet, and CMV immune globulin. Splenectomy was performed at age 9 months, due to massive hypersplenism with subsequent growth of MAC. CMV DNA was positive until age 11 months, while mycobacterial blood cultures were positive until age 10 months. At age 13 months, he underwent bone marrow transplantation from his HLA-identical father. Pre-transplant conditioning included busulfan, cyclophosphamide, and antithymocyte globulin (ATG). Post-transplant graft vs. host disease prophylaxis included methotrexate and cyclosporine. RFLP analysis revealed 98% donor cells on day +32 post-transplant. Transplant course was complicated by Clostridium difficile infection, fevers, hypertension and thrombocytopenia, but he is stable 94 days post-transplantation. Conclusions Our case is the only living patient who has undergone successful BMT for a defect in the IFNγR2. We conclude that bone marrow transplantation for IFNγR2 deficiency is an effective means of correcting this immunodeficiency.