Search

Background Mutations of CECR1 have been recently reported as causative of an inflammatory condition characterized by polyarteritis nodosa, cerebral stroke and immunodeficiency; the clinical manifestations of the disease are heterogeneous with a wide range of severity. Objectives To analyze the prevalence of CECR1 mutations in pediatric patients with polyarteritis nodosa, livedo reticularis and/or stroke. Methods Pediatric patients of Caucasian Italian origin with the following diseases/manifestations were included in the study: i) histologically confirmed polyartiritis nodosa (PAN) or cutaneous polyartiritis nodosa (cPAN), ii) persistent livedo reticularis with elevation of acute phase reactants, iii) ischemic or hemorrhagic strokes with systemic inflammation. Direct sequencing of CECR1 gene (exons 1-9) was performed with Sanger analysis. Results Up to January 2015, 27 patients from 25 families were included in the study. Homozygous or compound heterozygous CECR1 mutations with deleterious effects (G47R, G47A, P251L, R312X, E328D, T360A) were detected in 6 patients. A heterozygous causative mutation (G47V) was observed in 2 affected brothers, their father and the unaffected brother. So far a second mutation has not been detected; loss of heterozygosity could not be demonstrated and the mother is being investigated for a possible interstitial deletion. In the remaining patients common polymorphisms (L46L, N53N, H335R, Y453Y) were detected. The mean age of onset of the disease in genetically confirmed patients was 24 months (range 6 months – 5 years); all of them presented fever, elevation of acute phase reactants, livedo reticularis and a skin biopsy suggestive for vasculitis; two of them presented subcutaneous nodules while one of them presented ulcerations at extremities. Hypertension was detected in four patients, while one presented miocarditis. 3 patients presented one or more cerebral stroke during their disease course, while in 3 patients peripheral neuropathy was detected. 4 patients presented intestinal involvement (ranging from recurrent abdominal pain to intestinal perforation) and 2 patients presented growth delay, independent from steroidal treatment. Low immunoglobulin levels were detected in two patients. The clinical characteristics of the two heterozygous patients were similar: fever, livedo reticularis, increased acute phase reactants and hypogammaglobulinemia were detected in both; cerebral stroke occurred in one of them. Conclusions CECR1mutations are present in the Italian population and associated with severe cases of ADA2 deficiency. A clinical heterogeneity has been detected in genetically confirmed patients. In a few patients a typical phenotype was associated to incomplete or negative genotype, thus supporting the hypothesis of a genetic heterogeneity of this condition. Disclosure of Interest None declared

Background Chronic nonbacterial osteomyelitis (CNO)is the most common autoinflammatory bone disorders in childhood (1). CNO remains a diagnosis of exclusion because of the absence of specific clinical or laboratory findings.An important role in the diagnosis could be provided by whole body imaging techniques as TC-99 bone scintigraphy and/or whole body MRI. The treatment is not standardized;non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, bisphosphonates and tumour necrosis factor neutralizing agents have been used until now with variable response (2). Objectives To describe clinical, biological and radiological response to treatment with IL-1 receptor antagonist (anakinra) in a cohort of patients with CNO. Methods Seven patients with CNO refractory to NSAIDs, glucocorticoids and bisphosphonate (pamidronate) were treated with anakinra for at least 6 months in our institution. Response of treatment was evaluated assessing clinical manifestations (pain, local swelling, functional impairment), laboratory findings (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR] and serum amyloid A level [SAA]) and number of bone lesions on TC-99 bone scintigraphy at the start of treatment and in a 6 months follow-up. Results Seven patients (4 females and 3 males) were included in this study. The median age at diagnosis was 9.7 years (IQR 7.8-14.7) and the median age before starting anakinra treatment was 13.3 years (IQR 8.0-15.9). All the patients were treated with NSAIDs and bisphosphonates as first-line therapy. Glucocorticoid therapy was required in one patients with concomitant recurrent fever and pleural effusion. These patients did not respond satisfactorily and we decide to use anakinra (2 mg/kg/day) to control disease activity. At the start of treatment 7/7 patients (100%) had pain, 3/7 (43%) local swelling and 5/7 (71%) functional impairment; at 6 months of follow up 6/7 patients (86%) were completely asymptomatic, with one patient complaining of arthralgia. Before starting anakinra the median CRP, ESR and SAA were 2.7 mg/dl (IQR 1.7-4.9) 26 mm/h (IQR 12-46) and 53 mg/dl (IQR 27-112); at 6 months 5/7 patients (71%) have normalized CRP, ESR and SAA, 2/7 had a decrease in inflammatory markers. Before anakinra 59 osseous lesions were detected on TC-99 bone scintigraphy. After 6 months of therapy 24/59 lesions (40%) had completely resolved, 1/59 lesions (2%) had partially improved and 29/59 lesions (49%) remained stable. In two patients with persistent high biological inflammatory markers, new lesions (14) developed during treatment. Conclusions Our data suggest that anakinra appears effective in CNO patient, who have not responded to standard of care, in controlling symptoms and laboratory findings, although subclinical bone inflammation was still detectable by bone scintigraphy after 6 months of treatment. Long-term follow-up studies with a larger number of patients are needed. References Sara M. Stern, Polly J. Ferguson. Autoinflammatory Bone Diseases. Rheum Dis Clin N Am 39 (2013) 735-749. H J Girschick, P Raab, S Surbaum, A Trusen, et al. Chronic non-bacterial osteomyelitis in children. Ann Rheum Dis 2005;64:279-285. Disclosure of Interest None declared

Background Macrophage activation syndrome (MAS) is a potentially life-threatening complication of systemic juvenile idiopathic arthritis (sJIA). It is common view that sJIA-associated MAS bears a close clinical resemblance to the group of hemophagocytic lymphohistiocytosis (HLH) syndromes, including familial HLH (FHL). This has led to suggest the use of the HLH-2004 guidelines to diagnose MAS in sJIA. However, MAS develops in the context an underlying highly inflammatory condition, whereas FHL is a primary disorder with genetic basis. It is, thus, conceivable that some differences exist in the clinical expression and severity of the two conditions. However, their clinical picture has previously been compared only in a small study 1 Objectives To compare the demographic, clinical, laboratory and histopathologic features of sJIA-associated MAS and FHL Methods Data on sJIA-associated MAS were collected by pediatric rheumatologists and pediatric hemato-oncologists in a large multinational collaborative effort 2 . Data on FHL patients were gathered from the HLH-94 and HLH-2004 trials 2 . Clinical and laboratory features at disease onset were compared between by means of Mann-Whitney U test or chi-square/Fisher exact test, as appropriate Results A total of 620 patients were enrolled: 362 (58.4%) with sJIA-associated MAS and 258 (41.6%) with FHL. The main differences in demographic, clinical, laboratory and histopathologic features between the two patient groups are presented in Table 1 Conclusions Although MAS and FHL showed similar clinical features and laboratory abnormalities, the frequency of most clinical manifestations and the severity and trend of laboratory changes were different. FHL patients had greater frequency of hepatosplenomegaly and more profound cytopenia, hypofibrinogenemia and hypertransaminasemia, whereas MAS patients had higher levels of ferritin and LDH. The prevalence of CNS disease was comparable between the two groups. Hemophagocytosis was detected more commonly in FHL. The observed differences suggest the use of different diagnostic criteria for the two conditions References Lehmberg et al. Differentiating macrophage activation syndrome in systemic juvenile idiopathic arthritis from other forms of hemophagocytic lymphohistiocytosis. J Pediatr 2013;162:1245-51. Minoia et al. Clinical features, treatment and outcome of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis. A multinational, multicentre study of 362 patients. Arthritis Rheumatol 2014;66:3160-9. Henter et al. HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2007;48:124-31 Disclosure of Interest None declared

Background Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disorder of unknown ethiology. The clinical manifestations of CRMO are highly variable. One to 20 sites can be affected at one time. Since CNO is a systemic disorder that can affect multiple skeletal sites, whole-body imaging techniques (Tc-99 bone scintigraphy or MRI) provide major contribution to the initial diagnostic approach, as well as during follow-up (1-2). Objectives To evaluate typical patterns of bone involvement on MRI in paediatric patients with CRMO. Methods We retrospectively reviewed 112 MRI performed at the diagnosis and during follow-up from 2010 to 2014 of 40 children with CRMO. Thirty-two patients underwent bone biopsy that confirmed the diagnosis. 28/40 (70%) underwent one or more WBMRI. Coronal STIR images were obtained in all children. Additional sequences were performed in doubtful cases. Results A total of 360 lesions were detected. Lesions were multifocal in 36/40 patients (90%) and were symmetric in at least one localization in 24/40 patients (60%). In 30/40 patients (75%) lesions were located on the metaphyses of long bones (especially femur and tibia) close to one or both sides of an epiphyseal or apophyseal growth plate and/or on pelvic bones (particularly on the sacro-iliac joints and close to the triradiate cartilage) and/or on clavicle/sternum. The spine was involved in 14/40 (34.1%) patients, in all but 2 in combination to the submentioned locations. No patients had carpal or head bone involvement, 16/40 had tarsal involvement. Conclusions MRI, and particularly WBMRI, should be considered the diagnostic modality of choice in patients with clinical multifocal pain. Simmetricity, multifocality and particularly specific patterns of lesions appear highly suggestive of CRMO. References De Somer L. et al. Total body MRI, a guide to diagnosis in patients with osteo-articular pain and inflammation. Arthritis Rheumatol. 2014 March;66(S3):S119 Falip C. et al. Chronic recurrent multifocal osteomyelitis (CRMO): a longitudinal case series review. Pediatr Radiol. 2013 Mar;43(3):355-75. Disclosure of Interest None declared

Background The advent of biologic medications has considerably increased the potential for treatment benefit in juvenile idiopathic arthritis (JIA), with clinical remission being now achievable in a substantial proportion of patients. Objectives To evaluate the outcome of etanercept (ETN) therapy in Italian children with JIA. Methods This is a multicenter, observational study that includes all children with JIA who were given ETN at Italian pediatric rheumatology centers after January 2000. Patients were classified in 2 groups: patients who were no longer taking ETN at study start (Group 1); patients who were still receiving ETN at study start (Group 2). Patients in Group 1 underwent only retrospective assessments, whereas patients in Group 2 underwent both retrospective and cross-sectional assessments. The primary outcome of the study were reasons for ETN discontinuation in patients in Group 1, and achievement of the states of inactive disease (ID), minimal disease activity (MDA) and parent- and child-acceptable symptom state (PASS, CASS) in patients in Group 2. The above states were assessed through both formal definitions and JADAS cutoffs. The secondary outcome was the evaluation of frequency and characteristics of ETN-related side effects. Results So far, the data of 1019 patients (629 in Group 1 and 390 in Group 2) have been collected. Among the 629 patients in Group 1, reasons for ETN discontinuation evaluated in 460 patients included disease remission (48.5%), lack of efficacy (26.1%), and side effects (14.8%). The results of assessment of disease state through formal definitions in 371 children of the 390 children in Group 2 who had already undergone the cross-sectional evaluation were the following: ID 39.7%, MDA 63.0%, PASS 82.4%, CASS 75.8%. The percentages of patients who reached the same disease states assessed through JADAS cutoffs were: ID 45.9%, MDA 61.6%, PASS 70.0%, CASS 66.2%. Serious adverse events were seen in 17 patients and included inflammatory bowel disease (8 pts), tuberculosis (1 pt), CMV hepatitis (1 pt), recurrent pneumoniae (1 pt), varicella complicated by bronchopneumonia (1 pt), acute pancreatitis (1pt), bacterial osteomyelitis (1 pt), bladder carcinoma (1pt), thyroid carcinoma (1 pt); 1 patient died of sepsis. Conclusions A substantial proportion of children currently receiving ETN were in the states of ID or MDA, or were satisfied with treatment outcome. Half of the patients who had been discontinued from ETN before study start had the medication stopped because of disease remission. Serious adverse events were uncommon. Disclosure of Interest None declared

Background Autoinflammatory disorders (AIDs) represent a group of complex diseases characterized by periodic or chronic systemic inflammations with involvement of various organs and systems in the absence of evidence of autoimmunity or infections. Mutations in more than 15 genes, affecting several distinct pathways, have been associated with autoinflammatory recessive/dominant syndromes [1]. The molecular genetic analysis of these diseases based just on the candidate gene has low efficiency and it9s time consuming and expensive. Next Generation Sequencing (NGS) has emerged in the last year as new diagnostic tool in this field. Objectives To share data obtained by the application of NGS in a cohort of patients affected by an AIDs of undefined origin evaluated at our center. Methods In this study we enrolled 145 patients evaluated at our center from 2010 to 2014,affected by undefined AIDs. In order to improve variant detection, to reduce diagnosis time and to correlate phenotype of patients with their genotype on multiple genes, we developed NGS approaches starting with 11 genes (divided into two panels), already known to be involved in AID (Panel 1: MVK, MEFV, NRLP12, NRLP3, NOD2, TNFRSF1A and PSTPIP1; Panel 2: IL1RN, LPIN2, IL36RN, PSMB8). Targeted resequencing was performed using a uniquely customized panel and analyzed with the MiSeq® sequencing platform (Illumina, San Diego, CA). All variants identified have been confirmed by Sanger sequencing and,when possible,family members were tested to study the segregation of identified variants. Results NGS analysis led to the identification of 61 patients with different variants in the genes of panel 1, with a detection rate of 42%. 36% of the patients showed variants in the NLRP3 gene, 19% in NOD2, 31% in NLRP12, 23% in MEFV, 8% in MVK and TNFRSF1A, 6% in PSTPIP1. Some of these variants are novel and others are already known or polymorphisms. In 29% of patients the combination of variants in two different genes was found. Several variants are of unknown pathogenic significance,while some of them are described as risk factors. We performed 15 familial study to unravel the segregation of some variants. Conclusions NGS leads to the identification of many genetic variants that could be associated with disease susceptibility. The major challenge is in the interpretation of the clinical relevance of identified variants, particularly of variants that are found at low, but >1%, frequency in various populations. These may function as susceptibility alleles to inflammation rather than disease-associated mutations [2]. Some patients show variants in multiple analyzed genes: it can be assumed that different variants in different genes may cooperate to determine a pathological phenotype.This will necessitate large-scale population studies, in vitro functional assay and careful correlation of genetic information with phenotypic data [3]. Crucial is close collaboration with clinicians. References Martinon F, Aksentijevich I. New players driving inflammation in monogenic autoinflammatory diseases. Nat Rev Rheumatol 2015 Jan;11(1):11-20. Shinar Y, et al. Guidelines for the genetic diagnosis of hereditary recurrent fevers. Ann Rheum Dis 2012 Oct;71(10):1599-605. Aksentijevich I, Kastner D. Genetics of monogenic autoinflammatory diseases: past successes, future challenges. Nat Rev Rheumatol 2011 Jul 5;7(8):469-78. Disclosure of Interest None declared

Background & Aims: The syndrome of immunodysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) is a rare disorder resulting in the expression of multiple autoimmune and allergic features. Early onset enteropathy and type 1 diabetes (T1D) are the most common clinical features. The IPEX syndrome is caused by mutations of the FOXP3 gene, which is essential for the development of regulatory T cells (Treg). We describe 2 unrelated patients with IPEX syndrome with a mild clinical phenotype and with novel FOXP3 mutations and the phenotypic and functional characterization of their Treg cells. Methods: The FOXP3 gene was analyzed by sequencing amplimers from genomic DNA. Treg cells were characterized by evaluating the number of CD4+CD25+ T cells and their functional ability to suppress the proliferation of autologous CD4+CD25− effector T cells stimulated with anti-CD3 and anti-CD28 antibodies. Results: A 7-year-old boy and a 24-year-old man presented with autoimmune enteropathy characterized by early onset persistent diarrhea not associated with T1D or other endocrinopathies. These 2 patients carry novel FOXP3 mutations that do not abrogate the function of the forkhead domain. They have normal numbers of CD4+CD25+ T lymphocytes, however, these show severely defective suppressive function in vitro. Conclusions: Our 2 patients show that IPEX patients may present with early onset enteropathy and long-term survival without T1D or other endocrinopathies. This milder phenotype may be associated with FOXP3 mutations that do not abrogate the function of the forkhead domain.

We report a family with pyogenic sterile arthritis, pyoderna and acne syndrome (PAPA). The proband presented several episodes of sterile pyogenic arthritis and became unresponsive to glucocorticoids. After treatment with the tumor necrosis factor inhibitor etanercept, the disease underwent rapid and sustained clinical remission. Production of tumor necrosis factor-alpha by mononuclear cells of the proband and of the affected relatives was abnormally elevated.

Conflicting results obtained from animal studies suggest that B cells play a role in maintaining long-term T-cell memory and in skewing T-cell response toward a T-helper 2 (TH2) phenotype. X-linked agammaglobulinemia (XLA) is a genetic human disease characterized by the lack of circulating B cells due to the mutation of Bruton tyrosine kinase. This disease thus represents a unique model for studying the role of B lymphocytes in regulating T-cell functions in humans. To this aim, we analyzed hepatitis B envelope antigen (HBenvAg)–specific T-cell memory in a series of XLA patients vaccinated against hepatitis B virus (HBV). We found HBenvAg-specific T lymphocytes producing interferon–γ, interleukin-4, or both in the peripheral blood of XLA patients up to at least 24 months after completing the standard anti-HBV immunization protocol. The HBenvAg-specific T-cell frequencies and the percentage of patients with these responses were not significantly different from healthy vaccinated controls. By combining cell purification and enzyme-linked immunospot assay, we found that effector CD27− T cells, which promptly produced cytokines in response to antigen (Ag), and memory-resting CD27+ T cells, which required Ag restimulation to perform their functions, were maintained in both XLA patients and controls for up to 24 months after the last vaccination boost. These data strongly suggest that B cells are not an absolute requirement for the generation of effective T-cell memory in humans, nor do they seem to influence TH1/TH2 balance.

Acute transverse myelitis (ATM) is a very rare manifestation of the central nervous system in systemic lupus erythematosus (SLE), especially in case of involvement of continuous segments (longitudinal myelitis). We describe a 12-year-old female with lupus correlated with transverse myelitis with a longitudinal involvement of the spinal cord (D2 to D10) at the onset of the disease. Despite the administration of an early aggressive therapy, the outcome proved to be unfavourable. After 2 years of follow-up, the child still complains of paraplegia, sphincter incontinency and ipo-paresthesias of both legs.

MAS is a severe complication of rheumatic diseases, mostly sJIA. Clinical and laboratory features are similar to those of FHL resulting from mutations in selected genes involved in the cytotoxicity pathway.

Background Acute pericarditis is defined as at least 2 of the following: typical chest pain (sharp and pleuritic, improved by sitting up and leaning forward), pericardial friction rub, suggestive EKG changes (widespread ST elevation or PR depression), new or worsening pericardial effusion. Pericarditis may recur in 15-30% of cases; these children are frequently followed by pediatric Rheumatologists. At present the largest case series described 15 children affected by recurrent pericarditis. Objectives This is a multicenter, retrospective cohort study including all consecutive cases of recurrent pericarditis with at least 2 recurrences in pediatric patients seen in 7 referral centers in Italy. Methods We analyzed 107 children; the mean age at the time of the first attack was 11,1 years; 67 were males and 40 females. Results The mean recurrence number was 4.8 (2-25); pericarditis was idiopathic in the majority of cases (88%), post-pericardiotomic in 10%, related to Familiar Mediterranean fever in 2%. Most children had fever and CRP elevation at disease onset (77% fever, 93% CRP elevation), and so was pericardial effusion (76%: typically mild, with cardiac tamponade in 13%, only at disease onset), while pericardial rub and EKG changes were detected in a smaller number of patients (28% and 45% respectively). After a mean follow-up of 73 months, none of the patients with idiopathic RP developed a systemic autoimmune disease (even if ANA was positive in 19%) or was found as having an infectious disease. 80% children were treated with NSAIDs, 64% with steroids and 63% with colchicine. Refractory cases were treated with immunosuppressant drugs (AZA: 4, MTX: 2, IVIG: 1, Antimalarials: 5, CSA: 1), and 11 with Anakinra. Children treated with corticosteroids experienced more recurrences (5,9 vs 2,6, p Conclusions This is the largest ever published case-series on pediatric recurrent pericarditis. Because of lack of standardized treatment guidelines, we believe that our data will help clinicians in manage these children, typically treated with rheumatological drugs. Corticosteroids should be used with extreme caution and NSAIDs remain the mainstay of the therapy. Anti-IL1 may be useful in very selected cases. The long term outcome is good. References Imazio M, et al. A randomized trial of colchicines for acute pericarditis. New Engl J Med 2013; 369:1522-8. Gaspari S. et al. New insights in the pathogenesis and therapy of idiopathic recurrent pericarditis in children. Clin Exp Rheumatol 2013;31:788-94. Raatikka M et al. Recurrent pericarditis in children and adolescents. Report of 15 cases. J Am Coll Cardiol 2003;42:759-64. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1952

Blau syndrome (BS) is a rare autosomal dominant, autoinflammatory syndrome characterized by the clinical triad of granulomatous, recurrent uveitis, dermatitis and symmetric arthritis. Arthritis is usually a polyarticular exuberant synovitis and tenosynovitis and represents the characteristic phenotypic feature. Uveitis occurs in most patients and commonly evolves to a panuveitis. In the majority of patients, the disease is characterized by early onset, usually before 3-4years of age. The gene responsible for BS has been identified in the caspase recruitment domain gene NOD2/CARD15, and the most common mutations were found in codon 334 (R334Q and R334W). NOD2 is a member of a family of intracellular proteins with N-terminal caspase recruitment domains (CARDs). Since the first report of an association of the NOD2 variants with Crohn disease by Hugot et al, extensive studies have been focused on an association of NOD2 with inflammatory bowel disease (IBD), pediatric Blau syndrome, NOD2-associated autoinflammatory disease (NAID) and rheumatic disease.

No evidence-based classification criteria are so far available for the majority of autoinflammatory diseases

TNF-α is involved in regulation of herpes virus replication and dissemination, and varicella, herpes zoster and herpes labialis have been observed as adverse events during clinical trials with and in national registries for the use of etanercept in JIA, in some cases resulting in serious adverse events (saes).

At present, no guidelines on the appropriate withdrawal of ETN in JIA patients in clinical remission exist. The identification of predictors of clinical remission off medication (CROM) in these patients represents the initial step in their development.

Macrophage Activation Syndrome (MAS) is a severe complication of rheumatic diseases, frequently associated with systemic juvenile idiopathic arthritis (sJIA), but also described in others pediatric inflammatory disorders including Juvenile Systemic Lupus Erythematosus (SLE) and Kawasaki disease. Due to the close resemblance to a group of histiocytic disorders collectively known as hemophagocytic lymphohistiocytosis (HLH) it is currently classified among the secondary or acquired forms of HLH, and the term rheu-HLH has been proposed.

HUVS is a rare disease characterized by persistent urticarial lesions with histological evidence of leucocytoclastic vasculitis and complement activation with a marked decrease in circulating C1q levels. HUVS can present systemic features involving the musculoskeletal, pulmonary, renal and gastrointestinal systems; its peak incidence is in the fifth decade of life. The exact prevalence of HUVS in children is unknown.

The diagnosis of FMF is made clinically and may be confirmed by identifying mutations in the MEFV gene. The most commonly used diagnostic criteria for FMF are those of Tel Hashomer, which have been established in the Jewish adult population. Recently, a Turkish group (Yalcinkaya-Ozen's diagnostic criteria) proposed new criteria for diagnosis of FMF in children.

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.

No evidence-based classification criteria are so far available the majority of autoinflammatory diseases

Cryopyrin-associated periodic syndrome (CAPS) is an autoinflammatory syndrome caused by heterozygous mutations of CIAS1/NLRP3 gene. Affected patients may present with three different phenotypes: familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome and CINCA syndrome. Common symptoms include sporadic or cold-induced non pruritic urticarial rash and fever. Severe cases suffer from deafness, meningitis, articular contracture and secondary amyloidosis.

TRAPS is a rare lifelong disease. Optimal treatment is not established but tends to rely either on corticosteroids with risks of known short and long term side effects or anti cytokine agents which are expensive, and both types of agents lead to higher risk of infection.

Objectives The aim of this study was to compare the phenotype and genotype characteristics of familial Mediterranean fever (FMF) in children from the eastern Mediterranean to those from Europe. Methods We extracted all patients who were registered to the EUROFEVER database as FMF. The database includes demographic data, characteristics of disease episodes, molecular analysis, comprehensive list of signs/symptoms in 11 broad organs/systems, laboratory parameters, disease course, and outcome. Two experts independently reviewed extracted data (SO and, MG) and confirmed the diagnosis. Results A total of 438 patients with FMF were collected from 23 different countries. Patients were divided into two groups according to their country of origin as those from the eastern Mediterranean region (Group I) (n=175) and those from Europe (Group II) (n=125). Group I included countries where FMF has a high prevalence such as Turkey, Israel, Armenia, Azerbaijan and Arabic countries of the eastern Mediterranean region. The mean age of disease onset was younger in Group I (3.9±3.3 years) compared to the European patients (6.9±10.7 years) (p=0.003) as was the age at diagnosis (6.6±3.5 years versus 11.9±2.9 years, respectively) (p Comparison of clinical manifestations showed that, oligoarthritis was more common among patients from the eastern Mediterranean (30.9%) as compared to those from Europe (8.8%) (p Although the most frequent gene mutation was M694V in both groups, this mutation was significantly higher among patients from the eastern Mediterranean region (59.2%) as compared to those from Europe (47.0%) (p=0.004). There was no significant difference between groups regarding response to colchicine (p=0.371). However, the follow up data indicated that complete remission with colchicine treatment was higher among the patients from the eastern Mediterranean (p=0.002). Conclusions Our results show a number of phenotypic differences when FMF patients from the eastern Mediterranean were compared to those from Europe. Furthermore M694V was more frequent among patients from areas where FMF is frequent. The frequency of this mutation, the younger at onset, increased occurence of arthritis and pleurisy suggest a more severe disease in FMF patients from the eastern Mediterranean. Disclosure of Interest None Declared

Background Cryopyrin-associated periodic syndrome (CAPS) is an autoinflammatory syndrome caused by heterozygous mutations of CIAS1/NLRP3 gene. Affected patients may present three different phenotypes: familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome and CINCA syndrome. Common symptoms include sporadic or cold-induced non pruritic urticarial rash and fever. Severe cases suffers from deafness, meningitis, articular contracture and secondary amyloidosis Objectives To identify the genotype-phenotype correlation of our patient. Methods We describe a 13-year-old female who presented, starting at 12 years of age, recurrent episodes of high fever, pericarditis, arthralgia, arthritis of the knees, abdominal pain and marked increase in inflammatory markers (5 episodes in the first 5 months of disease). Symptoms were poorly responsive to therapy with NSAIDs and colchicine but responded to steroid therapy. Molecular analysis of the MEFV, TNFR and MVK genes did not show any pathogenic mutations. Serumamyloidlevel was normal. In the subsequent months she developed recurrent (up to daily) episodes of chest pain, skin rash and swelling of the subcutaneous tissue of limbs, trunk, joints and lips, in the absence of fever, with spontaneous resolution. Results Molecular analysis of the CIAS1 gene revealed the presence of a c.1105C>A mutation in the heterozygous state,that predicts a L369M amino acid substitution. To the best of our knowledge this variant has never been reported. One-Hundred chromosomes were examined and the variant was not found. In order to verify the potential pathogenic effects of the L369M amino acid substitution, daily therapy with anakinra (2 mg/kg/day) was started with rapid disappearance of clinical symptoms and normalization of CRP levels in 24 hours Conclusions The fast response to IL-1 inhibtion suggests that the disease of this patient is driven by IL-1 and support the conclusion that this novel mutation is pathogenic and may be associated with a new CAPS phenotype References Kuemmerle-Deschner JB, Hachulla E, Cartwright R, Hawkins PN, Tran TA, Bader-Meunier B, Hoyer J, Gattorno M, Gul A, Smith J, Leslie KS, Jimenez S, Morell-Dubois S, Davis N, Patel N, Widmer A, Preiss R, Lachmann HJ. Two-year results from an open-label, multicentre, phase III study evaluating the safety and efficacy of canakinumab in patients with cryopyrin-associated periodic syndrome across different severity phenotypes. Ann Rheum Dis. 2011 Dec;70(12):2095-102. Epub 2011 Aug 21. Disclosure of Interest None Declared

Background Chronic recurrent multifocal osteomyelitis (CRMO) is a rare childhood disease presenting with bone pain, fever and multifocal osteolytic bone lesions. CRMO is considered an autoinflammatory disease but its aetiology and pathogenesis are still unknown. Autoinflammatory diseases are usually characterized by abnormalities in the regulation of inflammasomes, macromolecular complexes involved in the processing and in the release of IL-1?. Aim To investigate the inflammasome response in CRMO patients. Methods In this study, 10 CRMO patients (mean age 10.7 ± 5.4 years) and 9 age-matched controls were enrolled. The basal mRNA expression of inflammatory cytokines such as IL-1?, IL-6 and TNF-? and of inflammasome components such as ASC, NLRP3 and CASP-1 were evaluated by quantitative real-time PCR in peripheral blood mononuclear cells (PBMCs). IL-1? levels released in conditioned media after LPS and ATP treatment of PBMCs were measured by ELISA. Results mRNA levels of IL-1? and IL-6 were significantly higher in PBMCs from CRMO patients than in healthy donors, with a ten-fold average increase in IL1? transcript (p= 0.0001) and a five-fold average increase of IL-6 transcript (p=0.001). mRNA levels of inflammasome components were comparable between the two groups. When PBMCs were stimulated in vitro with LPS alone, we observed higher levels of IL-1? in the conditioned media of PBMCs obtained from CRMO patients than in those obtained from controls (p=0.01). Controls cells released high IL1? levels only after stimulation with LPS and ATP with no difference with PBMCs from CRMO patients. Conclusion Our data suggest that an abnormal regulation of IL-1? axis characterize PBMCs of CRMO patients.

Methods A web-based registry collecting baseline and clinical information of autoinflammatory diseases was located at the member area of the PRINTO website (www.printo. it). Participating hospitals included pediatric rheumatology centers of the PRINTO network and adult centers with a specific interest in autoinflammatory diseases. Data was collected on Blau’s syndrome, Behcet’s disease, CAPS, CRMO, DIRA, FMF, MKD, NLRP12-mediated periodic fever, PAPA, PFAPA TRAPS and undefined periodic fevers. In total, 704 patients were included in this retrospective study on therapy.

CRMO primarily affects girls with a mean age at onset of8.5 years and a mean time to diagnosis of 8.5 months.Most patients were diagnosed in less than 1 month, but 2cases presented a delay due to atypical presentation. Atonset, 14 patients had inflammatory pain and 6 localswelling and fever. The lower limbs were predominantlyaffected, followed by the axial skeleton, the upper limbsand lastly by the mandible. Laboratory parameters pro-vided non-specific information on CRMO. Radiographicstudies were needed to exclude other pathologies. Thediagnosis should be reached by isotope bone scanning orby magnetic resonance imaging. In doubt case bonebiopsy was request to confirm the diagnosis.

Background and objectiveFamilial 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. Clinical diagnosis of FMF is complicated by overlap in symptoms with other diseases, and interpretation of genetic testing is confounded by the lack of a clear genotype–phenotype association for most of the 340 reported MEFV variants. In this study, the authors designed a functional assay and evaluated its potential in supporting FMF diagnosis.MethodsPeripheral blood mononuclear cells (PBMCs) were obtained from patients with Pyrin-associated autoinflammation with an FMF phenotype (n=43) or with autoinflammatory features not compatible with FMF (n=8), 10 asymptomatic carriers and 48 healthy donors. Sera were obtained from patients with distinct AIDs (n=10), and whole blood from a subset of patients and controls. The clinical, demographic, molecular genetic factors and other characteristics of the patient population were assessed for their impact on the diagnostic test read-out. Interleukin (IL)-1β and IL-18 levels were measured by Luminex assay.ResultsThe ex vivo colchicine assay may be performed on whole blood or PBMC. The functional assay robustly segregated patients with FMF from healthy controls and patients with related clinical disorders. The diagnostic test distinguished patients with classical FMF mutations (M694V, M694I, M680I, R761H) from patients with other MEFV mutations and variants (K695R, P369S, R202Q, E148Q) that are considered benign or of uncertain clinical significance.ConclusionThe ex vivo colchicine assay may support diagnosis of FMF and functional subtyping of Pyrin-associated autoinflammation.

Results The V198M mutation was found in 13 screened patients: 10 were heterozygous for the mutation only. In one patient with a typical MWS phenotype the V198M variant was associated with the Q703K and the D303N mutation of the same gene. In a patient a low-penetrance mutation of TNFRSF1A gene (P46L) was also found, while another one carried the A91V mutation of Pfr1 gene. Out of the 10 patients heterozygous for the V198M mutation, five displayed a story of periodic fever associated with urticarial rash, arthralgia and transient arthritis, associated with elevation of acute phase reactants and responding to steroid treatment on demand or to treatment with IL-1 blockers. In two patients the clinical picture was mild and uniquely characterized by urticarial rash and arthralgia, often induced by cold, but not associated with elevation of acute phase reactants. The other three patients presented episodes of fever with an inconstant elevation of acute phase reactants and not associated to other symptoms suggestive of CAPS; however one of this patients developed renal amiloidosis. The patients carrying the P46L mutation of TNFRSF1A gene presented periodic fever with athralgia and headache, not associated with elevation of acute phase reactants. The patient carrying the A91V mutation of Pfr1 gene presented some clinical characteristics suggestive of CINCA syndrome associated to not typical ones; this patient died at the age of 4.7 years with a clinical pictures consistent of MAS. 3 patients were treated with IL-1 blockers (anakinra at the staring dosage of 1 mg/kg and canakinumab at the starting dosage of 2 mg/kg every 8 weeks), two heterozygous for V198M and one compound heterozygous for V198M, D303D and Q703 K, with a rapid a complete control of the clinical manifestations. None of the healthy individuals screened for the V198M mutation turned out to be positive. Conclusion This study confirms the low-penetrance of the V198M mutation of the NLPR3 gene. However a minority of these patients may present a clinical phenotype consisting with a CAPS, thus requiring treatment with IL-1 blockers.

We recently proposed a set of provisional, evidence-based, clinical criteria for the classification of children and adults patients affected by monogenic periodic fevers. These criteria, built and validated in a cohort of 1215 patients with periodic fever enrolled in the Eurofever Registry from November 2009 to February 2013, displayed a high sensitivity and specificity.

Cryopyrin-associated periodic syndrome (CAPS) is an autoinflammatory syndrome caused by heterozygous mutations of CIAS1/NLRP3 gene. Affected patients may present three different phenotypes: familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome and CINCA syndrome. Common symptoms include sporadic or cold-induced non pruritic urticarial rash and fever. Severe cases suffers from deafness, meningitis, articular contracture and secondary amyloidosis.

Systemic juvenile idiopathic arthritis (sJIA) accounts for 10-20% of all patients with JIA. The clinical features include fever, evanescent rash, arthralgia and arthritis, myalgia, lymphadenopathy, hepatomegaly, splenomegaly and serositis. Interleukin 1 (IL-1) has been shown to be a major mediator of the inflammatory cascade that underlies sJIA (1). Treatment with anakinra, IL-1 receptor antagonist has been reported to be effective in a subset of patients with sJIA (2).

The NLRP12 related autoinflammatory disorder (NLRP12-RD) is a rare autosomal dominant disease, caused by mutations in the NLRP12 gene, a member of NLRs family involved in negative regulation of NF-kB pro-inflammatory pathways. At present, few cases have been reported, although novel NLRP12 variants have recently been described.

Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) syndrome is a newly described autoinflammatory disease.

Methods Pediatric patients of Caucasian Italian origin with the following diseases/manifestations were included in the study: i) histologically confirmed polyartiritis nodosa (PAN) or cutaneous polyartiritis nodosa (cPAN), ii) persistent livedo reticularis with elevation of acute phase reactants, iii) ischemic or hemorrhagic strokes with systemic inflammation. Direct sequencing of CECR1 gene (exons 1-9) was performed with Sanger analysis.

Chronic nonbacterial osteomyelitis (CNO) is the most common autoinflammatory bone disorder in childhood (1). Diagnostic information is provided by TC-99 bone scintigraphy (BS) and/or whole body MRI. Non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, bisphosphonates and tumour necrosis factor inhibitors have been used until now with variable response (2).

Background Uveitis occurs in 10%–15% of patients with JIA and is still one of the most frequent causes of acquired blindness in the developed world. Female sex, oligoarticular onset, serum antinuclear antibodies (ANA) and early onset of uveitis seem to increase the development of chronic uveitis. If topical treatment fails, second-line agents may be used, but not all patients respond. Infliximab has been reported to be effective in some of these cases. This study aims to assess the response and side effects associated with infliximab in JIA patients with uveitis

Autoinflammatory disorders (AIDs) represent an expanding group of complex diseases characterized by periodic or chronic systemic inflammations. Mutations in more than 15 geneshave been associated with autoinflammatory recessive or dominant syndromes. Next Generation Sequencing (NGS) has emerged in the last year as new diagnostic tool in this field.

Blau syndrome (BS) is a rare autosomal dominant, autoinflammatory syndrome characterized by the clinical triad of granulomatous, recurrent uveitis, dermatitis and symmetric arthritis. The arthritis is usually a polyarticular exuberant synovitis and tenosynovitis and represents the characteristic phenotypic feature. Uveitis occurs in most patients and commonly evolves to a panuveitis. In the majority of patients, the disease is characterized by early onset, usually before 3-4 years of age. The gene responsible for BS has been identified in the caspase recruitment domain gene NOD2/CARD15, and the most common mutations were found in codon 334 (R334Q and R334W) [1]. NOD2 is a member of a family of intracellular proteins with N-terminal caspase recruitment domains (CARDs). Since the first report of an association of the NOD2 variants with Crohn disease by Hugot et al. [2], extensive studies have been focused on an association of NOD2 with inflammatory bowel disease (IBD), pediatric Blau syndrome, NOD2-associated autoinflammatory disease (NAID) and rheumatic disease [3].

The term CAPS (Cryopyrin-Associated Periodic Syndromes) identifies a spectrum of autoinflammatory diseases caused by heterozygous mutations of the CIAS1/NLRP3. Affected individuals may present three different phenotypes: Familial Cold Autoinflammatory Syndrome (FCAS), Muckle-Wells Syndrome (MWS) and CINCA syndrome, the most severe form of the clinical spectrum. Clinical manifestations include urticaria-like rash, recurrent fever, arthralgia, conjunctivitis; chronic aseptic meningitis, cerebral atrophy and bone malformations in the severe cases. The term CAPS (Cryopyrin-Associated Periodic Syndromes) identifies a spectrum of autoinflammatory diseases caused by heterozygous mutations of the CIAS1/NLRP3. Affected individuals may present three different phenotypes: Familial Cold Autoinflammatory Syndrome (FCAS), Muckle-Wells Syndrome (MWS) and CINCA syndrome, the most severe form of the clinical spectrum. Clinical manifestations include urticaria-like rash, recurrent fever, arthralgia, conjunctivitis; chronic aseptic meningitis, cerebral atrophy and bone malformations in the severe cases.

The term CAPS (cryopyrin-associated periodic syndromes) identifies a spectrum of autoinflammatory diseases caused by heterozygous mutations of the CIAS1/NLRP3. Affected individuals may present three different phenotypes: familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS) and CINCA syndrome, the most severe form of the clinical spectrum. Clinical manifestations include urticaria-like rash, recurrent fever, arthralgia, conjunctivitis; chronic aseptic meningitis, cerebral atrophy and bone malformations in the severe cases.

Mevalonate kinase deficiency (MKD) is a rare autoinflammatory disease, caused by mutations in the isoprenoid pathway that lead to fever episodes. Approximately 300 MKD patients are known.

Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) syndrome is a newly described autoinflammatory disease, which had been recently reported in 9 patients. It is characterized by onset during the first year of life of recurrent fevers, purpuric skin lesions, arthralgia, progressive lipodystrophy, hypochromic or normocytic anemia, delayed physical development and increased levels of acute phase reactants.

Early diagnosis of macrophage activations syndrome (MAS) in systemic juvenile idiopathic arthritis (sjia) may be challenging because it may mimic the clinical features of the underlying disease or be confused with an infectious complication. However, the diagnostic value of the guidelines for hemophagocytic lymphohistiocytosis (HLH) or sjia-associated MAS has seldom been examined.

Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) syndrome is a newly described autoinflammatory disease, which had been recently reported in 9 patients. It is characterized by onset during the first year of life of recurrent fevers, purpuric skin lesions, arthralgia, progressive lipodystrophy, hypochromic or normocytic anemia, delayed physical development and increased levels of acute phase reactants.

FMF diagnosis is made clinically and may be supported by identifying mutations in the MEFV gene. The most commonly used diagnostic criteria for FMF are those of Tel Hashomer and the Livneh criteria, which have been established in the Jewish adult population. Recently, a Turkish group (Yalcinkaya-Ozen) proposed new criteria for diagnosis of FMF in children.

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.