Diagnostic value of serum immunoglobulinaemia D level in patients with a clinical suspicion of hyper IgD syndrome

OBJECTIVE

The hyperimmunoglobulinaemia D and periodic fever syndrome (HIDS) was originally defined by the presence of a high serum level of immunoglobulin D associated with recurrent fever. Since the discovery of the mevalonate kinase gene (MVK) gene encoding the mevalonate kinase enzyme, most patients with a clinical diagnostic of HIDS are now found to have a mevalonate kinase deficiency based on metabolic and genetic data. We aimed to asses the value of a high IgD serum level for the diagnosis of HIDS in a cohort of patients with a phenotype of recurrent fever, and to characterize patients with a high IgD serum level without mevalonate kinase mutation.

METHODS

Main clinical and biological data of 50 patients who presented with clinical signs compatible with HIDS have been prospectively registered on a standard form. Clinical data have been analysed according the IgD serum level and the presence of MVK mutation.

RESULTS

The metabolic and genetic data establishing the diagnosis of HIDS correlated in all cases. In this series of 50 patients, the sensitivity of a high IgD value for the diagnosis of HIDS is 0.79. In five patients with MVK mutation, IgD levels were found to be in the normal range. Likelihood ratios indicate that IgD measurement is not relevant for the diagnostic of HIDS. Most patients with a high serum IgD level and no MVK mutation have no definite diagnosis.

CONCLUSION

The clinical relevance of the IgD measurement for the diagnosis of MKD in our population appears as poor, as reflected by likelihood ratios which are both close to 1.

Overlap syndrome between FMF and TRAPS in a patient carrying MEFV and TNFRSF1A mutations

OBJECTIVE

Familial Mediterranean Fever (FMF) and TNF-Receptor Associated Periodic Syndrome (TRAPS) are two inheritable inflammatory disorders. They share some clinical manifestations but their treatments are different. We present here the case of an overlap syndrome of FMF and TRAPS in a patient carrying a mutation in both the MEFV and TNFRSF1A genes.

CASE REPORT

A 20-year-old woman of Mediterranean origin had suffered since childhood from attacks of fever and arthritis, with skin and ophthalmic manifestations. The initial diagnosis was FMF. The symptoms responded poorly to colchicine but regressed with steroids. Genetic analysis revealed a homozygous M694V mutation in MEFV and a heterozygous R92Q mutation in TNFRSF1A. We discuss the complexity of this combined FMF-TRAPS phenotype.

CONCLUSION

This case shows that mutations in MEFV and TNFRSF1A can occur together in a single patient, a condition that may modify its response to treatment. It would be interesting to evaluate the role of the R92Q mutation in TNFRSF1A in patients of Mediterranean origin with FMF unresponsive to colchicine.

Abcès tuberculeux métastatiques (gommes tuberculeuses) : un diagnostic rare en France

INTRODUCTION

Cutaneous tuberculosis is rare in the developed countries. We report a case of tuberculous gumma in an immunocompetent patient diagnosed late.

CASE-REPORT

A 33-year-old Moroccan woman was diagnosed with tuberculous gumma after presenting cutaneous nodules and subcutaneous abscesses that had developed during pregnancy and were present for 11 months. Cutaneous and pulmonary tuberculosis was discovered. The patient recovered under antimycobacterial treatment.

COMMENTS

Cutaneous tuberculosis presents with a wide spectrum of clinical lesions. It should be considered in the presence of poorly known lesions such as gumma, which require investigation for underlying tuberculosis.

[Ocular metastases heralding non-small cell lung cancer: two cases]

INTRODUCTION

Ocular metastases are rare in patients with lung cancer, and exceptionally indicate the condition.

EXEGESIS

We report 2 patients with symptomatic ocular metastases indicating lung adenocarcinoma, involving the choroid in the first case and the optic disc in the other, associated with other metastases. No improvement of visual acuity was observed after chemotherapy and radiotherapy.

DISCUSSION

Ocular metastases may indicate lung cancer, and are usually associated with other metastatic sites. The global prognosis is poor but an early treatment should result in improvement of visual prognosis.

Autoinflammatory diseases

Autoinflammatory diseases can be specified as inborn errors of the innate immune system. The main component of autoinflammatory diseases is the group of hereditary periodic fevers which are characterised by intermittent bouts of clinical inflammation with focal organ involvement mainly: abdomen, musculoskeletal system and skin. The most frequent one is familial Mediterranean fever that affects patients of Mediterranean descent all over the world. Recently, three other types have been characterised, clinically as well as genetically: Tumor Necrosis Factor receptor superfamilly 1A Associated Periodic Fever Syndrome, hyperimmunoglobulinemia D and periodic fever syndrome/ mevalonate kinase deficiency, and the most recently recognised entity which includes Muckle Wells, familial cold autoinflammatory/familial cold urticaria, and the Chronic infantile neurological cutaneous and articular/Neonatal onset multisystemic inflammatory disease syndromes. A thorough diagnosis is warranted, as clinical and therapeutic management is specific for each of these diseases. In addition to hereditary periodic fever, autoinflammatory diseases also encompass Blau, Majeed, and PAPA syndromes. The underlying genetic defects of these inflammatory diseases appear to be specific for each type, involving several so far unknown proteins involved in innate immunity, and have already opened new avenues in our understanding of the inflammatory response.

Unusual sites of Salmonella osteoarthritis in patients with sickle cell disease: two cases

Salmonella osteoarticular infections involve mainly long bones such as the femur, tibia, and humerus in patients with sickle cell disease (SCD). We report here two unusual cases of Salmonella osteoarthritis affecting sacroiliac and sternoclavicular joints in two patients with SCD, one patient also being followed for rheumatoid arthritis. Because of misleading presentation, diagnosis of septic osteoarthritis in patients with SCD requires a high index of suspicion and an early treatment.

Clinical significance of P46L and R92Q substitutions in the tumour necrosis factor superfamily 1A gene

OBJECTIVE

Tumour necrosis factor receptor-associated periodic syndrome (TRAPS) has been associated with several mutations in the TNF receptor super family 1A (TNFRSF1A), including most cysteine substitutions. However, the nature of two substitutions, P46L and R92Q, remains a topic of discussion. The aim of this study was to assess the actual role of these two sequence variations in a series of patients with TRAPS.

METHODS

The main clinical data of 89 patients with TRAPS have been prospectively registered on a standard form. 84 patients or members of families with recurrent episodes of inflammatory symptoms spanning a period of more than 6 months and harbouring a TNFRSF1A mutation were studied. Clinical data have been analysed according to the nature of the mutation-P46L, R92Q or others.

RESULTS

P46L is often seen in patients from Maghreb and is associated with a mild phenotype. P46L appears as a polymorphism with a non-specific role in inflammation. R92Q is associated with a variable phenotype and presents as a low-penetrance mutation. Interpreting these results will require a comparison with clinical signs and genetic background.

Intrafamilial segregation analysis of the p.E148Q MEFV allele in familial Mediterranean fever

BACKGROUND

Familial Mediterranean fever (FMF) is the most frequent of the recurrent inherited fevers. This autosomal recessive disorder is characterised by periodic episodes of fever and serositis that commonly affect the people of Arab, Armenian, Sephardic Jewish and Turkish origin. Most of the described MEFV gene anomalies responsible for the disease are missense mutations. In the absence of any functional test, epidemiological studies or pedigree analyses are the only means of proving the deleterious character of these sequence variations. Evidence was provided by our recent study using a population-based approach, that the p.E148Q allele is probably a benign polymorphism and not a disease-causing mutation. Its implication in FMF remains, however, controversial.

OBJECTIVE

To evaluate the segregation of the p.E148Q MEFV allele with FMF disease by using pedigree analysis.

PARTICIPANTS

21 patients and 48 unaffected relatives belonging to 18 independent families with FMF.

RESULTS

Segregation analysis of the p.E148Q allele was compatible with a Mendelian autosomal recessive transmission of the disease phenotype in only three families. In 15 of 18 families, segregation was partly or completely defective. The p.E148Q allele was not transmitted to 14 of 19 (74%) affected children.

CONCLUSIONS

No evidence of preferential transmission of p.E148Q from heterozygous parents to their affected offspring was observed. MEFV is not associated with the clinical manifestations of several patients carrying this variant. Considering p.E148Q to be a benign polymorphism should reduce the possibility of false-positive diagnoses, while highlighting genetic heterogeneity in FMF.

MEFV analysis is of particularly weak diagnostic value for recurrent fevers in Western European Caucasian patients

OBJECTIVE

Familial Mediterranean fever (FMF) is an autosomal-recessive disorder characterized by recurrent attacks of fever, with abdominal, thoracic, or articular pain. FMF is particularly common in Mediterranean populations, while other populations are rarely affected. MEFV gene analysis provides the only objective diagnostic criterion for FMF. However, the spectrum of MEFV mutations, which was first established in classically affected populations, remains insufficiently studied in other populations. The purpose of this study was to assess involvement of MEFV in the phenotype of western European Caucasian patients with a clinical diagnosis of FMF.

METHODS

Mutation analysis was performed in 208 Caucasian patients from western Europe, by screening for the most common MEFV mutations in exons 2, 3, 5, and 10, and by sequencing the promoter region and the whole MEFV coding sequence in 21 of these patients.

RESULTS

None of the patients carried 2 mutated alleles. Only 2 patients carried 1 mutated allele.

CONCLUSION

FMF-like syndromes in western European Caucasian populations cannot be explained by MEFV mutations. These results should be helpful in avoiding laborious and costly MEFV molecular analyses that, at the population level, seem to be of poor diagnostic value in the case of western European Caucasian patients, and rather should prompt a search for other causes in those patients.

[Tumor necrosis factor receptor superfamily 1A-associated periodic syndrome (TRAPS)]

PURPOSE

Tumor necrosis factor receptor superfamily 1A associated periodic syndrome (TRAPS) belongs to the group of hereditary fever syndromes, also called hereditary auto-inflammatory syndromes.

CURRENT KNOWLEDGE AND KEY POINTS

The diagnosis of TRAPS should be evoked in presence of the following clinical signs, whatever the population of the affected patients. TRAPS acute inflammatory access, of 1 to 3 weeks' duration, is characterised by the presence of fever, abdominal pain, myalgias, various types of skin rash including erysepela-like erythema. Long term inflammatory response can lead to AA amyloidosis. Genetic testing will confirm the diagnosis when showing a mutation in the extracellular part of the TNFRSF1A receptor. Therapeutic management of TRAPS is not definitely established. Daily colchicine does not seem to prevent efficiently inflammatory attacks. Corticosteroids, in contrast can attenuate the intensity and diminish the duration of attacks.

FUTURE PROSPECTS AND PROJECTS

The value of biological agents that inhibits TNF action is not yet completely determined in TRAPS. Mechanisms of the disease are not yet elucidated. In some families with specific mutations, a relative soluble TNF receptor deficiency has been found in the plasma. However this mechanism does not account for what is observed in other kindreds.

Clinical and genetic aspects of the hereditary periodic fever syndromes

Hereditary periodic fever syndromes are a group of diseases characterized by intermittent bouts of clinical inflammation with focal organ involvement, mainly of the abdomen, musculoskeletal system and skin. The most frequent is familial Mediterranean fever, which affects patients of Mediterranean descent all over the world. Three other types have recently been characterized clinically and genetically. A thorough diagnosis is warranted, as clinical and therapeutic management is specific for each of these diseases. The underlying mechanisms of these inflammatory diseases appear to be specific for each type, involving so far unknown proteins, and have already opened new avenues in our understanding of the inflammatory response.

CIAS1 mutation in a patient with overlap between Muckle-Wells and chronic infantile neurological cutaneous and articular syndromes

The Muckle-Wells syndrome is a rare autosomal dominant disorder belonging to the group of hereditary fever syndromes. The chronic infantile neurological cutaneous and articular (CINCA) syndrome is a systemic inflammatory disorder of unknown etiology with neonatal onset. They are considered as two different entities. We report the case of a 36-year-old man suffering since birth from a nonpruritic generalized urticaria, with inflammatory flares, joint manifestations and progressive deafness requiring a bilateral hearing aid. An initial diagnosis of Muckle-Wells syndrome was made. However, the patient had an unusual clinical presentation with slightly dysmorphic facial appearance, clubbing of the fingers, mild mental retardation and papilledema. After a genetic advice, a diagnosis of CINCA syndrome was made. Search for mutations in the CIAS1 gene revealed a new mutation in a heterozygous state. This case report really raises the question of a link between these two inflammatory diseases. Further studies are needed to confirm the involvement of mutations of the CIAS1 gene in CINCA syndrome.