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Kreps EO, Al Julandani D, Guly CM, Arostegui JI, Dick AD, Ramanan AV. Long-Term Visual Outcome of Patients with Blau Syndrome. Ocul Immunol Inflamm 2024:1-5. [PMID: 38180755 DOI: 10.1080/09273948.2023.2293922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE To document the long-term visual outcomes in patients with Blau syndrome. METHODS A retrospective institutional cohort study was conducted, and 13 patients with genetically confirmed Blau syndrome were included. Demographic and clinical data were collected from standardised medical charts. Baseline was defined as the first detected uveitis and data were recorded onwards at intervals of 1, 3, 5, 10, 15 and 20 years. RESULTS Anterior uveitis was the most common classification at baseline (57.1%). Among patients with documented uveitis lasting 10 years or more, all of them developed panuveitis. Median logMAR visual acuity at baseline was 0 (range -0.5; 0.7), 0.19 (range 0; 1.5) at year 5, and 0.7 (range 0.1 - no perception of light) at year 20, as recorded in 13, 16, and 10 eyes, respectively. All patients received treatment with topical and oral steroids, and multiple systemic immunosuppressants including biologics. Disease control, defined as having cells <1+ in both eyes and using topical steroid eye drops less than twice daily, was achieved in 14.3% to 37.5% of patients at the different time points. Cataract surgery was performed in 12 eyes of 8 patients, 3 eyes of 3 patients necessitated glaucoma surgery, and 4 eyes of 4 patients required surgery for retinal detachment. CONCLUSION Uveitis associated with Blau syndrome commonly leads to severe, chronic panuveitis, requiring long-term systemic immunosuppression. Early diagnosis and timely initiation of biologics may prevent significant visual impairment.
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Affiliation(s)
- Elke O Kreps
- Department of Ophthalmology, Ghent University Hospital, Ghent, Belgium
| | - Dalila Al Julandani
- Department of Pediatric Rheumatology, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Catherine M Guly
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Juan I Arostegui
- Department of Immunology, Hospital Clínic, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain
| | - Andrew D Dick
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Institute of Ophthalmology, University College London, London, UK
- Academic Unit of Ophthalmology, Translational Health Sciences, University of Bristol, Bristol, UK
- NIHR Biomedical Research Centre of Ophthalmology, Moorfields Eye Hospital, London, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Pediatric Rheumatology, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
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Lassoued Ferjani H, Kharrat L, Ben Nessib D, Kaffel D, Maatallah K, Hamdi W. Management of Blau syndrome: review and proposal of a treatment algorithm. Eur J Pediatr 2024; 183:1-7. [PMID: 37735224 DOI: 10.1007/s00431-023-05204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/16/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
Blau syndrome is a rare genetic granulomatosis affecting children. It could be responsible for vision-threatening complications and articular deformation. Due to the rarity of this disease, there are no standardized guidelines for its management. This work aimed to provide an updated overview of the different therapeutic options for Blau syndrome. We conducted research in the PubMed database for the different treatments used in Blau syndrome patients, and we proposed a therapeutic algorithm for disease management. High doses of corticosteroids are considered as a bridging therapy in Blau syndrome. Methotrexate should be initiated if the patient has articular or ocular involvement. An anti-tumor necrosis factor α should be added for patients with uveitis or residual arthritis. If the patient remains symptomatic, a switch to another anti-tumor necrosis factor α is the best option. In non-responders to the first- and second-line biotherapies, a switch to an anti-interleukin 1, an anti-interleukin 6, or tofacitinib is necessary. CONCLUSION This article suggested an algorithm for the treatment of Blau syndrome. Other studies are necessary to confirm the efficacy of these treatments. WHAT IS KNOWN • Blau syndrome is a rare but severe granulomatosis that could be responsible for vision-threatening complications and articular deformation. • Blau syndrome seems to be refractory to treatments. WHAT IS NEW • High doses of corticosteroids are usually insufficient and should be considered only as a bridging therapy. • Blau syndrome could be considered as a poor factor for uveitis, thus, an anti-tumor necrosis factor α should be initiated for patients with uveitis or with residual arthritis.
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Affiliation(s)
- Hanene Lassoued Ferjani
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Lobna Kharrat
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia.
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.
| | - Dorra Ben Nessib
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Dhia Kaffel
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Kaouther Maatallah
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
| | - Wafa Hamdi
- Rheumatology Department, Kassab Orthopedics Institute, Ksar Saïd, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, 2010, Tunis, Tunisia
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Ma Z, Gao X, Zhu S. Late-Onset Panuveitis in a Chinese Girl with Sporadic Blau Syndrome: A Case Report. Case Rep Ophthalmol 2024; 15:388-393. [PMID: 38660583 PMCID: PMC11042796 DOI: 10.1159/000536005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/15/2023] [Indexed: 04/26/2024] Open
Abstract
Introduction Blau syndrome (BS) is a rare autoimmune disease. We report here an atypical case of BS. Case Presentation We present a case of late-onset eye manifestations in a Chinese girl of 18 years old with sporadic BS, presenting with panuveitis. We performed comprehensive ocular examinations including fluorescein fundus angiography and indocyanine green angiography for her. The oral hormone plus local anti-inflammatory eye drops have well controlled the inflammation of her eyes. Conclusion Our case highlights the necessity of systemic medical history inquiry for every eye discomfort.
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Affiliation(s)
- Zicheng Ma
- Department of Ophthalmology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xinxiao Gao
- Department of Ophthalmology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Siquan Zhu
- Department of Ophthalmology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Matsuda T, Kambe N, Takimoto-Ito R, Ueki Y, Nakamizo S, Saito MK, Takei S, Kanazawa N. Potential Benefits of TNF Targeting Therapy in Blau Syndrome, a NOD2-Associated Systemic Autoinflammatory Granulomatosis. Front Immunol 2022; 13:895765. [PMID: 35711422 PMCID: PMC9195515 DOI: 10.3389/fimmu.2022.895765] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
Blau syndrome is a systemic autoinflammatory granulomatous disease caused by mutations in the nucleotide-binding oligomerization domain 2 (NOD2) gene. NOD2 is an intracellular pathogen recognition receptor. Upon binding to muramyl dipeptide (MDP), NOD2 activates the NF-κB pathway, leading to the upregulation of proinflammatory cytokines. Clinical manifestations of Blau syndrome appear in patients before the age of four. Skin manifestations resolve spontaneously in some cases; however, joint and eye manifestations are progressive, and lead to serious complications, such as joint contracture and blindness. Currently, there is no specific curative treatment for the disease. Administration of high-dose oral steroids can improve clinical manifestations; however, treatments is difficult to maintain due to the severity of the side effects, especially in children. While several new therapies have been reported, including JAK inhibitors, anti-IL-6 and anti-IL-1 therapies, anti-TNF therapy plays a central role in the treatment of Blau syndrome. We recently performed an ex vivo study, using peripheral blood and induced pluripotent stem cells from patients. This study demonstrated that abnormal cytokine expression in macrophages from untreated patients requires IFNγ stimulation, and that anti-TNF treatment corrects the abnormalities associated with Blau syndrome, even in the presence of IFNγ. Therefore, although the molecular mechanisms by which the genetic mutations in NOD2 lead to granuloma formation remain unclear, it is possible that prior exposure to TNFα combined with IFNγ stimulation may provide the impetus for the clinical manifestations of Blau syndrome.
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Affiliation(s)
- Tomoko Matsuda
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Naotomo Kambe
- Department of Dermatology, Kansai Medical University, Hirakata, Japan.,Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Riko Takimoto-Ito
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Ueki
- Department of Dermatology, Kansai Medical University, Hirakata, Japan
| | - Satoshi Nakamizo
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Megumu K Saito
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Syuji Takei
- Department of Pediatrics, Kagoshima University, Kagoshima, Japan
| | - Nobuo Kanazawa
- Department of Dermatology, Hyogo Medical University, Nishinomiya, Japan
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