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Garelli S, Dalla Costa M, Sabbadin C, Barollo S, Rubin B, Scarpa R, Masiero S, Fierabracci A, Bizzarri C, Crinò A, Cappa M, Valenzise M, Meloni A, De Bellis AM, Giordano C, Presotto F, Perniola R, Capalbo D, Salerno MC, Stigliano A, Radetti G, Camozzi V, Greggio NA, Bogazzi F, Chiodini I, Pagotto U, Black SK, Chen S, Rees Smith B, Furmaniak J, Weber G, Pigliaru F, De Sanctis L, Scaroni C, Betterle C. Autoimmune polyendocrine syndrome type 1: an Italian survey on 158 patients. J Endocrinol Invest 2021; 44:2493-2510. [PMID: 34003463 PMCID: PMC8502131 DOI: 10.1007/s40618-021-01585-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Autoimmune Polyglandular Syndrome type 1 (APS-1) is a rare recessive inherited disease, caused by AutoImmune Regulator (AIRE) gene mutations and characterized by three major manifestations: chronic mucocutaneous candidiasis (CMC), chronic hypoparathyroidism (CH) and Addison's disease (AD). METHODS Autoimmune conditions and associated autoantibodies (Abs) were analyzed in 158 Italian patients (103 females and 55 males; F/M 1.9/1) at the onset and during a follow-up of 23.7 ± 15.1 years. AIRE mutations were determined. RESULTS The prevalence of APS-1 was 2.6 cases/million (range 0.5-17 in different regions). At the onset 93% of patients presented with one or more components of the classical triad and 7% with other components. At the end of follow-up, 86.1% had CH, 77.2% AD, 74.7% CMC, 49.5% premature menopause, 29.7% autoimmune intestinal dysfunction, 27.8% autoimmune thyroid diseases, 25.9% autoimmune gastritis/pernicious anemia, 25.3% ectodermal dystrophy, 24% alopecia, 21.5% autoimmune hepatitis, 17% vitiligo, 13.3% cholelithiasis, 5.7% connective diseases, 4.4% asplenia, 2.5% celiac disease and 13.9% cancer. Overall, 991 diseases (6.3 diseases/patient) were found. Interferon-ω Abs (IFNωAbs) were positive in 91.1% of patients. Overall mortality was 14.6%. The AIRE mutation R139X was found in 21.3% of tested alleles, R257X in 11.8%, W78R in 11.4%, C322fsX372 in 8.8%, T16M in 6.2%, R203X in 4%, and A21V in 2.9%. Less frequent mutations were present in 12.9%, very rare in 9.6% while no mutations in 11% of the cases. CONCLUSIONS In Italy, APS-1 is a rare disorder presenting with the three major manifestations and associated with different AIRE gene mutations. IFNωAbs are markers of APS-1 and other organ-specific autoantibodies are markers of clinical, subclinical or potential autoimmune conditions.
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Affiliation(s)
- S Garelli
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
- Unit of Internal Medicine, Ospedale dell'Angelo, Mestre-Venice, Italy
| | - M Dalla Costa
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
- Unit of Internal Medicine, Ospedale di Feltre, Belluno, Italy
| | - C Sabbadin
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - S Barollo
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - B Rubin
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - R Scarpa
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - S Masiero
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - A Fierabracci
- Infectivology and Clinical Trials Research Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Bizzarri
- Endocrine Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - A Crinò
- Endocrine Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - M Cappa
- Endocrine Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - M Valenzise
- Unit of Pediatrics, Department of Adulthood and Childhood Human Pathology, University of Messina, Messina, Italy
| | - A Meloni
- Ospedale Microcitemico and Dipartimento di Scienze Biomediche e Biotecnologiche, University of Cagliari, Cagliari, Italy
| | - A M De Bellis
- Unit of Endocrinology and Metabolic Diseases, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - C Giordano
- Endocrine Unit, Department of Biomedical Internal and Specialist Medicine (DIBIMIS), Palermo University, Palermo, Italy
| | - F Presotto
- Unit of Internal Medicine, Ospedale dell'Angelo, Mestre-Venice, Italy
| | - R Perniola
- Department of Pediatrics, Regional Hospital Vito Fazzi, Lecce, Italy
| | - D Capalbo
- Department of Mother and Child, University Federico II, Naples, Italy
| | - M C Salerno
- Pediatric Section, Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - A Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - G Radetti
- Marienklinik, General Hospital, Bolzano, Italy
| | - V Camozzi
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - N A Greggio
- EU-Endo-ERN Advisory Board Member, National Coordinator Endo-ERN Pediatric (SIEDP), Padua, Italy
| | - F Bogazzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - I Chiodini
- Unit of Bone Metabolism Diseases and Diabetes, Istituto Auxologico Italiano, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - U Pagotto
- Unit of Endocrinology and Prevention and Care of Diabetes, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - S K Black
- FIRS Laboratories RSR Ltd, Cardiff, UK
| | - S Chen
- FIRS Laboratories RSR Ltd, Cardiff, UK
| | | | | | - G Weber
- Unit of Pediatrics, Vita-Salute San Raffaele University, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - F Pigliaru
- Endocrine Unit, Azienda Ospedaliera-Universitaria of Cagliari, Cagliari, Italy
| | - L De Sanctis
- Pediatric Endocrinology, Department of Public Health and Pediatric Sciences, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - C Scaroni
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy
| | - C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padua, Via Ospedale Civile 105, 35128, Padua, Italy.
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Cinque L, Angeletti C, Orrico A, Castellana S, Ferrito L, Ciuoli C, Mazza T, Castori M, Guarnieri V. Novel Pathogenic Variants of the AIRE Gene in Two Autoimmune Polyendocrine Syndrome Type I Cases with Atypical Presentation: Role of the NGS in Diagnostic Pathway and Review of the Literature. Biomedicines 2020; 8:biomedicines8120631. [PMID: 33352647 PMCID: PMC7767245 DOI: 10.3390/biomedicines8120631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 01/08/2023] Open
Abstract
Background. Autoimmune polyglandular syndrome type 1 (APS-1) with or without reversible metaphyseal dysplasia is a rare genetic disorder due to inactivating variants of the autoimmune regulator, AIRE, gene. Clinical variability of APS-1 relates to pleiotropy, and the general dysfunction of self-tolerance to organ-specific antigens and autoimmune reactions towards peripheral tissues caused by the underlying molecular defect. Thus, early recognition of the syndrome is often delayed, mostly in cases with atypical presentation, and the molecular confirm through the genetic analysis of the AIRE gene might be of great benefit. Methods. Our methods were to investigate, with a multigene panel next generation sequencing approach, two clinical cases, both presenting with idiopathic hypoparathyroidism, also comprising the AIRE gene; as well as to comment our findings as part of a more extensive review of literature data. Results. In the first clinical case, two compound heterozygote pathogenic variants of the AIRE gene were identified, thus indicating an autosomal recessive inheritance of the disease. In the second case, only one AIRE gene variant was found and an atypical dominant negative form of APS-1 suggested, later confirmed by further medical ascertainments. Conclusions. APS-1 might present with variable and sometimes monosymptomatic presentations and, if not recognized, might associate with severe complications. In this context, next generation diagnostics focused on a set of genes causative of partially overlapping disorders may allow early diagnosis.
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Affiliation(s)
- Luigia Cinque
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (L.C.); (M.C.)
| | - Cristina Angeletti
- UOC Pediatrics and Neonatology, POU AV2, 60122 Senigallia, Italy; (C.A.); (L.F.)
| | - Alfredo Orrico
- Molecular Diagnosis and Characterization of Pathogenic Mechanisms of Rare Genetic Diseases, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy;
- Clinical Genetics, ASL Toscana SudEst. Ospedale della Misericordia, 58100 Grosseto, Italy
| | - Stefano Castellana
- Unit of Bioinformatics, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (S.C.); (T.M.)
| | - Lucia Ferrito
- UOC Pediatrics and Neonatology, POU AV2, 60122 Senigallia, Italy; (C.A.); (L.F.)
| | - Cristina Ciuoli
- Department of Medical, Surgical and Neurological Sciences, UOC Endocrinology, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy;
| | - Tommaso Mazza
- Clinical Genetics, ASL Toscana SudEst. Ospedale della Misericordia, 58100 Grosseto, Italy
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (L.C.); (M.C.)
| | - Vito Guarnieri
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; (L.C.); (M.C.)
- Correspondence: ; Tel.: +39-0882-416347
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Beccuti G, Ghizzoni L, Cambria V, Codullo V, Sacchi P, Lovati E, Mongodi S, Iotti GA, Mojoli F. A COVID-19 pneumonia case report of autoimmune polyendocrine syndrome type 1 in Lombardy, Italy: letter to the editor. J Endocrinol Invest 2020; 43:1175-1177. [PMID: 32519200 PMCID: PMC7282538 DOI: 10.1007/s40618-020-01323-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/01/2020] [Indexed: 12/28/2022]
Affiliation(s)
- G Beccuti
- Department of Medical Sciences, Division of Endocrinology, Diabetes and Metabolism, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
| | - L Ghizzoni
- Department of Medical Sciences, Division of Endocrinology, Diabetes and Metabolism, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - V Cambria
- Department of Medical Sciences, Division of Endocrinology, Diabetes and Metabolism, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - V Codullo
- Department of Medical Sciences and Infectious Diseases, Division of Rheumatology, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - P Sacchi
- Department of Medical Sciences and Infectious Diseases, Division of Infectious and Tropical Diseases, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - E Lovati
- Department of Medical Sciences and Infectious Diseases, Division of General Medicine 1, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - S Mongodi
- Department of Anesthesia and Intensive Care Unit, Foundation IRCCS Polyclinic San Matteo Pavia, Pavia, Italy
| | - G A Iotti
- Department of Anesthesia and Intensive Care Unit, Foundation IRCCS Polyclinic San Matteo Pavia, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - F Mojoli
- Department of Anesthesia and Intensive Care Unit, Foundation IRCCS Polyclinic San Matteo Pavia, Pavia, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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4
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Fierabracci A. Type 1 Diabetes in Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy Syndrome (APECED): A "Rare" Manifestation in a "Rare" Disease. Int J Mol Sci 2016; 17:E1106. [PMID: 27420045 PMCID: PMC4964482 DOI: 10.3390/ijms17071106] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023] Open
Abstract
Type 1 autoimmune polyglandular syndrome (APS1) is a rare autosomal recessive disease, caused by mutations in the autoimmune regulator gene (AIRE); the encoded Aire protein plays an important role in the establishment of the immunological tolerance acting as a transcriptional regulator of the expression of organ-specific antigens within the thymus in perinatal age. While a high prevalence for this rare syndrome is reported in Finland and Scandinavia (Norway), autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome (APECED) cohorts of patients are also detected in continental Italy and Sardinia, among Iranian Jews, as well as in other countries. The syndrome is diagnosed when patients present at least two out of the three fundamental disorders including chronic mucocutaneous candidiasis, hypoparathyroidism, and Addison's disease. Among the associated conditions insulin-dependent diabetes mellitus (Type 1 diabetes) has been rarely reported in different series of patients and occurring more frequently in Finnish APECED patients. In this review, we analyze the incidence of Type 1 diabetes as a clinical manifestation of APECED in different populations highlighting the peculiar genetic and immunological features of the disease when occurring in the context of this syndrome.
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Affiliation(s)
- Alessandra Fierabracci
- Infectivology and Clinical Trials Area, Children's Hospital Bambino Gesù, Rome 00146, Italy.
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5
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Valenzise M, Fierabracci A, Cappa M, Porcelli P, Barcellona R, De Luca F, Barollo S, Garelli S, Betterle C. Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy: report of seven additional sicilian patients and overview of the overall series from sicily. Horm Res Paediatr 2014; 82:127-32. [PMID: 25059117 DOI: 10.1159/000363537] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 04/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare recessive inherited disease caused by the mutation of the AIRE gene on chromosome 21. To date, 8 Sicilian patients have been described and the R203X AIRE mutation was found to be the most common in this region. AIMS (1) To describe 7 additional Sicilian APECED patients and to review all 15 Sicilian APECED patients who have been investigated by our group in the last years, and (2) to report a novel AIRE gene mutation. RESULTS Among the 3 cardinal features of APECED, hypoparathyroidism has been already detected in all 15 patients, whereas Addison's disease and chronic mucocutaneous candidiasis have so far been found in 10/15 and 12/15 cases, respectively. In 2 consanguineous cases, AIRE gene analysis revealed a novel mutation, named IVS13+2T, in homozygosis. R203X was the most common mutation in this region (30% of alleles and 46.6% of patients), followed by R257X (20% of alleles and 40% of patients). CONCLUSIONS Sicilian APECED patients are confirmed to have some peculiar characteristics from a clinical and genetic point of view. No correlations between genotype and phenotype were identified.
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Affiliation(s)
- Mariella Valenzise
- Unit of Pediatrics, Department of Pediatric Sciences, University of Messina, Messina, Italy
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6
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Capalbo D, Improda N, Esposito A, De Martino L, Barbieri F, Betterle C, Pignata C, Salerno M. Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy from the pediatric perspective. J Endocrinol Invest 2013; 36:903-12. [PMID: 23723078 DOI: 10.3275/8999] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disease caused by mutations of the AutoImmune REgulator gene. The clinical spectrum of the disease encompasses several autoimmune endocrine and non-endocrine manifestations, which may lead to acute metabolic alterations and eventually life-threatening events. The clinical diagnosis is defined by the presence of at least two components of the classic triad including chronic mucocoutaneous candidiasis (CMC), chronic hypoparathyroidism (CH), Addison's disease (AD). Other common features of the disease are hypergonadotropic hypogonadism, alopecia, vitiligo, autoimmune hepatitis, Type 1 diabetes, gastrointestinal dysfunction. APECED usually begins in childhood. CMC is the first manifestation to appear, usually before the age of 5 yr, followed by CH and then by AD. The clinical phenotype may evolve over several years and many components of the disease may not appear until the 4th or 5th decade of life. The phenotypical expression of the syndrome shows a wide variability even between siblings with the same genotype. In view of this heterogeneity, an early diagnosis of APECED can be very challenging often leading to a considerable diagnostic delay. Therefore, clinicians should be aware that the presence of even a minor component of APECED in children should prompt a careful investigation for other signs and symptoms of the disease, thus allowing an early diagnosis and prevention of severe and life-threatening events. Aim of this review is to focus on clinical presentation, diagnosis and management of the major components of APECED in children particularly focusing on endocrine features of the disease.
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Affiliation(s)
- D Capalbo
- Pediatric Endocrinology Unit, Department of Translational Medical Sciences, University "Federico II" of Naples, Naples, Italy
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7
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De Martino L, Capalbo D, Improda N, D'Elia F, Di Mase R, D'Assante R, D'Acunzo I, Pignata C, Salerno M. APECED: A Paradigm of Complex Interactions between Genetic Background and Susceptibility Factors. Front Immunol 2013; 4:331. [PMID: 24167503 PMCID: PMC3805967 DOI: 10.3389/fimmu.2013.00331] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 09/30/2013] [Indexed: 01/08/2023] Open
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disease, caused by mutations of a single gene named Autoimmune regulator gene (AIRE) which results in a failure of T-cell tolerance. Central tolerance takes place within the thymus and represents the mechanism by which potentially auto-reactive T-cells are eliminated through the negative selection process. The expression of tissue-specific antigens (TSAs) by medullary thymic epithelial cells (mTECs) in the thymus is a key process in the central tolerance and is driven by the protein encoded by AIRE gene, the transcription factor autoimmune regulator (AIRE). A failure in this process caused by AIRE mutations is thought to be responsible of the systemic autoimmune reactions of APECED. APECED is characterized by several autoimmune endocrine and non-endocrine manifestations and the phenotype is often complex. Although APECED is the paradigm of a monogenic autoimmune disorder, it is characterized by a wide variability of the clinical expression even between siblings with the same genotype, thus implying that additional mechanisms, other than the failure of Aire function, are involved in the pathogenesis of the disease. Unraveling open issues of the molecular basis of APECED, will help improve diagnosis, management, and therapeutical strategies of this complex disease.
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Affiliation(s)
- Lucia De Martino
- Pediatric Section, Department of Translational Medical Sciences, "Federico II" University , Naples , Italy
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8
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Capalbo D, De Martino L, Giardino G, Di Mase R, Di Donato I, Parenti G, Vajro P, Pignata C, Salerno M. Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy: insights into genotype-phenotype correlation. Int J Endocrinol 2012; 2012:353250. [PMID: 23133448 PMCID: PMC3485503 DOI: 10.1155/2012/353250] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 09/17/2012] [Accepted: 09/17/2012] [Indexed: 12/21/2022] Open
Abstract
Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) is a rare autosomal recessive disease, caused by mutations of a single gene named autoimmune regulator gene (AIRE) which results in a failure of T cell tolerance within the thymus. Chronic mucocutaneous candidiasis, chronic hypoparathyroidism, and Addison's disease are the hallmarks of the syndrome. APECED is also characterized by several autoimmune endocrine and nonendocrine manifestations, and the phenotype is often complex. Moreover, even though APECED is a monogenic disease, its clinical picture is generally dominated by a wide heterogeneity both in the severity and in the number of components even among siblings with the same AIRE genotype. The variability of its clinical expression implies that diagnosis can be challenging, and a considerable delay often occurs between the appearance of symptoms and the diagnosis. Since a prompt diagnosis is essential to prevent severe complications, clinicians should be aware of all symptoms and signs of suspicion. The aim of this paper is to give an overview on the clinical presentation and diagnostic criteria of APECED and to focus on current knowledge on genotype-phenotype correlation.
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Affiliation(s)
- Donatella Capalbo
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
| | - Lucia De Martino
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
| | - Giuliana Giardino
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
| | - Raffaella Di Mase
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
| | - Iolanda Di Donato
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
| | - Giancarlo Parenti
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
| | - Pietro Vajro
- Department of Pediatrics, University of Salerno, 84081 Salerno, Italy
| | - Claudio Pignata
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
| | - Mariacarolina Salerno
- Department of Pediatrics, University of Naples Federico II, 80131 Naples, Italy
- *Mariacarolina Salerno:
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