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Betrains A, Mulders-Manders CM, Aarntzen EH, Vanderschueren S, Rovers CP. Update on imaging in fever and inflammation of unknown origin: focus on infectious disorders. Clin Microbiol Infect 2024; 30:288-295. [PMID: 37597617 DOI: 10.1016/j.cmi.2023.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are diagnostic challenges that often require an extensive work-up. When first-line tests do not provide any or only misleading clues, second-line investigations such as specialized imaging techniques are often warranted. OBJECTIVES To provide an overview of the diagnostic value of imaging techniques that are commonly used in patients with FUO/IUO. SOURCES MEDLINE database was searched to identify the most relevant studies, trials, reviews, or meta-analyses until 31 March 2023. CONTENT The most important types of second-line imaging tests for FUO and IUO are outlined, including [67Ga]-citrate single-photon emission computed tomography/computed tomography (CT), labelled leukocyte imaging, [18F]-fluorodeoxyglucose positron emission tomography CT ([18F]-FDG-PET), and whole-body magnetic resonance imaging. This review summarizes the diagnostic yield, extends on potential future imaging techniques (pathogen-specific bacterial imaging and [18F]-FDG-PET/magnetic resonance imaging), discusses cost-effectiveness, highlights practical implications and pitfalls, and addresses future perspectives. Where applicable, we provide additional data specifically for the infection subgroup. IMPLICATIONS Although many imaging examinations are proven to be useful in FUO and IUO, [18F]-FDG-PET/CT is the preferred second-line test when available as it provides a high diagnostic yield in a presumably cost-effective way.
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Affiliation(s)
- Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium.
| | | | - Erik H Aarntzen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Chantal P Rovers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Betrains A, Moreel L, Mulders-Manders CM, Auwaerter PG, Torné-Cachot J, Weitzer F, Terasawa T, Ly KH, Schönau V, Blockmans D, Wright WF, Rovers C, Vanderschueren S. Comparison of diagnostic spectrum between inflammation of unknown origin and fever of unknown origin: A systematic review and meta-analysis. Eur J Intern Med 2024:S0953-6205(24)00077-3. [PMID: 38431500 DOI: 10.1016/j.ejim.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Patients with inflammation of unknown origin (IUO) and fever of unknown origin (FUO) are commonly considered a single population. Differences in underlying causes between both groups may steer the diagnostic work-up. METHODS PubMed, Embase, Web of Science, and ClinicalTrials.gov were searched from July 2009 through December 2023. Studies including both FUO and IUO patients with a sample size of ≥20 were considered. The primary outcome was the difference in the rate of patients affected by predefined diagnostic categories according to meeting FUO or IUO criteria. Data were pooled using random-effects models. RESULTS A total of 8 studies met criteria for inclusion, with a total of 1452 patients (466 with IUO and 986 with FUO). The median rate of IUO patients among the included studies was 32 % (range 25-39 %). Patients with IUO had a lower likelihood of infection (OR 0.59 [95 % CI; 0.36-0.95]; I2 0 %). There were no significant differences in the rate of noninfectious inflammatory disorders, malignancies, miscellaneous disorders, or remaining undiagnosed. Comparison of diagnostic subgroups revealed that IUO patients were less likely to have systemic autoinflammatory disorders (OR 0.17 [95 % CI, 0.05-0.58]; I2 42 %) and more likely to have vasculitis (OR 2.04 [95 % CI, 1.23-3.38]; I2 21 %) and rheumatoid arthritis or spondylarthritis (OR 3.52 [95 % CI, 1.16-10.69]; I2 0 %). CONCLUSION Based on our findings, there is little reason to assume that FUO and IUO patients would benefit from a different initial diagnostic approach.
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Affiliation(s)
- Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - Lien Moreel
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Paul G Auwaerter
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States
| | | | - Friedrich Weitzer
- Division of Nuclear Medicine, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kim H Ly
- Department of Internal Medicine, Limoges University Hospital, Limoges, France
| | - Verena Schönau
- Department of Rheumatology and Immunology, University Hospital Erlangen, Erlangen, Germany
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Chantal Rovers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
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Wright WF, Betrains A, Stelmash L, Mulders-Manders CM, Rovers CP, Vanderschueren S, Auwaerter PG. Development of a Consensus-Based List of Potential Quality Indicators for Fever and Inflammation of Unknown Origin. Open Forum Infect Dis 2024; 11:ofad671. [PMID: 38333881 PMCID: PMC10853001 DOI: 10.1093/ofid/ofad671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 02/10/2024] Open
Abstract
With a growing emphasis on value-based reimbursement, developing quality indicators for infectious diseases has gained attention. Quality indicators for fever of unknown origin and inflammation of unknown origin are lacking. An assembled group of international experts developed 12 quality measures for these conditions, which could be validated with additional study.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Albrecht Betrains
- General Internal Medicine Department, University Hospitals Leuven, Leuven, Belgium
| | - Lauren Stelmash
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Catharina M Mulders-Manders
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Chantal P Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Steven Vanderschueren
- General Internal Medicine Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium
| | - Paul G Auwaerter
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Verschoof MA, van Meenen LCC, Andriessen MVE, Brinkman DMC, Kamphuis S, Kuijpers TW, Leavis HL, Legger GE, Mulders-Manders CM, de Pagter APJ, Rutgers A, van Well GTJ, Coutinho JM, Hak AE, van Montfrans JM, Klouwer FCC. Neurological phenotype of adenosine deaminase 2 deficient patients: a cohort study. Eur J Neurol 2024; 31:e16043. [PMID: 37584090 DOI: 10.1111/ene.16043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/22/2023] [Accepted: 08/11/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND PURPOSE Patients with adenosine deaminase 2 (ADA2) deficiency can present with various neurological manifestations due to vasculopathies and autoinflammation. These include ischaemic and hemorrhagic stroke, but less clearly defined neurological symptoms have also been reported. METHODS In this cohort study, patients with confirmed ADA2 deficiency from seven university hospitals in the Netherlands were included. The frequency and recurrence rates of neurological manifestations before and after initiation of tumor necrosis factor α (TNF-α) inhibiting therapy were analyzed. RESULTS Twenty-nine patients were included with a median age at presentation of 5 years (interquartile range 1-17). Neurological manifestations occurred in 19/29 (66%) patients and were the presenting symptom in 9/29 (31%) patients. Transient ischaemic attack (TIA)/ischaemic stroke occurred in 12/29 (41%) patients and was the presenting symptom in 8/29 (28%) patients. In total, 25 TIAs/ischaemic strokes occurred in 12 patients, one after initiation of TNF-α inhibiting therapy and one whilst switching between TNF-α inhibitors. None was large-vessel occlusion stroke. Two hemorrhagic strokes occurred: one aneurysmatic subarachnoid hemorrhage and one spontaneous intracerebral hemorrhage. Most neurological symptoms, including cranial nerve deficits, vertigo, ataxia and seizures, were caused by TIAs/ischaemic strokes and seldom recurred after initiation of TNF-α inhibiting therapy. CONCLUSIONS Neurological manifestations, especially TIA/ischaemic stroke, are common in patients with ADA2 deficiency and frequently are the presenting symptom. Because it is a treatable cause of young stroke, for which antiplatelet and anticoagulant therapy are considered contraindicated, awareness amongst neurologists and pediatricians is important. Screening for ADA2 deficiency in young patients with small-vessel ischaemic stroke without an identified cause should be considered.
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Affiliation(s)
| | - Laura C C van Meenen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Valérie E Andriessen
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniëlle M C Brinkman
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylvia Kamphuis
- Department of Pediatric Rheumatology, Sophia Children's Hospital, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Immunology and Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Helen L Leavis
- Department of Rheumatology and Clinical Immunology, University Medical Center and Utrecht University, Utrecht, The Netherlands
| | - G Elizabeth Legger
- Department of Pediatric Rheumatology and Immunology, University Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Catharina M Mulders-Manders
- Department of Internal Medicine, Radboud Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne P J de Pagter
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs T J van Well
- Division of Pediatric Infectious Diseases, Immunology & Rheumatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Elisabeth Hak
- Departments of Internal Medicine and Rheumatology and Clinical Immunology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Femke C C Klouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pediatric Neurology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Arts RJW, van der Linden TJ, van der Made CI, Hendriks MMC, van der Heijden WA, de Mast Q, Schuurs-Hoeijmakers JHM, Simons A, Spaan AN, Mulders-Manders CM, van de Veerdonk FL. OTULIN Haploinsufficiency-Related Fasciitis and Skin Necrosis Treated by TNF Inhibition. J Clin Immunol 2023; 44:10. [PMID: 38129331 DOI: 10.1007/s10875-023-01630-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
Here, we describe an adult female with severe fasciitis and skin necrosis who carried a private, predicted deleterious missense mutation in OTULIN in heterozygosity. OTULIN is a cellular regulator of deubiquitination that has been shown to play a key role in intrinsic immunity against staphylococcal α-toxin. The patient was treated with broad-spectrum antibiotics, and multiple surgical explorations were conducted without clinical response. Since autoinflammation was the predominant clinical feature, TNF inhibition was started with a good clinical response. We show that excessive inflammation in OTULIN haploinsufficiency can be effectively treated by TNF inhibition.
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Affiliation(s)
- Rob J W Arts
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands.
- Department of Medicine (463), Radboud University Nijmegen Medical Center, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, Netherlands.
| | - Tristan J van der Linden
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, 3584 CX, Utrecht, Netherlands
| | - Caspar I van der Made
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marianne M C Hendriks
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
- Department of Medicine (463), Radboud University Nijmegen Medical Center, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, Netherlands
| | - Wouter A van der Heijden
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Quirijn de Mast
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
- Department of Medicine (463), Radboud University Nijmegen Medical Center, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, Netherlands
| | | | - Annet Simons
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - András N Spaan
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, 3584 CX, Utrecht, Netherlands
| | - Catharina M Mulders-Manders
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
- Department of Medicine (463), Radboud University Nijmegen Medical Center, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, Netherlands
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud Institute of Molecular Life Sciences (RIMLS) and Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
- Department of Medicine (463), Radboud University Nijmegen Medical Center, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, Netherlands
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6
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Fayand A, Cescato M, Le Corre L, Terré A, Wacheux M, Zhu YYJ, Melet A, Moreau TRJ, Bodaghi B, Bonnet F, Bronnimann D, Cuisset L, Faria R, Grateau G, Pillet P, Mulders-Manders CM, Neven B, Quartier P, Richer O, Savey L, Truchetet ME, Py BF, Boursier G, Herbeuval JP, Georgin-Lavialle S, Rodero MP. Pathogenic variants in the NLRP3 LRR domain at position 861 are responsible for a boost-dependent atypical CAPS phenotype. J Allergy Clin Immunol 2023; 152:1303-1311.e1. [PMID: 37506976 DOI: 10.1016/j.jaci.2023.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Cryopyrin-associated periodic syndrome (CAPS) is associated with NLRP3 pathogenic variants, mostly located in the NACHT (neuronal apoptosis inhibitor protein, MHC class 2 transcription activator, incompatibility locus protein from Podospora anserina, telomerase-associated protein) domain. Cold-induced urticarial rash is among the main clinical features. However, this study identified a series of 14 patients with pathogenic variants of the Y861 residue (p.Tyr861) of the LRR domain of NLRP3 and minimal prevalence of cold-induced urticarial rash. OBJECTIVES This study aimed to address a possible genotype/phenotype correlation for patients with CAPS and to investigate at the cellular levels the impact of the Y861C substitution (p.Tyr861Cys) on NLRP3 activation. METHODS Clinical features of 14 patients with CAPS and heterozygous substitution at position 861 in the LRR domain of NLRP3 were compared to clinical features of 48 patients with CAPS and pathogenic variants outside the LRR domain of NLRP3. IL-1β secretion by PBMCs and purified monocytes from patients and healthy donors was evaluated following LPS and monosodium urate crystal stimulation. RESULTS Patients with substitution at position 861 of NLRP3 demonstrated a higher prevalence of sensorineural hearing loss while being less prone to skin urticarial. In contrast to patients with classical CAPS, cells from patients with a pathogenic variant at position 861 required an activation signal to secrete IL-1β but produced more IL-1β during the early and late phase of secretion than cells from healthy donors. CONCLUSIONS Pathogenic variants of Y861 of NLRP3 drive a boost-dependent oversecretion of IL-1β associated with an atypical CAPS phenotype.
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Affiliation(s)
- Antoine Fayand
- Department of Internal Medicine, National Reference Center for Autoinflammatory Diseases and Amyloid A Amyloidosis, Tenon Hospital, Sorbonne Université, Paris, France; Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France
| | - Margaux Cescato
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France
| | - Laurent Le Corre
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France
| | - Alexandre Terré
- Department of Internal Medicine, National Reference Center for Autoinflammatory Diseases and Amyloid A Amyloidosis, Tenon Hospital, Sorbonne Université, Paris, France; Laboratoire Mécanismes Cellulaires et Moléculaires des Désordres Hématologiques et Implications Thérapeutiques, Institut Imagine, Institut National de la Santé et de la Recherche Médicale, Université Paris Cité, Paris, France
| | - Margaux Wacheux
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France
| | - Yixiang Y J Zhu
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France
| | - Armelle Melet
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France
| | - Thomas R J Moreau
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France; Translational Immunology Unit, Institut Pasteur, Université Paris Cité, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, Instituts Hospitalo-Universitaires FOReSIGHT, Pitié-Salpêtrière Hospital, Assistance Publique-Hȏpitaux de Paris, Sorbonne Université, Paris, France
| | - Fabrice Bonnet
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Didier Bronnimann
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Laurence Cuisset
- Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Raquel Faria
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Gilles Grateau
- Department of Internal Medicine, National Reference Center for Autoinflammatory Diseases and Amyloid A Amyloidosis, Tenon Hospital, Sorbonne Université, Paris, France
| | - Pascal Pillet
- Service de Pédiatrie et Rhumatologie Pédiatrique, Hôpital Pellegrin-Enfants, Bordeaux, France
| | - Catharina M Mulders-Manders
- Department of Internal Medicine, Radboud Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Benedicte Neven
- Pediatric Immunology-Hematology and Rheumatology Unit, Necker Hospital, Université Paris Cité, Paris, France
| | - Pierre Quartier
- Pediatric Immunology-Hematology and Rheumatology Unit, Necker Hospital, Université Paris Cité, Paris, France; RAISE Reference Centre for Rare Diseases, Paris, France
| | - Olivier Richer
- Service de Pédiatrie et Rhumatologie Pédiatrique, Hôpital Pellegrin-Enfants, Bordeaux, France
| | - Léa Savey
- Department of Internal Medicine, National Reference Center for Autoinflammatory Diseases and Amyloid A Amyloidosis, Tenon Hospital, Sorbonne Université, Paris, France
| | - Marie-Elise Truchetet
- Department of Rheumatology, Hôpital Pellegrin, Bordeaux, France; Unite de Mixte Recherche 5164 ImmunoConcept, Bordeaux University Hospital, Bordeaux University, Bordeaux, France
| | - Bénédicte F Py
- Centre International de Recherche en Infectiologie, Université Lyon, Lyon, France; U1111, Institut National de la Santé et de la Recherche Médicale, Université Claude Bernard Lyon 1, Lyon, France; Unite de Mixte Recherche 5308, Centre National de la Recherche Scientifique, École Normale Supérieure de Lyon, Lyon, France
| | - Guilaine Boursier
- Laboratoire de Génétique des Maladies Rares et Autoinflammatoires, Service de Génétique Moléculaire et Cytogénomique, National Reference Center for Autoinflammatory Diseases and AA Amyloidosis, Centre Hospitalier Universitaire Montpellier, Université de Montpellier, Montpellier, France
| | - Jean-Philippe Herbeuval
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France
| | - Sophie Georgin-Lavialle
- Department of Internal Medicine, National Reference Center for Autoinflammatory Diseases and Amyloid A Amyloidosis, Tenon Hospital, Sorbonne Université, Paris, France.
| | - Mathieu P Rodero
- Laboratoire de Chimie et de Biochimie Pharmacologiques et Toxicologiques, Centre National de la Recherche Scientifique, Université Paris Cité, Paris, France.
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7
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Andriessen MVE, Legger GE, Bredius RGM, van Gijn ME, Hak AE, Muller PCEH, Kamphuis S, Klouwer FCC, Kuijpers TW, Leavis HL, Nierkens S, Rutgers A, van der Veken LT, van Well GTJ, Mulders-Manders CM, van Montfrans JM. Clinical Symptoms, Laboratory Parameters and Long-Term Follow-up in a National DADA2 Cohort. J Clin Immunol 2023; 43:1581-1596. [PMID: 37277582 PMCID: PMC10499949 DOI: 10.1007/s10875-023-01521-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/13/2023] [Indexed: 06/07/2023]
Abstract
Deficiency of adenosine deaminase-2 (DADA2) is an autosomal recessive autoinflammatory disease with an extremely variable disease presentation. This paper provides a comprehensive overview of the Dutch DADA2 cohort. We performed a retrospective cohort study in 29 ADA2-deficient patients from 23 families with a median age at inclusion of 26 years. All patients had biallelic pathogenic variants in the ADA2 gene. The most common clinical findings included cutaneous involvement (79.3%), (hepato)splenomegaly (70.8%) and recurrent infections (58.6%). Stroke was observed in 41.4% of the patients. The main laboratory abnormalities were hypogammaglobulinemia and various cytopenias. Patients presented most often with a mixed phenotype involving vasculopathy, immunodeficiency and hematologic manifestations (62.1%). In this cohort, malignancies were reported in eight patients (27.6%), of whom five presented with a hematologic malignancy and two with a basal cell carcinoma. Four patients developed hemophagocytic lymphohistiocytosis (HLH) or an HLH-like episode, of whom three passed away during or shortly after the occurrence of HLH. TNF-inhibitors (TNFi) were effective in treating vasculopathy-associated symptoms and preventing stroke, but were hardly effective in the treatment of hematologic manifestations. Three patients underwent hematopoietic cell transplantation and two of them are doing well with complete resolution of DADA2-related symptoms. The overall mortality in this cohort was 17.2%. In conclusion, this cohort describes the clinical, genetic and laboratory findings of 29 Dutch DADA2 patients. We describe the occurrence of HLH as a life-threatening disease complication and report a relatively high incidence of malignancies and mortality.
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Affiliation(s)
- Marie Valérie E Andriessen
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht, Utrecht University, PO Box 85050, 3508 GA, Utrecht, the Netherlands
| | - G Elizabeth Legger
- Department of Pediatric Rheumatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robbert G M Bredius
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Marielle E van Gijn
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - A Elisabeth Hak
- Departments of Internal Medicine and Rheumatology and Clinical Immunology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Petra C E Hissink Muller
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Sylvia Kamphuis
- Department of Pediatric Rheumatology, Sophia Children's Hospital, Erasmus MC University Centre, Rotterdam, the Netherlands
| | - Femke C C Klouwer
- Department of Neurology and Pediatric Neurology, Location AMC, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Taco W Kuijpers
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Helen L Leavis
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Stefan Nierkens
- Center for Translational Immunology, University Medical Center Utrecht & Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Lars T van der Veken
- Department of Genetics, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gijs T J van Well
- Department of Pediatrics: Division of Pediatric Infectious Diseases, Immunology and Rheumatology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Catharina M Mulders-Manders
- Department of Internal Medicine, Radboud Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht, Utrecht University, PO Box 85050, 3508 GA, Utrecht, the Netherlands.
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Abraham RS, Afzali B, Águeda A, Akin C, Albanesi C, Antiochos B, Aranow C, Atkinson JP, Aune TM, Babu S, Balko J, Ballow M, Bean R, Belavgeni A, Berek C, Beukelman T, Beziat V, Bimler L, Andrew Bird J, Blutt SE, Boguniewicz M, Boisson B, Boisson-Dupuis S, Borzova E, Bottazzi M, Boyaka PN, Bridges J, Browne SK, Burks AW, Bustamante J, Casanova JL, Chan A, Chan ES, Chatham WW, Chinen J, Christopher-Stine L, Coates E, Cope AP, Corry DB, Cosme J, Cron RQ, Dalakas MC, Dann SM, Das S, Daughety MM, Diamond B, Dispenzieri A, Durham SR, Eagar TN, Al-Hosni M, Elitzur S, Elmets CA, Erkan D, Fleisher TA, Fonacier L, Fontenot AP, Fragoulis G, Francischetti IM, Freiwald T, Frew AJ, Fujihashi K, Gadina M, Gapin L, Gatt ME, Gershwin ME, Gillespie SL, Gordon LK, Goronzy JJ, Grattan CE, Greenspan NS, Gschwend A, Gustafson CE, Hackett TL, Hamilton RG, Happe M, Harrison LC, Helbling A, Heckmann E, Hogquist K, Hohl TM, Holland SM, Hotez PJ, Houser K, Huntingdon ND, Hwangpo T, Izraeli S, Jaffe ES, Jalkanen S, Java A, Johnson DB, Johnson T, Jordan MB, Joshi SR, Jouanguy E, Kaminski HJ, Kaufmann SH, Khan DA, Kheradmand F, Khokar DS, Khoury P, Klein BS, Klion AD, Kohn DB, Kono M, Korngold R, Koulouri V, Kuhns DB, Kulkarni HS, Kuo CY, Kusner LL, Lahouti A, Lane LC, Laurence A, Lee JS, Lee ST, Leung DY, Levy O, Lewis DE, Li E, Libby P, Lichtman AH, Linkermann A, Lionakis MS, Liszewski MK, Lockshin MD, Priel DL, Lorenz AZ, Ludwig RJ, Luong A, Luqmani RA, Mackay M, Mahr A, Malley T, Mannon EC, Mannon PJ, Mannon RB, Manns MP, Maresso A, Matson SM, Mavragani CP, Maynard CL, McDonald D, Meylan F, Miller SD, Mitchell AL, Monos DS, Mueller SN, Mulders-Manders CM, Munshi PN, Murphy PM, Noel P, Notarangelo LD, Nunes-Santos CJ, Nussbaum RL, Nutman TB, Nutt SL, O'Neill L, O'Shea JJ, Ortel TL, Pai SY, Paul ME, Pearce S, Peterson EJ, Pittaluga S, Polverino F, Puck JM, Puel A, Radbruch A, Rajalingam R, Reece ST, Reveille JD, Rich RR, Ridley LK, Romeo AR, Rooney CM, Rosen A, Rosenzweig S, Rouse BT, Rowley SD, Sahiner UM, Sakaguchi S, Salinas W, Salmi M, Satola S, Schechter M, Schmidt E, Schroeder HW, Schwartzberg PL, Sciumè G, Segal BM, Selmi C, Sharabi A, Shimano KA, Sikorski PM, Simon A, Smith GP, Song JY, Stephens DS, Stephens R, Sun MM, Beretta-Piccoli BT, Tonnus W, Torgerson TR, Torres RM, Treat JD, Tsokos GC, Uzel G, Uzonna JE, van der Hilst JC, van der Meer JW, Varga J, Waldman M, Weatherhead J, Weiser P, Weyand CM, Wigley FM, Wing JB, Wood KJ, Wilde S, Xu H, Yusuf N, Zerbe CS, Zhang Q, Ben-Yehuda D, Zhang SY, Zieske AW. List Of Contributors. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00102-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Munoz MA, Skinner OP, Masle-Farquhar E, Jurczyluk J, Xiao Y, Fletcher EK, Kristianto E, Hodson MP, O'Donoghue SI, Kaur S, Brink R, Zahra DG, Deenick EK, Perry KA, Robertson AA, Mehr S, Hissaria P, Mulders-Manders CM, Simon A, Rogers MJ. Increased core body temperature exacerbates defective protein prenylation in mouse models of mevalonate kinase deficiency. J Clin Invest 2022; 132:160929. [PMID: 36189795 PMCID: PMC9525117 DOI: 10.1172/jci160929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
Mevalonate kinase deficiency (MKD) is characterized by recurrent fevers and flares of systemic inflammation, caused by biallelic loss-of-function mutations in MVK. The underlying disease mechanisms and triggers of inflammatory flares are poorly understood because of the lack of in vivo models. We describe genetically modified mice bearing the hypomorphic mutation p.Val377Ile (the commonest variant in patients with MKD) and amorphic, frameshift mutations in Mvk. Compound heterozygous mice recapitulated the characteristic biochemical phenotype of MKD, with increased plasma mevalonic acid and clear buildup of unprenylated GTPases in PBMCs, splenocytes, and bone marrow. The inflammatory response to LPS was enhanced in compound heterozygous mice and treatment with the NLRP3 inflammasome inhibitor MCC950 prevented the elevation of circulating IL-1β, thus identifying a potential inflammasome target for future therapeutic approaches. Furthermore, lines of mice with a range of deficiencies in mevalonate kinase and abnormal prenylation mirrored the genotype-phenotype relationship in human MKD. Importantly, these mice allowed the determination of a threshold level of residual enzyme activity, below which protein prenylation is impaired. Elevated temperature dramatically but reversibly exacerbated the deficit in the mevalonate pathway and the defective prenylation in vitro and in vivo, highlighting increased body temperature as a likely trigger of inflammatory flares.
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Affiliation(s)
- Marcia A Munoz
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Oliver P Skinner
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Etienne Masle-Farquhar
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Julie Jurczyluk
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Ya Xiao
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Emma K Fletcher
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Esther Kristianto
- Victor Chang Cardiac Innovation Centre, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Mark P Hodson
- School of Pharmacy, University of Queensland, Woolloongabba, Queensland, Australia
| | - Seán I O'Donoghue
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sandeep Kaur
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Robert Brink
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - David G Zahra
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Elissa K Deenick
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Kristen A Perry
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Avril Ab Robertson
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Queensland, Australia
| | - Sam Mehr
- Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Pravin Hissaria
- Royal Adelaide Hospital, SA Pathology and University of Adelaide, Adelaide, South Australia, Australia
| | - Catharina M Mulders-Manders
- Department of Internal Medicine, Radboudumc Expertise Centre for Immunodeficiency and Autoinflammation, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Anna Simon
- Department of Internal Medicine, Radboudumc Expertise Centre for Immunodeficiency and Autoinflammation, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Michael J Rogers
- Garvan Institute of Medical Research and School of Clinical Medicine, UNSW Sydney, Sydney, New South Wales, Australia
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van Lith TJ, Sluis WM, Wijers NT, Meijer FJA, Kamphuis-van Ulzen K, de Bresser J, Dankbaar JW, van den Heuvel FMA, Antoni ML, Mulders-Manders CM, de Mast Q, van de Veerdonk FL, Klok FA, Tuladhar AM, Cannegieter SC, Wermer MJH, van der Worp HB, Huisman MV, de Leeuw FE. Prevalence, risk factors, and long-term outcomes of cerebral ischemia in hospitalized COVID-19 patients – study rationale and protocol of the CORONIS study: A multicentre prospective cohort study. Eur Stroke J 2022; 7:180-187. [PMID: 35647315 PMCID: PMC9134783 DOI: 10.1177/23969873221092538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/16/2022] [Indexed: 12/18/2022] Open
Abstract
Background: COVID-19 is often complicated by thrombo-embolic events including ischemic
stroke. The underlying mechanisms of COVID-19-associated ischemic stroke,
the incidence and risk factors of silent cerebral ischemia, and the
long-term functional outcome in these patients are currently unknown. Patients and methods: CORONavirus and Ischemic Stroke (CORONIS) is a multicentre prospective cohort
study investigating the prevalence, risk factors and long-term incidence of
(silent) cerebral ischemia, and the long-term functional outcome among
patients with COVID-19. We aim to include 200 adult patients hospitalized
with COVID-19 without symptomatic ischemic stroke to investigate the
prevalence of silent cerebral ischemia compared with 60 (matched) controls
with MRI. In addition, we will identify potential risk factors and/or causes
of cerebral ischemia in COVID-19 patients with (n = 70) or
without symptomatic stroke (n = 200) by means of blood
sampling, cardiac workup and brain MRI. We will measure functional outcome
and cognitive function after 3 and 12 months with standardized
questionnaires in all patients with COVID-19. Finally, the long-term
incidence of (new) silent cerebral ischemia in patients with COVID-19 will
be assessed with follow up MRI (n = 120). Summary: The CORONIS study is designed to add further insight into the prevalence,
long-term incidence and risk factors of cerebral ischemia, and the long-term
functional outcome in hospitalized adult patients with COVID-19.
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Affiliation(s)
- Theresa J van Lith
- Department of Neurology, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wouter M Sluis
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Naomi T Wijers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederick JA Meijer
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology and Nuclear Medicine, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | | | - M Louisa Antoni
- Department of Cardiology, Heart and Lung Centre, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Quirijn de Mast
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank L van de Veerdonk
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frederikus A Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anil M Tuladhar
- Department of Neurology, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suzanne C Cannegieter
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marieke JH Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno V Huisman
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Center for Medical Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
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Wright WF, Mulders-Manders CM, Auwaerter PG, Bleeker-Rovers CP. Fever of Unknown Origin (FUO) - A Call for New Research Standards and Updated Clinical Management. Am J Med 2022; 135:173-178. [PMID: 34437835 DOI: 10.1016/j.amjmed.2021.07.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023]
Abstract
Prolonged fever of 38.3°C or higher for at least 3 weeks' duration has been termed fever of unknown origin if unexplained after preliminary investigations. Initially codified in 1961, classification with subgroups was revised in 1991. Additional changes to the definition were proposed in 1997, recommending a set of standardized initial investigations. Advances in diagnosis and management and diagnostic testing over the last 3 decades have prompted a needed update to the definition and approaches. While a 3-week fever duration remains part of the criteria, a lower temperature threshold of 38°C and revised minimum testing criteria will assist clinicians and their patients, setting a solid foundation for future research.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Catharina M Mulders-Manders
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Chantal P Bleeker-Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Mulders-Manders CM, Kouijzer IJ, de Geus-Oei LF. 18F-FDG-PET/CT imaging in fever and inflammation of unknown origin. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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13
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Mulders-Manders CM, Kouijzer IJ, Janssen MJ, Oyen WJ, Simon A, Bleeker-Rovers CP. Optimal use of [18F]FDG-PET/CT in patients with fever or inflammation of unknown origin. Q J Nucl Med Mol Imaging 2019; 65:51-58. [PMID: 31271266 DOI: 10.23736/s1824-4785.19.03129-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND [18F]FDG-PET/CT is one of the most important diagnostic techniques in the work-up of patients with fever of unknown origin (FUO)/inflammation of unknown origin (IUO). Little is known on how to optimize the diagnostic value of [18F]FDG-PET/CT in patients with FUO/IUO. METHODS Retrospective study in all patients who underwent [18F]FDG-PET/CT during the work-up of FUO/IUO in a tertiary expert center between 2005 and 2014. Data were extracted from medical records. RESULTS One hundred and four patients were identified, of whom 68 had a final diagnosis (65.4%). Mainly infections (30.8%) and non-infectious inflammatory diseases (30.8%). [18F]FDG-PET/CT contributed to the final diagnosis in 47 of the 68 patients (69.1%). In 21 patients [18F]FDG-PET/CT did not help making a diagnosis. In ten of these patients [18F]FDG-PET/CT was performed while body temperature, CRP and ESR were normal or unknown. Sixteen of 104 patients underwent repeated [18F]FDG-PET/CT. The second scan contributed to the final diagnosis in five of these patients. In two of these patients, the first scan retrospectively was truly non-contributory. In both patients the first [18F]FDG-PET/CT was made while CRP/ESR was low and fever was not present or not measured. A third or fourth scan never contributed to the final diagnosis when the second one did not. CONCLUSIONS [18F]FDG-PET/CT contributed to the final diagnosis in 45.2% of patients, but never contributed when both inflammatory parameters and body temperature were normal. Repeating [18F]FDG-PET/CT should only be done in patients with a non-contributory [18F]FDG-PET/CT when new symptoms or signs appear, or when the first scan was made in absence of fever or elevated inflammatory parameters.
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Affiliation(s)
| | - Ilse J Kouijzer
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel J Janssen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wim J Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Nuclear Medicine, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Anna Simon
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Abraham RS, Albanesi C, Alevizos I, Anguita J, Antiochos B, Aranow C, Atkinson JP, Austin HA, Babu S, Ballow MC, Balow JE, Belmont JW, Berek C, Beukelman T, Bhavsar T, Bird JA, Blutt SE, Boguniewicz M, Bonamichi-Santos R, Boisson B, Borzova E, Boyaka PN, Boyce J, Browne SK, Burks W, Bustamante J, Calder VL, Campbell M, Cardones ARG, Casanova JL, Castells M, Cavacini LA, Chan ES, Chaplin DD, Chatham WW, Chen ES, Chinen J, Christopher-Stine L, Ciancanelli M, Cope AP, Corry DB, Crea F, Cron RQ, Cuellar-Rodriguez JM, Dalakas MC, Dann SM, Diamond B, Du TW, Dupuis-Boisson S, Eagar TN, Elmets CA, Erkan D, Fanning L, Fikrig E, Flego D, Fleisher TA, Fonacier L, Fontenot AP, Freeman AF, Frew AJ, Fujihashi K, Gadina M, Gatt ME, Gershwin ME, Gillespie SL, Goronzy JJ, Goswami S, Grattan CE, Greenspan NS, Gupta S, Gustafson CE, Hall RP, Hamilton RG, Harrington LE, Harrison LC, Hasni SA, Helbling A, Hester J, Holland SM, Hourcade D, Huntington ND, Hwangpo T, Imboden JB, Issa F, Izraeli S, Jaffe ES, Jalkanen S, Jones S, Jouanguy E, Kabbani S, Kaufmann SH, Kheradmand F, Kohn DB, Korngold R, Kovalszki A, Kuhns DB, Kulkarni H, Kuo CY, Lahouti A, Landgren CO, Laurence A, Lee JS, Lemière C, Leung DY, Levinson AI, Levy O, Lewis DE, Lin P, Linkermann A, Liuzzo G, Lockshin MD, Lord AK, Lozier JN, Luong A, Luqmani R, Mackay M, Maltzman JS, Mannon PJ, Manns MP, Martin JG, Maynard CL, McCash S, McDonald DR, Melby PC, Miller SD, Mitchell AL, Mohd-Zaki A, Mold C, Moller DR, Monos DS, Mueller SN, Mulders-Manders CM, Mulligan MJ, Müller UR, Munshi PN, Murata K, Murphy PM, Navasa N, Noel P, Notarangelo LD, Nussbaum RL, Nutman TB, Nutt SL, Oliveira JB, Ortel TL, O'Shea JJ, Pai SY, Pandit L, Paul ME, Pearce SH, Pedicino D, Peterson EJ, Picard C, Pittaluga S, Priel DL, Puck J, Puel A, Radbruch A, Reece ST, Reveille JD, Rich RR, Roifman CM, Rosen A, Rosenbaum JT, Rosenzweig SD, Rouse BT, Rowley SD, Sakaguchi S, Salmi M, Sant AJ, Satola SW, Saw V, Schechter MC, Schroeder HW, Segal BM, Selmi C, Shankar S, Sharma A, Sharma P, Shearer WT, Siegel RM, Simon A, Smith GP, Stephens DS, Stephens R, Straumann A, Teos LY, Timares L, Tonnus W, Torres RM, Uzel G, van der Hilst JC, van der Meer JW, Varga J, Vyas JM, Waldman M, Weiser P, Weller PF, Weyand CM, Wigley FM, Winchester RJ, Wing JB, Wood KJ, Wu X, Xu H, Yee C, Zhang SY. List of Contributors. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00104-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Mulders-Manders CM, Hilst JCVD, Meer JWVD, Simon A. Systemic Autoinflammatory Syndromes. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00060-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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16
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Mulders-Manders CM, Engwerda C, Simon A, van der Meer JW, Bleeker-Rovers CP. Long-term prognosis, treatment, and outcome of patients with fever of unknown origin in whom no diagnosis was made despite extensive investigation: A questionnaire based study. Medicine (Baltimore) 2018; 97:e11241. [PMID: 29924054 PMCID: PMC6024966 DOI: 10.1097/md.0000000000011241] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In 30-50% of patients with fever of unknown origin (IUO) no explanation for the fever can be found. Prognosis and effects of empirical treatment of these patients are largely unknown.With this retrospective, questionnaire based corort study in all unexplained FUO patients in an expert center between 2003 and 2014 we studied mortality and outcome.In 131 of 274 FUO patients, FUO remained unexplained. Ninety-nine of them responded to the long-term follow up questionnaire. Adter a median duration of follow-up of 60 months, spontaneous remission of fever occured in 47.3%. Empirical treatment was effective in 66.7% of patients. Mortality was 6.9%. The cause of death was considered not to be related to the febrile disease in five out of six patients. Ten out of 99 responders reported to have received a final explanation for FUO after evaluation in the expertise center, but this diagnosis could not be confirmed in six cases and was considered to be an unlikely explanation for FUO in four out of six cases.We conclude that mortality in unexplained FUO is low en mostly unrelated to the febrile disease. Spontaneous resolution of fever is common. Empirical treatment prescribed by an expert physician is often effective, but should be avoided untill all diagnostic possibilities have been exhaused.
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Affiliation(s)
- Catharina M. Mulders-Manders
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Anna Simon
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jos W.M. van der Meer
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Chantal P. Bleeker-Rovers
- Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Nijmegen, the Netherlands
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Mulders-Manders CM, Kanters TA, van Daele PLA, Hoppenreijs E, Legger GE, van Laar JAM, Simon A, Hakkaart-van Roijen L. Decreased quality of life and societal impact of cryopyrin-associated periodic syndrome treated with canakinumab: a questionnaire based cohort study. Orphanet J Rare Dis 2018; 13:59. [PMID: 29678136 PMCID: PMC5910566 DOI: 10.1186/s13023-018-0799-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/04/2018] [Indexed: 01/01/2023] Open
Abstract
Background Cryopyrin-associated periodic syndrome (CAPS) is a rare disease. Knowledge on the quality of life (QoL) and the disease’s societal impact is limited. Canakinumab is used in increasing frequency for the treatment of CAPS. Methods Observational study in Dutch CAPS patients. Patients completed questionnaires regarding treatment with canakinumab at baseline and retrospectively. Quality of life was assessed using the EQ-5D-5L in adults and CHQ-PF50 in children. Impact on work and school was assessed. Caregivers' quality of life was assessed using the CarerQol. Results Mean quality of life scores during treatment with canakinumab were 0.769 (EQ-5D-5L), 51.1 (CHQ-P) and 57–1 (CHQ-M). Most patients experienced problems on the pain/discomfort dimension. Higher disease activity and the presence of complications negatively influenced QoL. Half of the patients with a paid job reported absenteeism from work due to CAPS, for an average of 8.7 days in a 4-week period. All schoolgoing patients (N = 5) reported absence from school due to CAPS, for an average of 2.9 days. Caregivers reported gaining a lot fulfillment from providing care for their family members. Conclusion QoL during treatment is lower than in the general Dutch population. CAPS leads to productivity loss and absenteeism from school, and impacts the quality of life in informal caregivers. Electronic supplementary material The online version of this article (10.1186/s13023-018-0799-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catharina M Mulders-Manders
- Department of Internal Medicine, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands. .,Expertise Center for Immunodeficiency and Autoinflammation, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Tim A Kanters
- Erasmus University Rotterdam, Institute for Medical Technology Assessment, Bayle Building - Campus Woudestein, PO box 1738, 3000, DR, Rotterdam, The Netherlands
| | - Paul L A van Daele
- Department of Internal Medicine and Immunology, Erasmus MC, Front Service Immunology, room: Nb-1218, PO box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Esther Hoppenreijs
- Department of Paediatric Rheumatology, Radboud university medical center, Amalia Children's Hospital, 804, PO box 9101, 6500, HB, Nijmegen, the Netherlands
| | - G Elizabeth Legger
- Department of Pediatrics, University Medical Center Groningen, PO box 30.001, 9700, RB, Groningen, the Netherlands
| | - Jan A M van Laar
- Department of Internal Medicine and Immunology, Erasmus MC, Front Service Immunology, room: Nb-1218, PO box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Anna Simon
- Department of Internal Medicine, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands.,Expertise Center for Immunodeficiency and Autoinflammation, Radboud university medical center, 463, PO box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Leona Hakkaart-van Roijen
- Erasmus University Rotterdam, Institute for Medical Technology Assessment, Bayle Building - Campus Woudestein, PO box 1738, 3000, DR, Rotterdam, The Netherlands
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Affiliation(s)
- C M Mulders-Manders
- From the Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Simon
- From the Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C P Bleeker-Rovers
- From the Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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19
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Abstract
Fever of unknown origin (FUO) is commonly defined as fever higher than 38.3°C on several occasions during at least 3 weeks with uncertain diagnosis after a number of obligatory investigations. The differential diagnosis of FUO can be subdivided in four categories: infections, malignancies, noninfectious inflammatory diseases, and miscellaneous causes. In most cases of FUO, there is an uncommon presentation of a common disease. FDG-PET/CT is a sensitive diagnostic technique for the evaluation of FUO by facilitating anatomical localization of focally increased FDG uptake, thereby guiding further diagnostic tests to achieve a final diagnosis. FDG-PET/CT should become a routine procedure in the workup of FUO when diagnostic clues are absent. FDG-PET/CT appears to be a cost-effective routine imaging technique in FUO by avoiding unnecessary investigations and reducing the duration of hospitalization.
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Affiliation(s)
- Ilse J E Kouijzer
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina M Mulders-Manders
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Nuclear Medicine, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom.
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20
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Mulders-Manders CM, Pietersz G, Simon A, Bleeker-Rovers CP. Referral of patients with fever of unknown origin to an expertise center has high diagnostic and therapeutic value. QJM 2017; 110:793-801. [PMID: 29036369 DOI: 10.1093/qjmed/hcx158] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/15/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND up to 50% of patients with fever of unknown origin (FUO) remain undiagnosed despite extensive evaluation. In expertise centers, at least 25-63% of these patients are referred after evaluation in another hospital. The diagnostic and therapeutic yields of referral to an expertise center are currently unknown. AIM To determine the diagnostic and therapeutic yield of referral of patients with fever of unknown origin (FUO) that remain undiagnosed in non-expertise hospitals. DESIGN Data on workup, outcome, treatment and prognosis were extracted from medical records of all 236 patients referred to the Radboud university medical center's department of internal medicine because of FUO between January 2005 and June 2014. RESULTS A final diagnosis could be made in 110 of 192 tertiary referred FUO patients. The rate of diagnosis did not differ between patients referred for first opinion or after tertiary referral (68.2 vs. 57.3%, P = 0.234). Over half of undiagnosed tertiary referred patients were treated, and fever resolved in half of these patients. Of 96 undiagnosed patients, two died (2.1)% and in both death was considered unrelated to the febrile disease. CONCLUSION The diagnostic rate in patients with FUO does not differ between patients that are tertiary referred and patients that have not been previously evaluated in another hospital. With a total diagnostic value of 57.3% and an additional therapeutic yield of 10.9% in undiagnosed patients, tertiary referral should therefore be considered in patients that remain undiagnosed in a non-expertise center.
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Affiliation(s)
- C M Mulders-Manders
- From the Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Huispost 463, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - G Pietersz
- From the Department of Internal Medicine
| | - A Simon
- From the Department of Internal Medicine
- Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical Center, Huispost 463, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Mulders-Manders CM, Baas MC, Molenaar FM, Simon A. Peri- and Postoperative Treatment with the Interleukin-1 Receptor Antagonist Anakinra Is Safe in Patients Undergoing Renal Transplantation: Case Series and Review of the Literature. Front Pharmacol 2017; 8:342. [PMID: 28620307 PMCID: PMC5449651 DOI: 10.3389/fphar.2017.00342] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/19/2017] [Indexed: 12/29/2022] Open
Abstract
In patients undergoing solid organ transplantation, the presence of an interleukin-1 (IL-1) driven disease may require the addition of IL-1 inhibiting drugs to the standard immunosuppressive regimen to protect against inflammation and negative graft outcome. Three patients undergoing renal transplantation were treated perioperatively with the interleukin-1 receptor antagonist anakinra. Kidney function increased rapidly in all three and the only complications seen were minor infections. In vitro studies report associations between serum and urinary levels of IL-1β and IL-1 receptor antagonist and negative graft outcome, and studies in animals and two small human trials illustrate a possible protective effect of anti-IL-1 therapy after solid organ transplantation. Peri- and postoperative use of anakinra is safe and effective in patients undergoing renal transplantation.
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Affiliation(s)
- Catharina M Mulders-Manders
- Department of Internal Medicine and Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical CenterNijmegen, Netherlands
| | - Marije C Baas
- Department of Nephrology, Radboud University Medical CenterNijmegen, Netherlands
| | - Femke M Molenaar
- Department of Nephrology, University Medical CenterUtrecht, Netherlands
| | - Anna Simon
- Department of Internal Medicine and Expertise Center for Immunodeficiency and Autoinflammation, Radboud University Medical CenterNijmegen, Netherlands
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