Pathogenesis, and Outcome of Autoinflammatory Diseases, NOMID/CAPS, DIRA, CANDLE, SAVI, NLRC4-MAS, Still's-like Diseases, and other Undifferentiated Autoinflammatory Diseases

A. SAID自然史的特征： 1.我们跟踪NOMID、DIRA、CANDLE和SAVI患者队列，并评估目前推荐治疗的生物标志物变化。 2.我们继续描述NEMO-NDAS的遗传学和发病机制。3.我们的研究有助于制定IL-1介导的疾病、自身炎性干扰素病（包括CANDLE和SAVI）的治疗指导文件。 B。结局标准的制定和验证：我们正在开发治疗自身炎症性疾病的模块化结局，目标是生成标准化结局，这些结局将被监管机构批准用于靶向治疗。 C.我们启动的靶向治疗的长期结局和安全性评价。1. NOMID是CAPS中最严重的疾病，通常严重的炎性CNS疾病需要用阿那白滞素进行慢性高剂量治疗以抑制炎症。 我们观察了阿那白滞素淀粉样变性患者在高剂量治疗的发展。在注射部位局部发展的淀粉样变性可随时间扩散并累及肾脏。 患者需要进行监测，我们正在探索降低慢性阿那白滞素剂量的替代方案。 2.我们描述了CANDLE和SAVI患者使用小分子baricitinib抑制JAK的获益（Sanchez GAM et al JCI 2019），并对患者进行了长期随访，以表征baricitinib持续治疗的安全性特征（Gedic K Arthritis Rheum摘要2020）。正如我们之前描述的BK病毒尿和病毒血症的发生，我们监测了肾功能和血液学参数，并描述了疾病发作和显著剂量降低，从而验证了我们提出的治疗这些患者的临床方案（Gedic K Arthritis Rheum摘要2021）。 D.早发性自身炎症性疾病患者的临床和遗传学评价，包括新型自身炎症性疾病的特征 使用三重全外显子组测序：1.我们确定了3例林恩激酶致病突变的患者，表现为围产期发作的嗜中性皮肤小血管炎和全身性炎症，2例患者在出生后第一年发生肝纤维化。功能研究显示，诱导内皮细胞（iEC）活化和中性粒细胞粘附增加，患者中性粒细胞2-整合素表达增加，导致中性粒细胞粘附和血管跨内皮迁移（TEM）增加。TNF抑制治疗改善了全身炎症; Src激酶抑制剂达沙替尼治疗后，肝纤维化消退。我们的研究结果揭示了林恩激酶在调节炎症信号、调节微血管通透性和中性粒细胞募集以及促进肝纤维化方面的关键作用（De Jesus Nature Communications 2023），并扩大了导致自身炎症的疾病表现的临床谱。 2.我们在PSMA 5和POMP中鉴定了导致CANDLE的其他CANDLE致突变（Papendorf et al Frontiers Immunol.2023）。3.我们将继续评估和治疗婴儿早期出现的严重炎症性疾病患者，这些疾病具有高度升高的干扰素特征，但基因突变未知。所有患者均接受详细的免疫评估，包括评估其IFN应答基因特征，使用下一代测序进行遗传分析（全外显子组测序（WES）和/或全基因组测序（WGS））。 E.开发和验证表征基线和随时间推移免疫调节障碍的生物标志物。 1.我们的努力，以确定细胞来源的干扰素生产的血液和人类病变活检正在进行中。 我们在其他单基因和复杂疾病（包括患有COVID-19的儿科患者）中验证了我们的28个基因I型IFN基因表达谱，并扩展了我们表征和定量NF κ B活化和II型IFN介导的炎症的能力（Scarlet et al 2022）。2.在合作中，我们的患者样本通过建立蛋白激酶R（PKR）作为蛋白毒性应激的先天性免疫传感器，帮助解开了蛋白酶体突变与I型IFN产生之间的联系，PKR通过感应IL-24的胞质积累，IL-24在应激期间错误折叠并通过内质网相关降解途径（ERAD）流出到胞质溶胶中，从而作为IL-24相关分子模式（DAMP）（Davidson等Science Immunol 2022）。PKR还通过触发eIF 2的磷酸化来充当蛋白毒性应激的变阻器，这可以阻止新蛋白的翻译以恢复稳态。 F.单核细胞和巨噬细胞分化对炎性细胞因子产生的影响 1.我们正在分析和评估来自活动性NOMID和SAVI患者的单核细胞中的免疫失调，目的是鉴定炎性小体和STING功能获得介导的对单核细胞分化和功能的影响的标志物。 G.使用体外细胞培养系统模拟选定的自身炎症性疾病中的器官特异性免疫调节障碍和器官损伤。1.与NHLBI的Manfred Boehms博士团队合作，我们对LAVLI中林恩激酶介导的炎症中的内皮功能障碍进行了建模（哈珀R等人，干细胞研究2022）。

A. CHARACERIZATION OF THE NATURAL HISTROY OF SAIDs: 1. We follow patient cohorts with NOMID, DIRA, CANDLE and SAVI and are assessing biomarker changes on currently recommended treatment. 2. We continue to characterize the genetics and pathogenesis of NEMO-NDAS. 3. Our studies contributed to the development of treatment guidance documents for IL-1 mediated diseases, autoinflammatory interferonopathies including CANDLE and SAVI. B. DEVELOPMENT AND VALIDATION OF OUTCOME CRITERIA: We are developing modular outcomes for the treatment of autoinflammatory diseases with the goals to generate standardized outcomes that will be accepted for regulatory approval of targeted treatments. C. LONG-TERM OUTCOME AND SAFETY EVALUATION ON TARGETED TREATMENTS WE INITIATED. 1. NOMID is at the most severe spectrum of CAPS and the often-severe inflammatory CNS disease requires chronic high-dose treatment with anakinra to suppress inflammation. We observed the development of anakinra amyloidosis in patients on high dose treatment. The amyloidosis that develops locally at the site of injection can disseminate over time and involve the kidney. Patients need to be monitored and we are exploring alternatives to lower chronic anakinra doses. 2. We have described the benefit of JAK inhibition with the small molecule baricitinib in patients with CANDLE and SAVI (Sanchez GAM et al JCI 2019) and followed patients long-term to characterize the safety profile on ongoing treatment with baricitinib (Gedic K Arthritis Rheum abstract 2020). As we previously described the development of BK viruria and viremia, we monitor kidney function and hematologic parameters and have described disease flares with significant dose reductions thus validating the clinical regimen we proposed for the treatment of these patients (Gedic K Arthritis Rheum abstract 2021). D. CLINICAL AND GENETIC EVALUATION OF PATIENTS WITH EARLY-ONSET AUTOINFLAMMATORY DISEASES INCLUDING THE CHARACTERIZATION OF NOVEL AUTOINFLAMMATORY DISEASES Using trio whole exome sequencing: 1. We identified 3 patients with disease-causing mutations in Lyn kinase who presented with perinatal-onset of neutrophilic cutaneous small vessel vasculitis and systemic inflammation and two patients developed liver fibrosis in their first year of life. Functional studies revealed increased induced endothelial cells (iECs) activation and neutrophil adhesion and increased 2-integrin expression on patient neutrophils that resulted in increased neutrophil adhesion and vascular transendothelial migration (TEM). Treatment with TNF inhibition improved systemic inflammation; and liver fibrosis resolved on treatment with the Src kinase inhibitor dasatinib. Our findings reveal a critical role for Lyn kinase in modulating inflammatory signals, regulating microvascular permeability and neutrophil recruitment, and in promoting hepatic fibrosis (De Jesus Nature Communications 2023) and expand the clinical spectrum of disease manifestations that cause autoinflammation. 2. We identified additional CANDLE-causing mutations in PSMA5 and POMP that cause CANDLE (Papendorf et al Frontiers Immunol. 2023). 3. We continue to evaluate and treat patients with severe inflammatory diseases that present early in infancy with highly elevated interferon signatures but yet unknown genetic mutations. All patients undergo a detailed immune evaluation that includes assessment of their assessed their IFN response gene signature, genetic analyses using next generation sequencing, (whole exome sequencing (WES) and/or whole genome sequencing (WGS). E. DEVELOPMENT AND VALIDATION OF BIOMARKERS THAT CHARACTERIZE THE IMMUNE DYSREGULATION AT BASELINE AND OVER TIME. 1. Our effort to identify the cellular sources of IFN production in blood and in human lesional biopsies is ongoing. We validated our 28 gene Type-I IFN gene expression profile in other monogenic and complex diseases including in pediatric patients with COVID-19 and expanded our ability to characterize and quantify NFKB activation and Type II IFN mediated inflammation (Sacco et al 2022). 2. In collaboration, our patient samples aided in unraveling the that linked proteasome mutations to type-I IFN production by establishing protein kinase R (PKR) as an innate immune sensor for proteotoxic stress by sensing the accumulation of cytoplasmic of IL-24 which is during stress is misfolded and egressed into the cytosol through the endoplasmic reticulumassociated degradation pathway (ERAD) and thus acts as danger-associated molecular pattern (DAMP) (Davidson et al. Science Immunol 2022). PKR also acts as rheostat for proteotoxic stress by triggering phosphorylation of eIF2, which can prevent the translation of new proteins to restore homeostasis. F. ASESSMENT OF THE IMPACT OF MONOCYTE AND MACROPHAGE DIFFERENTIATION ON PROINFLAMMATORY CYTOKINE PRODUCTION 1. We are profiling and assessing the immune dysregulation in monocytes from active NOMID and SAVI patients with the goal to identify markers of inflammasome and STING gain-of function mediated impacts on monocyte differentiation and function. G. USE OF IN VITRO CELL CULTURE SYSTEMS TO MODEL ORGAN-SPECIFIC IMMUNE DYSREGULATION AND ORGAN DAMAGE IN SELECTED AUTOINFLAMMATORY DISEASES. 1. In collaboration with Dr. Manfred Boehms group at NHLBI we model endothelial dysfunction in Lyn kinase-mediated inflammation in LAVLI (Harper R et al. Stem Cell Res 2022).