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

A.SAID的自然历史的分类： 1.我们跟踪使用NOMID、DERA、CONTLE和SAVI的患者队列，并正在评估当前推荐治疗的生物标记物的变化。2.我们继续对Nemo-NDA的遗传学和发病机制进行研究。3.我们的研究为IL-1介导的疾病、自身炎症性干扰素病(包括COLARE和SAVI)的治疗指导文件的制定做出了贡献。 B.制定和验证结果标准：我们正在为自体炎症性疾病的治疗制定模块化结果，目标是产生标准化结果，并接受这些结果，以供监管部门批准靶向治疗。 C.我们发起的靶向治疗的长期结果和安全性评估。1.NOMID是CAPS中最严重的一种，通常情况下严重的炎症性中枢神经系统疾病需要长期大剂量的Anakinra治疗来抑制炎症。我们观察了大剂量治疗患者中无淀粉样变性的发展情况。注射部位局部形成的淀粉样变性可随着时间的推移而扩散，并累及肾脏。需要对患者进行监测，我们正在探索降低慢性阿纳金拉剂量的替代方案。 2.我们已经描述了小分子巴利西尼在蜡烛和SAVI患者中抑制JAK的益处(Sanchez GAM等人JCI 2019)，并对患者进行长期跟踪观察，以表征巴利西尼持续治疗的安全性(Gedic K关节炎大黄摘要2020)。正如我们之前描述的BK病毒尿症和病毒血症的发展，我们监测肾功能和血液学参数，并描述了显著减少剂量的疾病发作，从而验证了我们为这些患者建议的临床治疗方案(Gedic K Artis Rheum Abstrum 2021)。 D.对早发性自体炎症性疾病患者的临床和遗传学评估，包括新自体炎症性疾病的特征 利用三重外显子测序：1.我们鉴定了3例Lyn激酶致病突变患者，他们在围产期表现为中性粒细胞皮肤小血管炎和全身性炎症，2例患者在出生后第一年就出现了肝纤维化。功能研究显示，诱导内皮细胞(IECS)激活和中性粒细胞黏附增加，患者中性粒细胞上2-整合素表达增加，导致中性粒细胞黏附和血管内皮细胞迁移(TEM)增加。肿瘤坏死因子抑制治疗可改善全身炎症反应，而肝纤维化则可通过使用Src激酶抑制剂达沙替尼治疗而缓解。我们的发现揭示了Lyn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、促进肝纤维化方面的关键作用(De Jesse自然通讯2023)，并扩大了导致自体炎症的疾病表现的临床范围。2.我们发现了PSMA5和PPUP中其他导致蜡烛的突变，这些突变导致蜡烛(Papendorf等人的Frontiers免疫。2023年)。3.我们继续评估和治疗患有严重炎症性疾病的患者，这些患者在婴儿早期出现高度升高的干扰素信号，但未知的基因突变。所有患者都要接受详细的免疫评估，包括评估他们的干扰素反应基因签名、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变化的免疫失调的生物标记物。 1.我们正在努力确定血液和人类皮损活检中产生干扰素的细胞来源。我们验证了我们的28个基因的I型干扰素基因在其他单基因和复杂疾病中的表达谱，包括儿童新冠肺炎患者，并扩大了我们表征和量化NFKB激活和II型干扰素介导的炎症的能力(SACO等人2022)。2.在合作中，我们的患者样本帮助解开了将蛋白酶体突变与I型干扰素产生联系起来的机制，方法是建立蛋白激酶R(PKR)作为蛋白质毒性应激的天然免疫传感器，通过检测应激期间细胞质的积累，IL-24在应激期间被错误折叠并通过内质网相关降解途径(ERAD)进入胞浆，从而起到危险相关分子模式(DAMP)的作用(Davidson等人)。科学免疫2022)。PKR还通过触发eIF2的磷酸化来作为蛋白毒性应激的变阻器，这可以阻止新蛋白质的翻译来恢复体内平衡。 F.单核细胞和巨噬细胞分化对促炎细胞因子产生的影响 1.我们正在分析和评估活动期NOMID和SAVI患者单核细胞的免疫失调，目的是确定炎症小体和刺痛功能获得的标志物对单核细胞分化和功能的影响。 使用体外细胞培养系统在选定的自体炎症性疾病中模拟器官特异性免疫失调和器官损伤。1.与NHLBI的Manfred Boehms博士合作，我们在LAVLI中模拟了Lyn激酶介导的炎症中的内皮功能障碍(Harper R等人)。干细胞分辨率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).