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

A.SAID自然历史的分类： 1.CONTLE、SAVI：我们使用JAK抑制剂治疗前的DATA评估了CALT和SAVI患者的基因表型相关性，以表征炎症性疾病的表现谱、未经治疗的炎症对累积的器官损害的影响、围产儿发病率和死亡率以及评估的细胞因子和其他生物标记物失调。2.我们对一种新疾病--LYN相关性自身炎症性疾病的临床表现进行了分析。 B.结果标准的制定和验证：我们已经为几种自体炎症性疾病制定了结果参数，并验证了以下方面的结果：1.父母/患者的结果；2.缓解；3.疾病活动性低。4.维持结果，包括5.生长和发育参数和6.全身糖皮质激素的断奶能力。 C.对先前治疗方案中登记的患者进行靶向治疗的长期结果和安全性评估。1.SAVI和CONTLE/PRAAS患者需要长期治疗，目前JAK抑制剂(JAKI)提供了最一致的益处。我们对小分子Jaki，巴利替尼的研究证实，BK在大多数患者的尿液和血液中重新激活(3)。我们长期跟踪患者的自然病史研究，并制定了指导意见，以监测需要更高剂量JAK抑制剂的患者的BK病毒尿和病毒血症。 2.对一组NOMID患者的随访我们确定了长期疗效和副作用，并确定了在注射部位长期接受大剂量Anakinra治疗的患者中淀粉样变性的发展情况。我们评估了这种副作用的程度。 D.新的自身炎症性疾病的基因发现和特征，以及尚未表现为早发性自身炎症性疾病特征的患者的临床和遗传学评估 1.我们描述了两种新的自身炎症性疾病，一种是临床上模仿蜡烛的疾病，一种是Nemo外显子5缺失的自体炎综合征(Nemo-NDas)(4，5)，另一种是由Lyn激酶GOF突变引起的疾病。 我们继续评估和治疗早期表现为严重炎症性疾病的患者，特别是那些患有干扰素疾病但尚不清楚的基因突变的患者。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(目前是全基因组测序)。 E.生物标志物的开发和验证，并侧重于了解单核细胞和巨噬细胞的分化，以改进对自身免疫性疾病的诊断和监测。 1.我们正在比较干扰素的产生、干扰素的来源以及外周血和组织中干扰素反应基因的特征。我们正在验证干扰素签名在其他单基因和复杂疾病中的应用，包括成人和儿童新冠肺炎患者。 2.我们与Scott Canna博士和一个更广泛的团队合作，对生物标志物进行了表征，这些生物标志物可以识别现在被称为SOJIA-LD的IL-18 PAP-MAS(4)患者，他们患有肺泡蛋白沉着症，并有发展为巨噬细胞激活综合征的风险。 F.探索单核细胞和巨噬细胞分化，以提高诊断和了解致病影响 1.建立了单核细胞分化在IL-1介导的疾病中的作用，并比较了Nemo-NDAs和Candle患者的单核细胞分化。我们描述了导致疾病的Nemo-NDAS突变对单核细胞和巨噬细胞分化和功能的免疫学影响。 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。我们模拟了两种疾病，SAVI和Lyn Kinase介导的疾病中器官炎症和损伤的方面。1.STING1基因以p.V155M突变为主的SAVI患者的间质性肺疾病严重，是SAVI患者死亡的主要原因。尽管有JAKI，但仍会出现肺纤维化的并发症和进展。与Boehm实验室(NHLBI)合作，我们开发了IPSC模型来评估内皮细胞的分化。2.我们从一名Lyn激酶GOF突变患者身上培养了IPS细胞来研究小血管炎 自然病史方案是为自身炎症性疾病患者的初始和随访评估而开发的。受影响的参与者(登记上限为1000人)在NIH CC接受临床评估和表型鉴定，其中包括最先进的放射分子成像。收集研究样本，包括血液、皮肤、唾液、尿液和脑脊液，以及用于微生物组分析的皮肤拭子和粪便样本。未患病的亲属和无亲属关系的健康志愿者(各500人)参加对照生物样品的采集。所有受影响的患者及其父母都要接受基因评估。随访的频率取决于参与者的临床状况和与患者疾病相关的科学目标。我们收集和存储样本，包括用于全面遗传分析的DNA，用于基因表达谱分析的RNA，用于生物标记物分析的血清、血浆和细胞，以及临床指定手术遗留下来的活组织检查材料。我们从选定的患者中培养成纤维细胞系，在选定的患者中，我们可能会产生IPSCs来模拟器官和组织中的疾病发病机制。我们通过成像来评估发炎或受损的器官。在COVID大流行期间，我们关闭了一项同情使用计划，并对使用CALLEE、SAVI和其他自身炎症性干扰素病的患者进行自然病史方案的跟踪。

A. CHARACERIZATION OF THE NATURAL HISTORY OF SAIDs: 1. CANDLE, SAVI: We have assessed geno-phenotype correlations in CANDLE and SAVI patients using data pre-JAK inhibitor treatment to characterize the spectrum of inflammatory disease manifestations, the impact of untreated inflammation on accumulating organ damage, the rate of perinatal morbidity and mortality and assessed cytokine and other biomarker dysregulation. 2. We have clinically characterized the disease manifestations of a novel disease Lyn associated autoinflammatory disease. B. DEVELOPMENT AND VALIDATION OF OUTCOME CRITERIA: We have developed outcome parameters for several autoinflammatory diseases and have validated the outcomes in the following areas for patients with DIRA and CANDLE: 1. parents/ patient outcomes, 2. remission, and 3. low disease activity. 4. Maintenance of a outcome inclusion of 5. growth and development parameters and 6. Ability to wean systemic glucocorticoids. C. LONG-TERM OUTCOME AND SAFETY EVALUATION ON TARGETED TREAT-MENTS ON PATIENTS ENROLLED IN PREVIOUS TREATMENT PROTOCOLS. 1. SAVI and CANDLE/PRAAS patients require long-term treatment and currently JAK inhibitors (JAKi) provide the most consistent benefit. Our studies with the small molecule JAKi, baricitinib, identified that BK reactivation in urine in most patients and in blood (3). We follow patients long-term on the natural history study and developed guidance to monitor BK viruria and viremia in patients requiring higher doses of JAK inhibitors. 2. Follow-up of a cohort of NOMID patients we characterized a long-term efficacy and side effects and identified the development of amyloidosis in a subset of patients who are receiving long-term high dose anakinra at the injections site. We evaluating the extend of this side effect. D. GENETIC DISCOVERY AND CHARACTERIZATION OF NOVEL AUTO-INFLAMMATORY DISEASES AND CLINICAL AND GENETIC EVALUATION OF PATIENTS WITH NOT YET CHARACTERIZED EARLY-ONSET AUTOINFLAMMATORY DISEASES 1. We characterized 2 novel autoinflammatory diseases, one that clinically mimics CANDLE, NEMO exon5 deleted autoinflammatory syndrome (NEMO-NDAS) (4, 5) and another disease caused by GOF mutations in Lyn kinase. We continue to evaluate and treat patients with severe inflammatory diseases that present early in infancy particularly those with interferonopathies 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, (currently whole genome sequencing (WGS)). E. DEVELOPMENT AND VALIDATION OF BIOMARKERS AND FOCUS ON UNDERSTANDING MONOCYTE AND MACROPHAGE DIFFERENTIATION TO IMPROVE DIAGNOSIS AND MONITORING OF AUTOINFLMAMMTORY DISEASES. 1. We are comparing IFN production, the source of IFN and of the IFN response gene signature in peripheral blood and tissues. We are validating the IFN signature in other monogenic and complex diseases including in adult and pediatric patients with COVID-19. 2. We collaborated with Dr. Scott Canna and a wider group to characterize biomarkers that allow the identification of patients with IL-18 PAP-MAS (4) now referred to as SOJIA-LD who develop pulmonary alveolar proteinosis and are at risk for the development of macrophage activation syndrome. F. EXPLORE MONOCYTE AND MACROPHAGE DIFFERENTIATION TO IMPROVE DIAGNOSIS AND UNDERSTAND PATHOGENIC IMPACT 1. We established that monocyte differentiation in the IL-1 mediated disease and compared monocyte differentiation in NEMO-NDAS and CANDLE patients. We are describing the immunological impact of the disease-causing NEMO-NDAS mutations on monocyte and macrophage differentiation and function. G. USE OF IN VITRO CELL CULTURE SYSTEMS TO MODEL ORGAN-SPECIFIC IMMUNE DYSREGULATION AND ORGAN DAMAGE IN SELECTED AUTOINFLAMMATORY DISEASES. We modeled aspects of organ inflammation and damage in two diseases, SAVI and LYN kinase mediated disease. 1. The interstitial lung disease in patients with SAVI with predominantly p.V155M mutations in STING1 are severe, and the predominant cause for mortality in SAVI. Complications and progression of lung fibrosis occur despite JAKis. In collaboration with the Boehm laboratory (NHLBI) we developed iPSC model to assess endothelial cells differentiation. 2. We developed iPScells from a patient with a GOF mutation in Lyn kinase to investigate small vessel vasculitis THE NATURAL HISTORY PROTOCOL was developed for initial and follow-up evaluations of patients with autoinflammatory diseases. Affected participants (enrollment ceiling of n = 1000) are clinically evaluated and phenotyped at the NIH CC which includes state of the art radiologic molecular imaging. Research samples are collected and include blood, skin, saliva, urine, and CSF as well as skin swabs and stool samples for microbiome analyses. Unaffected relatives and unrelated healthy volunteers (n = 500 of each) are enrolled for the collection of control biological samples. All affected patients and their parents undergo genetic evaluation. The frequency of the follow-up visits is based on the participants clinical status and the scientific objective related to the patient's disease. We collect and store samples including DNA for comprehensive genetic analyses, RNA for gene expression profiling, serum, plasma and cells for biomarker analysis and biopsy material if left over from clinically indicated procedures. We generate fibroblast cells lines from selected patients, and in selective patients we may generate iPSCs to model disease pathogenesis in organs and tissues. We obtain imaging to evaluate organs that are inflamed or damaged. During the COVID pandemic we closed a compassionate use program and we follow patients with CANDLE, SAVI and with other autoinflammatory interferonopathies on the natural history protocol.