JAK Inhibition in the Aicardi-Goutières Syndrome

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Interface Gain-of-Function Mutations in TLR7 Cause Systemic and Neuro-inflammatory Disease

TLR7 recognizes pathogen-derived single-stranded RNA (ssRNA), a function integral to the innate immune response to viral infection. Notably, TLR7 can also recognize self-derived ssRNA, with gain-of-function mutations in human TLR7 recently identified to cause both early-onset systemic lupus erythematosus (SLE) and neuromyelitis optica. Here, we describe two novel mutations in TLR7, F507S and L528I. While the L528I substitution arose de novo, the F507S mutation was present in three individuals from the same family, including a severely affected male, notably given that the TLR7 gene is situated on the X chromosome and that all other cases so far described have been female. The observation of mutations at residues 507 and 528 of TLR7 indicates the importance of the TLR7 dimerization interface in maintaining immune homeostasis, where we predict that altered homo-dimerization enhances TLR7 signaling. Finally, while mutations in TLR7 can result in SLE-like disease, our data suggest a broader phenotypic spectrum associated with TLR7 gain-of-function, including significant neurological involvement

Efficacy of the Janus kinase 1/2 inhibitor ruxolitinib in the treatment of vasculopathy associated with TMEM173-activating mutations in 3 children

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Juvenile neuropsychiatric systemic lupus erythematosus: identification of novel central neuroinflammation biomarkers

International audienceIntroduction Juvenile systemic lupus erythematosus (j-SLE) is a rare chronic autoimmune disease affecting multiple organs. Ranging from minor features, such as headache or mild cognitive impairment, to serious and life-threatening presentations, j-neuropsychiatric SLE (j-NPSLE) is a therapeutic challenge. Thus, the diagnosis of NPSLE remains difficult, especially in pediatrics, with no specific biomarker of the disease yet validated. Objectives To identify central nervous system (CNS) disease biomarkers of j-NPSLE. Methods A 5-year retrospective tertiary reference monocentric j-SLE study. A combination of standardized diagnostic criteria and multidisciplinary pediatric clinical expertise was combined to attribute NP involvement in the context of j-SLE. Neopterin and interferon-alpha (IFN-α) protein levels in cerebrospinal fluid (CSF) were assessed, together with routine biological and radiological investigations. Results Among 51 patients with j-SLE included, 39% presented with j-NPSLE. J-NPSLE was diagnosed at onset of j-SLE in 65% of patients. No specific routine biological or radiological marker of j-NPSLE was identified. However, CSF neopterin levels were significantly higher in active j-NPSLE with CNS involvement than in j-SLE alone ( p = 0.0008). Neopterin and IFN-α protein levels in CSF were significantly higher at diagnosis of j-NPSLE with CNS involvement than after resolution of NP features (respectively p = 0.0015 and p = 0.0010) upon immunosuppressive treatment in all patients tested ( n = 10). Both biomarkers correlated strongly with each other ( R s = 0.832, p < 0.0001, n = 23 paired samples). Conclusion CSF IFN-α and neopterin constitute promising biomarkers useful in the diagnosis and monitoring of activity in j-NPSLE

JAK inhibition in Aicardi-Goutières syndrome: a monocentric multidisciplinary real-world approach study

International audienceThe paradigm type I interferonopathy Aicardi-Goutières syndrome (AGS) is most typically characterized by severe neurological involvement. AGS is considered an immune-mediated disease, poorly responsive to conventional immunosuppression. Premised on a chronic enhancement of type I interferon signaling, JAK1/2 inhibition has been trialed in AGS, with clear improvements in cutaneous and systemic disease manifestations. Contrastingly, treatment efficacy at the level of the neurological system has been less conclusive. Here, we report our real-word approach study of JAK1/2 inhibition in 11 patients with AGS, providing extensive assessments of clinical and radiological status; interferon signaling, including in cerebrospinal fluid (CSF); and drug concentrations in blood and CSF. Over a median follow-up of 17 months, we observed a clear benefit of JAK1/2 inhibition on certain systemic features of AGS, and reproduced results reported using the AGS neurologic severity scale. In contrast, there was no change in other scales assessing neurological status; using the caregiver scale, only patient comfort, but no other domain of everyday-life care, was improved. Serious bacterial infections occurred in 4 out of the 11 patients. Overall, our data lead us to conclude that other approaches to treatment are urgently required for the neurologic features of AGS. We suggest that earlier diagnosis and adequate central nervous system penetration likely remain the major factors determining the efficacy of therapy in preventing irreversible brain damage, implying the importance of early and rapid genetic testing and the consideration of intrathecal drug delivery

Assessment of Type I Interferon Signaling in Pediatric Inflammatory Disease

International audiencePURPOSE: Increased type I interferon is considered relevant to the pathology of a number of monogenic and complex disorders spanning pediatric rheumatology, neurology, and dermatology. However, no test exists in routine clinical practice to identify enhanced interferon signaling, thus limiting the ability to diagnose and monitor treatment of these diseases. Here, we set out to investigate the use of an assay measuring the expression of a panel of interferon-stimulated genes (ISGs) in children affected by a range of inflammatory diseases. DESIGN, SETTING, AND PARTICIPANTS: A cohort study was conducted between 2011 and 2016 at the University of Manchester, UK, and the Institut Imagine, Paris, France. RNA PAXgene blood samples and clinical data were collected from controls and symptomatic patients with a genetically confirmed or clinically well-defined inflammatory phenotype. The expression of six ISGs was measured by quantitative polymerase chain reaction, and the median fold change was used to calculate an interferon score (IS) for each subject compared to a previously derived panel of 29 controls (where +2 SD of the control data, an IS of \textgreater2.466, is considered as abnormal). Results were correlated with genetic and clinical data. RESULTS: Nine hundred ninety-two samples were analyzed from 630 individuals comprising symptomatic patients across 24 inflammatory genotypes/phenotypes, unaffected heterozygous carriers, and controls. A consistent upregulation of ISG expression was seen in 13 monogenic conditions (455 samples, 265 patients; median IS 10.73, interquartile range (IQR) 5.90-18.41), juvenile systemic lupus erythematosus (78 samples, 55 patients; median IS 10.60, IQR 3.99-17.27), and juvenile dermatomyositis (101 samples, 59 patients; median IS 9.02, IQR 2.51-21.73) compared to controls (78 samples, 65 subjects; median IS 0.688, IQR 0.427-1.196), heterozygous mutation carriers (89 samples, 76 subjects; median IS 0.862, IQR 0.493-1.942), and individuals with non-molecularly defined autoinflammation (89 samples, 69 patients; median IS 1.07, IQR 0.491-3.74). CONCLUSIONS AND RELEVANCE: An assessment of six ISGs can be used to define a spectrum of inflammatory diseases related to enhanced type I interferon signaling. If future studies demonstrate that the IS is a reactive biomarker, this measure may prove useful both in the diagnosis and the assessment of treatment efficacy

Reverse-Transcriptase Inhibitors in the Aicardi–Goutières Syndrome

International audienceTo the Editor:The Aicardi–Goutières syndrome is a genetic encephalopathy that is associated with childhood illness and death. The syndrome is hypothesized to be due to misidentification of self-derived nucleic acids as nonself and the subsequent induction of a type I interferon–mediated response that simulates an antiviral reaction.1 Endogenous retroelements, mobile genetic elements that can be transcribed to RNA and then to DNA by reverse transcription, constitute 40% of the human genome and represent a potential source of immunostimulatory nucleic acid in patients with this syndrome.

Type I interferon-mediated autoinflammation due to DNase II deficiency

Microbial nucleic acid recognition serves as the major stimulus to an antiviral response, implying a requirement to limit the misrepresentation of self nucleic acids as non-self and the induction of autoinflammation. By systematic screening using a panel of interferon-stimulated genes we identify two siblings and a singleton variably demonstrating severe neonatal anemia, membranoproliferative glomerulonephritis, liver fibrosis, deforming arthropathy and increased anti-DNA antibodies. In both families we identify biallelic mutations in DNASE2, associated with a loss of DNase II endonuclease activity. We record increased interferon alpha protein levels using digital ELISA, enhanced interferon signaling by RNA-Seq analysis and constitutive upregulation of phosphorylated STAT1 and STAT3 in patient lymphocytes and monocytes. A hematological disease transcriptomic signature and increased numbers of erythroblasts are recorded in patient peripheral blood, suggesting that interferon might have a particular effect on hematopoiesis. These data define a type I interferonopathy due to DNase II deficiency in humans

Caractéristiques cliniques et moléculaires et approches thérapeutiques des interféronopathies de type I

Le concept d'interféronopathie de type I émerge en 2011 et fait référence à un ensemble de pathologies Mendéliennes caractérisées par une hyperactivation des interférons (IFN) de type I. Tous les gènes associés au syndrome d'Aicardi-Goutières (SAG), la première interféronopathie de type I décrite, sont impliqués dans la détection ou le métabolisme des acides nucléiques. Les autres protéines mutées associées aux interféronopathies de type I modifient toutes la voie de signalisation des acides nucléiques, de manière directe, indirecte ou encore non définie. Les IFN de type I se fixent à un récepteur unique et activent la Janus kinase 1 (JAK1) et la tyrosine kinase 2 conduisant à l'expression de gènes stimulés par les IFN (IFN-stimulated genes, ISGs) via la phosphorylation des facteurs de transcription STAT1 et STAT2. Notre équipe a développé des outils diagnostiques des interféronopathies de type I, comprenant la signature IFN, analyse combinée de l'expression de 6 ISGs, et, plus récemment, une méthode de détection de l'IFN alpha à l'aide de la technologie «single molecule array». Les mutations monogéniques associées jusqu'à présent aux interféronopathies de type I causent des phénotypes variables. Leurs points communs sont une morbidité et une mortalité importantes, notamment en raison de leur réponse faible aux immunomodulateurs classiques. Les mutations activatrices de TMEM173 codant pour STING (Stimulator of IFN genes) sont responsables d'une inflammation sévère, connue sous le nom de STING-associated vasculopathy with onset in infancy (SAVI), et caractérisée par une vascularite cutanée et une atteinte interstitielle pulmonaire conduisant à une insuffisance respiratoire terminale. STING, une protéine du réticulum endoplasmique (RE), agit comme un adaptateur cytosolique de la détection de l'ADN, permettant la synthèse d'IFN de type I via la phosphorylation d'IRF3. Une cohorte internationale de 20 patients SAVI est décrite dans cette thèse soulignant l'hétérogénéité clinique de cette maladie. Nous avons également étudié le lien entre des mutations hétérozygotes de COPA et une activation de la voie des IFN de type I. COPA code pour la sous-unité alpha du complexe du coatomère I, impliqué dans le transport rétrograde entre le RE et le Golgi. Les mutations hétérozygotes de COPA sont à l'origine d'un phénotype proche du SAVI et entraînent une hausse du stress du RE et une réponse immunitaire de type Th17. Cependant, la physiopathologie de cette maladie reste peu connue. Nous avons étudié un groupe de 8 patients qui illustre l'hétérogénéité phénotypique de cette affection nouvellement décrite. Nous avons observé des similitudes entre l'histologie pulmonaire du syndrome COPA et du SAVI, ainsi qu'une signature IFN, des taux élevés d'IFN alpha dans le sérum et une phosphorylation de STAT1 dans les lymphocytes des patients. Dans un modèle cellulaire, la coexpression de COPA muté et de STING sauvage entraîne la phosphorylation d'IRF3 et à une induction d'ISGs, suggérant que les mutations de COPA conduisent à une activation dépendante de STING de la voie des IFN de type I. Nous avons mené avec succès le premier essai clinique d'un inhibiteur de JAK1, le ruxolitinib, dans le contexte du SAVI. L'amélioration clinique remarquable a été confirmée in vitro et ex vivo. La gravité de la maladie nous a également poussé à chercher des alternatives thérapeutiques pour contrôler la voie des IFN de type I. Nous avons montré que l'inhibition d'IKK bloquait efficacement la production et la signalisation des IFN de type I dans les cellules de patients STING in vitro. Devant les résultats prometteurs de l'inhibition de JAK1 dans le SAVI, nous avons ensuite testé le ruxolitinib dans le cadre d'autres interféronopathies de type I monogéniques (COPA, TREX1) mais aussi chez une enfant ayant une dermatomyosite sévère, une maladie pour laquelle le rôle pathogénique de l'IFN de type I a été suggéré.The term 'type I interferonopathies', first coined in 2011, refers to a set of Mendelian disorders associated with constitutive up-regulation of type I interferon (IFN) signalling. All of the genes associated with Aicardi-Goutières syndrome (AGS), the first Mendelian type I interferonopathy described, have been implicated in either the processing or sensing of nucleic acids. Beyond AGS, the other mutated proteins associated with type I interferonopathies have a direct, indirect, or currently undefined action on nucleic acid signalling. Type I IFNs drive the expression of IFN-stimulated genes (ISGs) through the engagement of a common receptor and the subsequent activation of Janus kinase 1 (JAK1) and tyrosine kinase 2, and phosphorylation of STAT1 and STAT2. Our team has developed diagnostic tools to identify type I interferonopathies, comprising a so-called IFN signature, involving the assessment of mRNA expression of 6 ISGs and, more recently, a high sensitivity assay of IFN alpha protein using single molecule array technology. Monogenic mutations so far recognised as type I interferonopathies are associated with a wide spectrum of phenotype. The hallmark of these diseases is their significant morbidity and mortality, associated with an apparent absence of response to conventional immunosuppressive therapies. Activating mutations in TMEM173, encoding stimulator of IFN genes (STING), cause a severe inflammatory condition referred to as STING-associated vasculopathy with onset in infancy (SAVI), characterised by skin vasculopathy and interstitial lung disease leading to end-stage respiratory failure. The endoplasmic reticulum (ER) protein STING is a central component of DNA sensing that induces type I IFNs through phosphorylation of IRF3. An international cohort of 20 STING patients is reported in this thesis, emphasising the clinical heterogeneity of this condition. We also investigated the link between heterozygous mutations in COPA and type I IFN signalling. COPA encodes the alpha subunit of the 7 member coatomer complex I, involved in retrograde transport from the golgi to the ER. Heterozygous mutations in COPA cause a phenotype showing some overlap with SAVI, and are associated with increased ER stress and priming of a Th17 response. However, the precise pathophysiology of this disease is so far undefined. We have studied a group of 8 patients illustrating the phenotypic variability of this emerging disease. We observed commonalities in the lung pathology in COPA and SAVI, as well as an IFN signature, raised levels of IFN alpha in the serum and phosphorylation of STAT1 in patient T cells. In a cellular model, phosphorylation of IRF3 and increased ISG expression were observed in cells co-transfected with wild type STING and mutant COPA plasmids, suggesting that mutations in COPA lead to constitutive activation of type IFN signalling through STING. We reported, for the first time, the successful use of a JAK1 inhibitor, ruxolitinib, in the context of SAVI. We observed a marked clinical effect, which was mirrored by the results of in vitro and ex vivo experiments. Because of the severity of SAVI, we also aimed to evaluate alternative therapeutic approaches to block type I IFN signalling and showed that IKK inhibition efficiently abrogated in vitro constitutive activation of type I IFN production and signalling in cells from STING patients. Considering the promising results of JAK1 blockade in SAVI, we then trialled ruxolitinib in other monogenic type I interferonopathies (TREX1, COPA) and in a child with severe dermatomyositis, a disease where type I IFN has been suggested to play a key pathogenic role