Bolling, Marieke C

Cuperus, Edwin

Pasmans, Suzanne G M A

Sigurdsson, Vigfús

van den Akker, Peter C

van Gijn, Mariëlle E

English

University of Groningen

   University of GroningenDiagnostic next generation sequencing in neonatal erythrodermaCuperus, Edwin; Sigurdsson, Vigfús; van den Akker, Peter C; Bolling, Marieke C; van Gijn,Mariëlle E; Pasmans, Suzanne G M APublished in:Journal der deutschen dermatologischen gesellschaftDOI:10.1111/ddg.14298IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Cuperus, E., Sigurdsson, V., van den Akker, P. C., Bolling, M. C., van Gijn, M. E., & Pasmans, S. G. M. A.(2021). Diagnostic next generation sequencing in neonatal erythroderma. Journal der deutschendermatologischen gesellschaft, 19(4), 612-614. https://doi.org/10.1111/ddg.14298CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023Correspondence Clinical Letter1© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Dear Editors,The list of differential diagnoses of neonatal erythroderma (NE) is long. Ichthyoses, immunodeficiencies and infections are the most frequent underlying causes while metabolic dis-orders, drugs and more rare causes such as atopic dermati-tis, psoriasis and seborrheic dermatitis are the less frequent [1, 2]. Neonatal erythroderma is often accompanied by a col-lodion membrane. A correct diagnostic approach to neonatal erythroderma is difficult based on the clinical presentation alone. To our knowledge, this is the first report on the ap-plication of next generation sequencing (NGS) in a cohort of patients with NE as main inclusion criterium. This study revealed a variety of genetic diagnoses. Next generation se-quencing was proven to be particularly valuable for detecting life-threatening disorders that are difficult to clinically reco-gnize in the early stages in NE patients without a collodion.To obtain a definite genetic diagnosis in 23 patients, NGS was performed prospectively (September 1, 2014–January 1, 2018) in 15 patients at birth and retrospectively in eight patients born before September 1, 2014 in which a definite diagnosis was not present yet. The NGS panel was regularly updated during the study. The last version of the NGS panel as present on January 1, 2018 was run on patients without a genetic diagnosis earlier in the study. Non-genetic diagnoses such as infections or drug-use were less plausible based on history, laboratory results and clinical characteristics. Infor-med consent was obtained from parents of the patients along with approval of the medical ethics committee.A targeted NGS panel of 60 genes associated with neo-natal erythroderma and collodion membrane was used (see Table S1 in the online supplement), based on extensive lite-rature search. The gene panel comprised uniquely mapped coding regions of 60 genes from the built genome GRCh37/hg19 (www.ncbi.nlm.nih.gov/assembly/2758) as well as 50 bp flanks into intronic regions. The DNA was enriched using the SureSelect XT Target or Human All Exon v5 kit (Agilent Technologies B. V. Netherlands) and sequenced using the HiSeq2500 system on rapid run mode (Illumina, Netherlands) at a mean target depth of 100x. The reads were aligned to hg19 using BWA (BWA-MEM v0.7.5a); variants were called using the GATK haplotype caller (v2.7-2). The correlation between the diagnosis and clinical presentation (erythroderma or collodion) was calculated using the odds ratio and chi-squared tests.A genetic diagnosis was found in 70 % of the cases (16/23) (Table 1); 60 % in the prospective cohorts (9/15) and 88 % (7/8) in the retrospective cohorts, respectively. A col-lodion membrane was present in 14/23 patients (61 %) of which 12 (86 %) had an underlying type of ichthyosis. Muta-tions linked to ichthyoses were found in the genes: TGM 1 (4/14), ALOX12B (3/14), PNPLA1, ABCA12, ALOXE3, KRT10 and ALDH3A2 [1/14 each]. In two collodion pati-ents, no definite genetic diagnosis could be made; variants of unknown significance (VUS) were found in BTD and ALO-X12B, which were unlikely to have contributed to the clini-cal presentation. In patients without a collodion membrane, an underlying diagnosis was made in 67 % of cases (6/9), with an underlying type of ichthyosis in 44 % (4/9). In two patients, mutations were found in IL36RN and SPINK5, defining: Deficiency of Interleukin-36 Receptor Antagonist (DITRA) and Netherton syndrome, respectively. In two pa-tients, no pathogenic mutations could be found, and in one patient, a VUS in C5 was found, which was unlikely to have contributed to the clinical presentation.The obtained diagnostic yield of 60 % in the prospecti-ve group was higher compared to, for instance, NGS panels for other heterogeneous entities like primary immunodefi-ciencies (33–48 %) [3], hereditary anemias (45.8 %) [4] and monogenic liver diseases (17 %) [5]. This confirms the strong genetic etiology of neonatal erythroderma. Along with the genetic heterogeneity this demonstrates the relevance of per-forming NGS for NE.Additionally, our results confirm that a form of ichthyo-sis is the most likely diagnosis in cases of NE accompanied by a collodion. In contrast, in patients without a collodion membrane, other diagnoses are more likely (OR 6, chi-squa-red: 0.03). In the patient with DITRA, the diagnosis resulted in a significant therapeutic change later on [6]. Since results are limited to a Dutch population, genetic differences are possible in other populations [7, 8]. A limitation in this study relates to the use of a targeted NGS panel: since causal genes, such as SULT2B1, were not known as related to ichthyosis and thus not included during the study, a higher yield in di-agnostic outcome in our study population could have been achieved if open exome (WES; Whole Exome Sequencing) analysis had been performed. On the other hand, the patients lacking a genetic diagnosis might not have had a genetic basis for their NE.In conclusion, this study underscores the relevance of the use of NGS to establish a diagnosis for patients with NE. In the absence of a collodion membrane, causes other than the relatively non-life-threatening ichthyoses, such as DOI: 10.1111/ddg.14298Diagnostic next generation sequencing in neonatal erythroderma Clinical LetterThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.2 © 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical LetterTable 1 Next generation sequencing outcome of (likely) pathogenic mutations in nine prospective (1–9) and eight retrospective (10–17) patients with neonatal erythroderma.PatientCollodionGeneVariant descriptionProteinStatus of mutationType of mutationClinical significance*Diagnosis (inheritance)1YesABCA12NM_173076: c.6091T>Gp.Trp2031GlyHomMissenseLikely pathogenicHI (AR)2YesALOX12BNM_001139.3: c.1463G>Ap.Arg488HisHomMissensePathogenicSHCB (AR)3YesALOX12BNM_001139: c.1642C>TNM_001139: c.1349G>Ap.Arg548Trpp.Gly450GluHetHetMissenseMissensePathogenicVUSLI* (AR)4YesALOX12BNM_001139: c..467_470dupNM_001139: c. 1562A>Gp.His158fsp.Tyr521CysHetHetFrameshiftMissensePathogenicPathogenicARCI (AR)5NoALOXE3NM_001165960.1: c.2285C>Tp.Pro762LeuHomMissensePathogenicARCI (AR)6YesPNPLA1NM_173676.2: c.488C>Tp.Pro163LeuHomMissensePathogenicARCI (AR)7YesTGM1NM_00359.3: c.877-2A>Gp.(?); (?)HomSplice sitePathogenicARCI (AR)8YesTGM1NM_00359.3: c.968G>Ap.Arg323GlnHomMissenseLikely pathogenicSHCB (AR)9YesTGM1NM_00359.3: c.857G>A; 857G>Ap.Arg286GlnHomMissenseLikely pathogenicSHCB (AR)10NoABCA12NM_173076: c.6440dupNM_173076.2: c.3180-6T>Gp.Gln2149fsp.(?)HetHetFrameshiftSplice sitePathogenicVUSARCI* (AR)11YesALDH3A2NM_000382.3: c.1297_1298delp.Glu433fsHomFrameshiftPathogenicSLS (AR)12YesALOXE3NM_001165960.1: c.1642T>CNM_001165960.1: c.2285C>Tp.Cys548Argp.Pro762LeuHetHetMissenseMissenseLikely pathogenicPathogenicARCI (AR)13NoIL36RNNM_173170.1: c.80T>Cp.Leu27ProHomMissensePathogenicDITRA (AR)14YesKRT10NM_000421.3: c.1468_1473delinsAGTTCCGp.Gly490fsHetFrameshiftLikely pathogenicIchthyosis with confetti (AD)15NoSPINK5NM_006846.3: c.649C>TNM_006846.3: c.724G>Tp.Arg217*p.Glu242*HetHetNonsenseNonsenseLikely PathogenicNS (AR)16YesTGM1NM_00359.3: c.1472C>Tp.Thr491MetHetMissensePathogenicLI* (AR)17NoDSG1NM_001942.2: c.382C>Tp. Arg128*HetNonsensePathogenicSAM* (AR)Abbr.: AD, autosomal dominant; AR, autosomal recessive; ARCI, autosomal recessive congenital ichthyosis; DITRA, deficiency of interleukin receptor-36 antagonist; Het, Heterozygous; HI, Harlequin ichthyosis; Hom, Homozygous; LI, Lamellar ichthyosis; N/A, Not Available; NGS, Next Generation Sequencing; NS, Netherton syndrome; SAM, severe dermatitis, atopic diathesis and metabolic syndrome; SHCB, self-healing collodion baby; SLS, Sjögren-Larsson syndrome.*According to AMCG guidelines 2015 [10]; **Clinically conform diagnosis; ***No genetic diagnosis; ****2nd  mutation (large deletion) was detected elsewhere, but not with current NGS method.3© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical Letterimmunodeficiencies, metabolic disorders or DITRA, are pos-sible. In newborns, these might be detected through genetic evaluations at an earlier stage than onset of clinical signs. Immunodeficiencies such as Omenn syndrome can be present with congenital erythroderma but without typical associated systemic symptoms such as a failure to thrive, infections and fever [9]. These life-threating conditions require immediate and adequate therapy, which can be facilitated by rapid NGS diagnostics. This is now feasible for newborns with NE.AcknowledgmentsThe authors thank all parents who gave informed consent for their children. The authors acknowledge all physicians, dermatologists and pediatricians for their efforts and con-tributions to this study in The Netherlands. This study is part of the Academic Centers of Excellence of Congenital Anatomical Abnormalities and Primary Immunodeficiency Center of the Erasmus MC University Medical Center-So-phia Children’s Hospital and of European Reference Net-work-SKIN-Ichthyosis. The authors are indebted to M. van Geel, MD, PhD, clinical geneticist, Maastricht University Medical Center, the Netherlands, for his contribution in SAM syndrome.FundingThe study was funded by Fonds NutsOhra and Stichting Coolsingel.Conflict of interestNone.Edwin Cuperus1,2, Vigfús Sigurdsson3, Peter C. van den Akker4, Marieke C. Bolling5, Mariëlle E. van Gijn4,6,*, Suzanne G. M. A. Pasmans1(1) Department of Dermatology, Center of Pediatric Dermatology, Erasmus MC University Medical Center Rotterdam-Sophia Children’s Hospital, Rotterdam, The Netherlands(2) Department of Dermatology, St Jansdal Hospital, Harderwijk, The Netherlands(3) Department of Dermatology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands(4) Department of Genetics, University Medical Center, University of Groningen, Groningen, The Netherlands(5) Department of Dermatology, University Medical Center, University of Groningen, Groningen, The Netherlands(6) Department of Genetics, University Medical Center Utrecht and Wilhelmina’s Children Hospital Utrecht, Utrecht, The Netherlands*The last two authors contributed equally to the present article.Correspondence toSuzanne G. M. A. Pasmans, MD, PhDDepartment of DermatologyErasmus MC-Sophia Children’s HospitalUniversity Medical Centre RotterdamWytemaweg 803015 CN Rotterdam, The NetherlandsE-mail: s.pasmans@erasmusmc.nlReferences1 Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Im-munol 2019; 30(3): 259–68.2 Pruzskowski A, Bodemer C, Fraitag S et al. Neonatal and infan-tile erythrodermas. A retrospective study of 51 patients. Arch Dermatol 2000; 136: 875–80.3 Rae W, Ward D, Mattocks C et al. Clinical efficacy of a next-generation sequencing gene panel for primary immunodefi-ciency diagnostics. Clin Genet 2018; 93(3): 647–55.4 Russo R, Andolfo I, Manna F et al. Multi-gene panel testing im-proves diagnosis and management of patients with hereditary anemias. Am J Hematol 2018; 93(5): 672–82.5 Stalke A, Skawran B, Auber B et al. Diagnosis of monogenic liver diseases in childhood by next-generation sequencing. Clin Genet 2018; 93(3): 665–70.6 Cuperus E, Koevoets R, van der Smagt JJ et al. Juvenile inter-leukin-36 receptor antagonist deficiency (DITRA) with c.80T>C (p.Leu27Pro) mutation successfully treated with etanercept and acitretin. JAAD Case Rep 2018; 4(2): 192–5.7 El-Sayed N, Seifeldin NS, Gobrial CKT. High frequency of pri-mary hereditary icthyoses in the North-East region of Cairo, Egypt. Postepy Dermatol Alergol 2018; 35(2): 161–6.8 Youssefian L, Vahidnezhad H, Saeidian AH et al. Autosomal recessive congenital ichthyosis: Genomic landscape and phe-notypic spectrum in a cohort of 125 consanguineous families. Human Mutation 2019; 40: 288–98.9 Cuperus E, van Montfrans JM, van Gijn ME et al. Congenital erythroderma should be considered as an urgent warning sign of immunodeficiency: a case of Omenn syndrome. Eur J Dermatol 2017; 27(3): 313–4.10 Richards S, Aziz N, Bale S et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med 2015; 17(5): 405–24.

Diagnostic next generation sequencing in neonatal erythroderma

Dissertations of the University of Groningen

   University of GroningenDiagnostic next generation sequencing in neonatal erythrodermaCuperus, Edwin; Sigurdsson, Vigfús; van den Akker, Peter C; Bolling, Marieke C; van Gijn,Mariëlle E; Pasmans, Suzanne G M APublished in:Journal der deutschen dermatologischen gesellschaftDOI:10.1111/ddg.14298IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Cuperus, E., Sigurdsson, V., van den Akker, P. C., Bolling, M. C., van Gijn, M. E., & Pasmans, S. G. M. A.(2021). Diagnostic next generation sequencing in neonatal erythroderma. Journal der deutschendermatologischen gesellschaft, 19(4), 612-614. Advance online publication.https://doi.org/10.1111/ddg.14298CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 10-09-2023Correspondence Clinical Letter1© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Dear Editors,The list of differential diagnoses of neonatal erythroderma (NE) is long. Ichthyoses, immunodeficiencies and infections are the most frequent underlying causes while metabolic dis-orders, drugs and more rare causes such as atopic dermati-tis, psoriasis and seborrheic dermatitis are the less frequent [1, 2]. Neonatal erythroderma is often accompanied by a col-lodion membrane. A correct diagnostic approach to neonatal erythroderma is difficult based on the clinical presentation alone. To our knowledge, this is the first report on the ap-plication of next generation sequencing (NGS) in a cohort of patients with NE as main inclusion criterium. This study revealed a variety of genetic diagnoses. Next generation se-quencing was proven to be particularly valuable for detecting life-threatening disorders that are difficult to clinically reco-gnize in the early stages in NE patients without a collodion.To obtain a definite genetic diagnosis in 23 patients, NGS was performed prospectively (September 1, 2014–January 1, 2018) in 15 patients at birth and retrospectively in eight patients born before September 1, 2014 in which a definite diagnosis was not present yet. The NGS panel was regularly updated during the study. The last version of the NGS panel as present on January 1, 2018 was run on patients without a genetic diagnosis earlier in the study. Non-genetic diagnoses such as infections or drug-use were less plausible based on history, laboratory results and clinical characteristics. Infor-med consent was obtained from parents of the patients along with approval of the medical ethics committee.A targeted NGS panel of 60 genes associated with neo-natal erythroderma and collodion membrane was used (see Table S1 in the online supplement), based on extensive lite-rature search. The gene panel comprised uniquely mapped coding regions of 60 genes from the built genome GRCh37/hg19 (www.ncbi.nlm.nih.gov/assembly/2758) as well as 50 bp flanks into intronic regions. The DNA was enriched using the SureSelect XT Target or Human All Exon v5 kit (Agilent Technologies B. V. Netherlands) and sequenced using the HiSeq2500 system on rapid run mode (Illumina, Netherlands) at a mean target depth of 100x. The reads were aligned to hg19 using BWA (BWA-MEM v0.7.5a); variants were called using the GATK haplotype caller (v2.7-2). The correlation between the diagnosis and clinical presentation (erythroderma or collodion) was calculated using the odds ratio and chi-squared tests.A genetic diagnosis was found in 70 % of the cases (16/23) (Table 1); 60 % in the prospective cohorts (9/15) and 88 % (7/8) in the retrospective cohorts, respectively. A col-lodion membrane was present in 14/23 patients (61 %) of which 12 (86 %) had an underlying type of ichthyosis. Muta-tions linked to ichthyoses were found in the genes: TGM 1 (4/14), ALOX12B (3/14), PNPLA1, ABCA12, ALOXE3, KRT10 and ALDH3A2 [1/14 each]. In two collodion pati-ents, no definite genetic diagnosis could be made; variants of unknown significance (VUS) were found in BTD and ALO-X12B, which were unlikely to have contributed to the clini-cal presentation. In patients without a collodion membrane, an underlying diagnosis was made in 67 % of cases (6/9), with an underlying type of ichthyosis in 44 % (4/9). In two patients, mutations were found in IL36RN and SPINK5, defining: Deficiency of Interleukin-36 Receptor Antagonist (DITRA) and Netherton syndrome, respectively. In two pa-tients, no pathogenic mutations could be found, and in one patient, a VUS in C5 was found, which was unlikely to have contributed to the clinical presentation.The obtained diagnostic yield of 60 % in the prospecti-ve group was higher compared to, for instance, NGS panels for other heterogeneous entities like primary immunodefi-ciencies (33–48 %) [3], hereditary anemias (45.8 %) [4] and monogenic liver diseases (17 %) [5]. This confirms the strong genetic etiology of neonatal erythroderma. Along with the genetic heterogeneity this demonstrates the relevance of per-forming NGS for NE.Additionally, our results confirm that a form of ichthyo-sis is the most likely diagnosis in cases of NE accompanied by a collodion. In contrast, in patients without a collodion membrane, other diagnoses are more likely (OR 6, chi-squa-red: 0.03). In the patient with DITRA, the diagnosis resulted in a significant therapeutic change later on [6]. Since results are limited to a Dutch population, genetic differences are possible in other populations [7, 8]. A limitation in this study relates to the use of a targeted NGS panel: since causal genes, such as SULT2B1, were not known as related to ichthyosis and thus not included during the study, a higher yield in di-agnostic outcome in our study population could have been achieved if open exome (WES; Whole Exome Sequencing) analysis had been performed. On the other hand, the patients lacking a genetic diagnosis might not have had a genetic basis for their NE.In conclusion, this study underscores the relevance of the use of NGS to establish a diagnosis for patients with NE. In the absence of a collodion membrane, causes other than the relatively non-life-threatening ichthyoses, such as DOI: 10.1111/ddg.14298Diagnostic next generation sequencing in neonatal erythroderma Clinical LetterThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.2 © 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical LetterTable 1 Next generation sequencing outcome of (likely) pathogenic mutations in nine prospective (1–9) and eight retrospective (10–17) patients with neonatal erythroderma.PatientCollodionGeneVariant descriptionProteinStatus of mutationType of mutationClinical significance*Diagnosis (inheritance)1YesABCA12NM_173076: c.6091T>Gp.Trp2031GlyHomMissenseLikely pathogenicHI (AR)2YesALOX12BNM_001139.3: c.1463G>Ap.Arg488HisHomMissensePathogenicSHCB (AR)3YesALOX12BNM_001139: c.1642C>TNM_001139: c.1349G>Ap.Arg548Trpp.Gly450GluHetHetMissenseMissensePathogenicVUSLI* (AR)4YesALOX12BNM_001139: c..467_470dupNM_001139: c. 1562A>Gp.His158fsp.Tyr521CysHetHetFrameshiftMissensePathogenicPathogenicARCI (AR)5NoALOXE3NM_001165960.1: c.2285C>Tp.Pro762LeuHomMissensePathogenicARCI (AR)6YesPNPLA1NM_173676.2: c.488C>Tp.Pro163LeuHomMissensePathogenicARCI (AR)7YesTGM1NM_00359.3: c.877-2A>Gp.(?); (?)HomSplice sitePathogenicARCI (AR)8YesTGM1NM_00359.3: c.968G>Ap.Arg323GlnHomMissenseLikely pathogenicSHCB (AR)9YesTGM1NM_00359.3: c.857G>A; 857G>Ap.Arg286GlnHomMissenseLikely pathogenicSHCB (AR)10NoABCA12NM_173076: c.6440dupNM_173076.2: c.3180-6T>Gp.Gln2149fsp.(?)HetHetFrameshiftSplice sitePathogenicVUSARCI* (AR)11YesALDH3A2NM_000382.3: c.1297_1298delp.Glu433fsHomFrameshiftPathogenicSLS (AR)12YesALOXE3NM_001165960.1: c.1642T>CNM_001165960.1: c.2285C>Tp.Cys548Argp.Pro762LeuHetHetMissenseMissenseLikely pathogenicPathogenicARCI (AR)13NoIL36RNNM_173170.1: c.80T>Cp.Leu27ProHomMissensePathogenicDITRA (AR)14YesKRT10NM_000421.3: c.1468_1473delinsAGTTCCGp.Gly490fsHetFrameshiftLikely pathogenicIchthyosis with confetti (AD)15NoSPINK5NM_006846.3: c.649C>TNM_006846.3: c.724G>Tp.Arg217*p.Glu242*HetHetNonsenseNonsenseLikely PathogenicNS (AR)16YesTGM1NM_00359.3: c.1472C>Tp.Thr491MetHetMissensePathogenicLI* (AR)17NoDSG1NM_001942.2: c.382C>Tp. Arg128*HetNonsensePathogenicSAM* (AR)Abbr.: AD, autosomal dominant; AR, autosomal recessive; ARCI, autosomal recessive congenital ichthyosis; DITRA, deficiency of interleukin receptor-36 antagonist; Het, Heterozygous; HI, Harlequin ichthyosis; Hom, Homozygous; LI, Lamellar ichthyosis; N/A, Not Available; NGS, Next Generation Sequencing; NS, Netherton syndrome; SAM, severe dermatitis, atopic diathesis and metabolic syndrome; SHCB, self-healing collodion baby; SLS, Sjögren-Larsson syndrome.*According to AMCG guidelines 2015 [10]; **Clinically conform diagnosis; ***No genetic diagnosis; ****2nd  mutation (large deletion) was detected elsewhere, but not with current NGS method.3© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical Letterimmunodeficiencies, metabolic disorders or DITRA, are pos-sible. In newborns, these might be detected through genetic evaluations at an earlier stage than onset of clinical signs. Immunodeficiencies such as Omenn syndrome can be present with congenital erythroderma but without typical associated systemic symptoms such as a failure to thrive, infections and fever [9]. These life-threating conditions require immediate and adequate therapy, which can be facilitated by rapid NGS diagnostics. This is now feasible for newborns with NE.AcknowledgmentsThe authors thank all parents who gave informed consent for their children. The authors acknowledge all physicians, dermatologists and pediatricians for their efforts and con-tributions to this study in The Netherlands. This study is part of the Academic Centers of Excellence of Congenital Anatomical Abnormalities and Primary Immunodeficiency Center of the Erasmus MC University Medical Center-So-phia Children’s Hospital and of European Reference Net-work-SKIN-Ichthyosis. The authors are indebted to M. van Geel, MD, PhD, clinical geneticist, Maastricht University Medical Center, the Netherlands, for his contribution in SAM syndrome.FundingThe study was funded by Fonds NutsOhra and Stichting Coolsingel.Conflict of interestNone.Edwin Cuperus1,2, Vigfús Sigurdsson3, Peter C. van den Akker4, Marieke C. Bolling5, Mariëlle E. van Gijn4,6,*, Suzanne G. M. A. Pasmans1(1) Department of Dermatology, Center of Pediatric Dermatology, Erasmus MC University Medical Center Rotterdam-Sophia Children’s Hospital, Rotterdam, The Netherlands(2) Department of Dermatology, St Jansdal Hospital, Harderwijk, The Netherlands(3) Department of Dermatology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands(4) Department of Genetics, University Medical Center, University of Groningen, Groningen, The Netherlands(5) Department of Dermatology, University Medical Center, University of Groningen, Groningen, The Netherlands(6) Department of Genetics, University Medical Center Utrecht and Wilhelmina’s Children Hospital Utrecht, Utrecht, The Netherlands*The last two authors contributed equally to the present article.Correspondence toSuzanne G. M. A. Pasmans, MD, PhDDepartment of DermatologyErasmus MC-Sophia Children’s HospitalUniversity Medical Centre RotterdamWytemaweg 803015 CN Rotterdam, The NetherlandsE-mail: s.pasmans@erasmusmc.nlReferences1 Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Im-munol 2019; 30(3): 259–68.2 Pruzskowski A, Bodemer C, Fraitag S et al. Neonatal and infan-tile erythrodermas. A retrospective study of 51 patients. Arch Dermatol 2000; 136: 875–80.3 Rae W, Ward D, Mattocks C et al. Clinical efficacy of a next-generation sequencing gene panel for primary immunodefi-ciency diagnostics. Clin Genet 2018; 93(3): 647–55.4 Russo R, Andolfo I, Manna F et al. Multi-gene panel testing im-proves diagnosis and management of patients with hereditary anemias. Am J Hematol 2018; 93(5): 672–82.5 Stalke A, Skawran B, Auber B et al. Diagnosis of monogenic liver diseases in childhood by next-generation sequencing. Clin Genet 2018; 93(3): 665–70.6 Cuperus E, Koevoets R, van der Smagt JJ et al. Juvenile inter-leukin-36 receptor antagonist deficiency (DITRA) with c.80T>C (p.Leu27Pro) mutation successfully treated with etanercept and acitretin. JAAD Case Rep 2018; 4(2): 192–5.7 El-Sayed N, Seifeldin NS, Gobrial CKT. High frequency of pri-mary hereditary icthyoses in the North-East region of Cairo, Egypt. Postepy Dermatol Alergol 2018; 35(2): 161–6.8 Youssefian L, Vahidnezhad H, Saeidian AH et al. Autosomal recessive congenital ichthyosis: Genomic landscape and phe-notypic spectrum in a cohort of 125 consanguineous families. Human Mutation 2019; 40: 288–98.9 Cuperus E, van Montfrans JM, van Gijn ME et al. Congenital erythroderma should be considered as an urgent warning sign of immunodeficiency: a case of Omenn syndrome. Eur J Dermatol 2017; 27(3): 313–4.10 Richards S, Aziz N, Bale S et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med 2015; 17(5): 405–24.

Proceedings - University of Groningen

   University of GroningenDiagnostic next generation sequencing in neonatal erythrodermaCuperus, Edwin; Sigurdsson, Vigfús; van den Akker, Peter C; Bolling, Marieke C; van Gijn,Mariëlle E; Pasmans, Suzanne G M APublished in:Journal der deutschen dermatologischen gesellschaftDOI:10.1111/ddg.14298IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Cuperus, E., Sigurdsson, V., van den Akker, P. C., Bolling, M. C., van Gijn, M. E., & Pasmans, S. G. M. A.(2021). Diagnostic next generation sequencing in neonatal erythroderma. Journal der deutschendermatologischen gesellschaft, 19(4), 612-614. https://doi.org/10.1111/ddg.14298CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 19-11-2022Correspondence Clinical Letter1© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Dear Editors,The list of differential diagnoses of neonatal erythroderma (NE) is long. Ichthyoses, immunodeficiencies and infections are the most frequent underlying causes while metabolic dis-orders, drugs and more rare causes such as atopic dermati-tis, psoriasis and seborrheic dermatitis are the less frequent [1, 2]. Neonatal erythroderma is often accompanied by a col-lodion membrane. A correct diagnostic approach to neonatal erythroderma is difficult based on the clinical presentation alone. To our knowledge, this is the first report on the ap-plication of next generation sequencing (NGS) in a cohort of patients with NE as main inclusion criterium. This study revealed a variety of genetic diagnoses. Next generation se-quencing was proven to be particularly valuable for detecting life-threatening disorders that are difficult to clinically reco-gnize in the early stages in NE patients without a collodion.To obtain a definite genetic diagnosis in 23 patients, NGS was performed prospectively (September 1, 2014–January 1, 2018) in 15 patients at birth and retrospectively in eight patients born before September 1, 2014 in which a definite diagnosis was not present yet. The NGS panel was regularly updated during the study. The last version of the NGS panel as present on January 1, 2018 was run on patients without a genetic diagnosis earlier in the study. Non-genetic diagnoses such as infections or drug-use were less plausible based on history, laboratory results and clinical characteristics. Infor-med consent was obtained from parents of the patients along with approval of the medical ethics committee.A targeted NGS panel of 60 genes associated with neo-natal erythroderma and collodion membrane was used (see Table S1 in the online supplement), based on extensive lite-rature search. The gene panel comprised uniquely mapped coding regions of 60 genes from the built genome GRCh37/hg19 (www.ncbi.nlm.nih.gov/assembly/2758) as well as 50 bp flanks into intronic regions. The DNA was enriched using the SureSelect XT Target or Human All Exon v5 kit (Agilent Technologies B. V. Netherlands) and sequenced using the HiSeq2500 system on rapid run mode (Illumina, Netherlands) at a mean target depth of 100x. The reads were aligned to hg19 using BWA (BWA-MEM v0.7.5a); variants were called using the GATK haplotype caller (v2.7-2). The correlation between the diagnosis and clinical presentation (erythroderma or collodion) was calculated using the odds ratio and chi-squared tests.A genetic diagnosis was found in 70 % of the cases (16/23) (Table 1); 60 % in the prospective cohorts (9/15) and 88 % (7/8) in the retrospective cohorts, respectively. A col-lodion membrane was present in 14/23 patients (61 %) of which 12 (86 %) had an underlying type of ichthyosis. Muta-tions linked to ichthyoses were found in the genes: TGM 1 (4/14), ALOX12B (3/14), PNPLA1, ABCA12, ALOXE3, KRT10 and ALDH3A2 [1/14 each]. In two collodion pati-ents, no definite genetic diagnosis could be made; variants of unknown significance (VUS) were found in BTD and ALO-X12B, which were unlikely to have contributed to the clini-cal presentation. In patients without a collodion membrane, an underlying diagnosis was made in 67 % of cases (6/9), with an underlying type of ichthyosis in 44 % (4/9). In two patients, mutations were found in IL36RN and SPINK5, defining: Deficiency of Interleukin-36 Receptor Antagonist (DITRA) and Netherton syndrome, respectively. In two pa-tients, no pathogenic mutations could be found, and in one patient, a VUS in C5 was found, which was unlikely to have contributed to the clinical presentation.The obtained diagnostic yield of 60 % in the prospecti-ve group was higher compared to, for instance, NGS panels for other heterogeneous entities like primary immunodefi-ciencies (33–48 %) [3], hereditary anemias (45.8 %) [4] and monogenic liver diseases (17 %) [5]. This confirms the strong genetic etiology of neonatal erythroderma. Along with the genetic heterogeneity this demonstrates the relevance of per-forming NGS for NE.Additionally, our results confirm that a form of ichthyo-sis is the most likely diagnosis in cases of NE accompanied by a collodion. In contrast, in patients without a collodion membrane, other diagnoses are more likely (OR 6, chi-squa-red: 0.03). In the patient with DITRA, the diagnosis resulted in a significant therapeutic change later on [6]. Since results are limited to a Dutch population, genetic differences are possible in other populations [7, 8]. A limitation in this study relates to the use of a targeted NGS panel: since causal genes, such as SULT2B1, were not known as related to ichthyosis and thus not included during the study, a higher yield in di-agnostic outcome in our study population could have been achieved if open exome (WES; Whole Exome Sequencing) analysis had been performed. On the other hand, the patients lacking a genetic diagnosis might not have had a genetic basis for their NE.In conclusion, this study underscores the relevance of the use of NGS to establish a diagnosis for patients with NE. In the absence of a collodion membrane, causes other than the relatively non-life-threatening ichthyoses, such as DOI: 10.1111/ddg.14298Diagnostic next generation sequencing in neonatal erythroderma Clinical LetterThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.2 © 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical LetterTable 1 Next generation sequencing outcome of (likely) pathogenic mutations in nine prospective (1–9) and eight retrospective (10–17) patients with neonatal erythroderma.PatientCollodionGeneVariant descriptionProteinStatus of mutationType of mutationClinical significance*Diagnosis (inheritance)1YesABCA12NM_173076: c.6091T>Gp.Trp2031GlyHomMissenseLikely pathogenicHI (AR)2YesALOX12BNM_001139.3: c.1463G>Ap.Arg488HisHomMissensePathogenicSHCB (AR)3YesALOX12BNM_001139: c.1642C>TNM_001139: c.1349G>Ap.Arg548Trpp.Gly450GluHetHetMissenseMissensePathogenicVUSLI* (AR)4YesALOX12BNM_001139: c..467_470dupNM_001139: c. 1562A>Gp.His158fsp.Tyr521CysHetHetFrameshiftMissensePathogenicPathogenicARCI (AR)5NoALOXE3NM_001165960.1: c.2285C>Tp.Pro762LeuHomMissensePathogenicARCI (AR)6YesPNPLA1NM_173676.2: c.488C>Tp.Pro163LeuHomMissensePathogenicARCI (AR)7YesTGM1NM_00359.3: c.877-2A>Gp.(?); (?)HomSplice sitePathogenicARCI (AR)8YesTGM1NM_00359.3: c.968G>Ap.Arg323GlnHomMissenseLikely pathogenicSHCB (AR)9YesTGM1NM_00359.3: c.857G>A; 857G>Ap.Arg286GlnHomMissenseLikely pathogenicSHCB (AR)10NoABCA12NM_173076: c.6440dupNM_173076.2: c.3180-6T>Gp.Gln2149fsp.(?)HetHetFrameshiftSplice sitePathogenicVUSARCI* (AR)11YesALDH3A2NM_000382.3: c.1297_1298delp.Glu433fsHomFrameshiftPathogenicSLS (AR)12YesALOXE3NM_001165960.1: c.1642T>CNM_001165960.1: c.2285C>Tp.Cys548Argp.Pro762LeuHetHetMissenseMissenseLikely pathogenicPathogenicARCI (AR)13NoIL36RNNM_173170.1: c.80T>Cp.Leu27ProHomMissensePathogenicDITRA (AR)14YesKRT10NM_000421.3: c.1468_1473delinsAGTTCCGp.Gly490fsHetFrameshiftLikely pathogenicIchthyosis with confetti (AD)15NoSPINK5NM_006846.3: c.649C>TNM_006846.3: c.724G>Tp.Arg217*p.Glu242*HetHetNonsenseNonsenseLikely PathogenicNS (AR)16YesTGM1NM_00359.3: c.1472C>Tp.Thr491MetHetMissensePathogenicLI* (AR)17NoDSG1NM_001942.2: c.382C>Tp. Arg128*HetNonsensePathogenicSAM* (AR)Abbr.: AD, autosomal dominant; AR, autosomal recessive; ARCI, autosomal recessive congenital ichthyosis; DITRA, deficiency of interleukin receptor-36 antagonist; Het, Heterozygous; HI, Harlequin ichthyosis; Hom, Homozygous; LI, Lamellar ichthyosis; N/A, Not Available; NGS, Next Generation Sequencing; NS, Netherton syndrome; SAM, severe dermatitis, atopic diathesis and metabolic syndrome; SHCB, self-healing collodion baby; SLS, Sjögren-Larsson syndrome.*According to AMCG guidelines 2015 [10]; **Clinically conform diagnosis; ***No genetic diagnosis; ****2nd  mutation (large deletion) was detected elsewhere, but not with current NGS method.3© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical Letterimmunodeficiencies, metabolic disorders or DITRA, are pos-sible. In newborns, these might be detected through genetic evaluations at an earlier stage than onset of clinical signs. Immunodeficiencies such as Omenn syndrome can be present with congenital erythroderma but without typical associated systemic symptoms such as a failure to thrive, infections and fever [9]. These life-threating conditions require immediate and adequate therapy, which can be facilitated by rapid NGS diagnostics. This is now feasible for newborns with NE.AcknowledgmentsThe authors thank all parents who gave informed consent for their children. The authors acknowledge all physicians, dermatologists and pediatricians for their efforts and con-tributions to this study in The Netherlands. This study is part of the Academic Centers of Excellence of Congenital Anatomical Abnormalities and Primary Immunodeficiency Center of the Erasmus MC University Medical Center-So-phia Children’s Hospital and of European Reference Net-work-SKIN-Ichthyosis. The authors are indebted to M. van Geel, MD, PhD, clinical geneticist, Maastricht University Medical Center, the Netherlands, for his contribution in SAM syndrome.FundingThe study was funded by Fonds NutsOhra and Stichting Coolsingel.Conflict of interestNone.Edwin Cuperus1,2, Vigfús Sigurdsson3, Peter C. van den Akker4, Marieke C. Bolling5, Mariëlle E. van Gijn4,6,*, Suzanne G. M. A. Pasmans1(1) Department of Dermatology, Center of Pediatric Dermatology, Erasmus MC University Medical Center Rotterdam-Sophia Children’s Hospital, Rotterdam, The Netherlands(2) Department of Dermatology, St Jansdal Hospital, Harderwijk, The Netherlands(3) Department of Dermatology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands(4) Department of Genetics, University Medical Center, University of Groningen, Groningen, The Netherlands(5) Department of Dermatology, University Medical Center, University of Groningen, Groningen, The Netherlands(6) Department of Genetics, University Medical Center Utrecht and Wilhelmina’s Children Hospital Utrecht, Utrecht, The Netherlands*The last two authors contributed equally to the present article.Correspondence toSuzanne G. M. A. Pasmans, MD, PhDDepartment of DermatologyErasmus MC-Sophia Children’s HospitalUniversity Medical Centre RotterdamWytemaweg 803015 CN Rotterdam, The NetherlandsE-mail: s.pasmans@erasmusmc.nlReferences1 Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Im-munol 2019; 30(3): 259–68.2 Pruzskowski A, Bodemer C, Fraitag S et al. Neonatal and infan-tile erythrodermas. A retrospective study of 51 patients. Arch Dermatol 2000; 136: 875–80.3 Rae W, Ward D, Mattocks C et al. Clinical efficacy of a next-generation sequencing gene panel for primary immunodefi-ciency diagnostics. Clin Genet 2018; 93(3): 647–55.4 Russo R, Andolfo I, Manna F et al. Multi-gene panel testing im-proves diagnosis and management of patients with hereditary anemias. Am J Hematol 2018; 93(5): 672–82.5 Stalke A, Skawran B, Auber B et al. Diagnosis of monogenic liver diseases in childhood by next-generation sequencing. Clin Genet 2018; 93(3): 665–70.6 Cuperus E, Koevoets R, van der Smagt JJ et al. Juvenile inter-leukin-36 receptor antagonist deficiency (DITRA) with c.80T>C (p.Leu27Pro) mutation successfully treated with etanercept and acitretin. JAAD Case Rep 2018; 4(2): 192–5.7 El-Sayed N, Seifeldin NS, Gobrial CKT. High frequency of pri-mary hereditary icthyoses in the North-East region of Cairo, Egypt. Postepy Dermatol Alergol 2018; 35(2): 161–6.8 Youssefian L, Vahidnezhad H, Saeidian AH et al. Autosomal recessive congenital ichthyosis: Genomic landscape and phe-notypic spectrum in a cohort of 125 consanguineous families. Human Mutation 2019; 40: 288–98.9 Cuperus E, van Montfrans JM, van Gijn ME et al. Congenital erythroderma should be considered as an urgent warning sign of immunodeficiency: a case of Omenn syndrome. Eur J Dermatol 2017; 27(3): 313–4.10 Richards S, Aziz N, Bale S et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med 2015; 17(5): 405–24.

ARTS repository - University of Groningen

   University of GroningenDiagnostic next generation sequencing in neonatal erythrodermaCuperus, Edwin; Sigurdsson, Vigfús; van den Akker, Peter C; Bolling, Marieke C; van Gijn,Mariëlle E; Pasmans, Suzanne G M APublished in:Journal der deutschen dermatologischen gesellschaftDOI:10.1111/ddg.14298IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Cuperus, E., Sigurdsson, V., van den Akker, P. C., Bolling, M. C., van Gijn, M. E., & Pasmans, S. G. M. A.(2021). Diagnostic next generation sequencing in neonatal erythroderma. Journal der deutschendermatologischen gesellschaft, 19(4), 612-614. Advance online publication.https://doi.org/10.1111/ddg.14298CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 31-10-2023Correspondence Clinical Letter1© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Dear Editors,The list of differential diagnoses of neonatal erythroderma (NE) is long. Ichthyoses, immunodeficiencies and infections are the most frequent underlying causes while metabolic dis-orders, drugs and more rare causes such as atopic dermati-tis, psoriasis and seborrheic dermatitis are the less frequent [1, 2]. Neonatal erythroderma is often accompanied by a col-lodion membrane. A correct diagnostic approach to neonatal erythroderma is difficult based on the clinical presentation alone. To our knowledge, this is the first report on the ap-plication of next generation sequencing (NGS) in a cohort of patients with NE as main inclusion criterium. This study revealed a variety of genetic diagnoses. Next generation se-quencing was proven to be particularly valuable for detecting life-threatening disorders that are difficult to clinically reco-gnize in the early stages in NE patients without a collodion.To obtain a definite genetic diagnosis in 23 patients, NGS was performed prospectively (September 1, 2014–January 1, 2018) in 15 patients at birth and retrospectively in eight patients born before September 1, 2014 in which a definite diagnosis was not present yet. The NGS panel was regularly updated during the study. The last version of the NGS panel as present on January 1, 2018 was run on patients without a genetic diagnosis earlier in the study. Non-genetic diagnoses such as infections or drug-use were less plausible based on history, laboratory results and clinical characteristics. Infor-med consent was obtained from parents of the patients along with approval of the medical ethics committee.A targeted NGS panel of 60 genes associated with neo-natal erythroderma and collodion membrane was used (see Table S1 in the online supplement), based on extensive lite-rature search. The gene panel comprised uniquely mapped coding regions of 60 genes from the built genome GRCh37/hg19 (www.ncbi.nlm.nih.gov/assembly/2758) as well as 50 bp flanks into intronic regions. The DNA was enriched using the SureSelect XT Target or Human All Exon v5 kit (Agilent Technologies B. V. Netherlands) and sequenced using the HiSeq2500 system on rapid run mode (Illumina, Netherlands) at a mean target depth of 100x. The reads were aligned to hg19 using BWA (BWA-MEM v0.7.5a); variants were called using the GATK haplotype caller (v2.7-2). The correlation between the diagnosis and clinical presentation (erythroderma or collodion) was calculated using the odds ratio and chi-squared tests.A genetic diagnosis was found in 70 % of the cases (16/23) (Table 1); 60 % in the prospective cohorts (9/15) and 88 % (7/8) in the retrospective cohorts, respectively. A col-lodion membrane was present in 14/23 patients (61 %) of which 12 (86 %) had an underlying type of ichthyosis. Muta-tions linked to ichthyoses were found in the genes: TGM 1 (4/14), ALOX12B (3/14), PNPLA1, ABCA12, ALOXE3, KRT10 and ALDH3A2 [1/14 each]. In two collodion pati-ents, no definite genetic diagnosis could be made; variants of unknown significance (VUS) were found in BTD and ALO-X12B, which were unlikely to have contributed to the clini-cal presentation. In patients without a collodion membrane, an underlying diagnosis was made in 67 % of cases (6/9), with an underlying type of ichthyosis in 44 % (4/9). In two patients, mutations were found in IL36RN and SPINK5, defining: Deficiency of Interleukin-36 Receptor Antagonist (DITRA) and Netherton syndrome, respectively. In two pa-tients, no pathogenic mutations could be found, and in one patient, a VUS in C5 was found, which was unlikely to have contributed to the clinical presentation.The obtained diagnostic yield of 60 % in the prospecti-ve group was higher compared to, for instance, NGS panels for other heterogeneous entities like primary immunodefi-ciencies (33–48 %) [3], hereditary anemias (45.8 %) [4] and monogenic liver diseases (17 %) [5]. This confirms the strong genetic etiology of neonatal erythroderma. Along with the genetic heterogeneity this demonstrates the relevance of per-forming NGS for NE.Additionally, our results confirm that a form of ichthyo-sis is the most likely diagnosis in cases of NE accompanied by a collodion. In contrast, in patients without a collodion membrane, other diagnoses are more likely (OR 6, chi-squa-red: 0.03). In the patient with DITRA, the diagnosis resulted in a significant therapeutic change later on [6]. Since results are limited to a Dutch population, genetic differences are possible in other populations [7, 8]. A limitation in this study relates to the use of a targeted NGS panel: since causal genes, such as SULT2B1, were not known as related to ichthyosis and thus not included during the study, a higher yield in di-agnostic outcome in our study population could have been achieved if open exome (WES; Whole Exome Sequencing) analysis had been performed. On the other hand, the patients lacking a genetic diagnosis might not have had a genetic basis for their NE.In conclusion, this study underscores the relevance of the use of NGS to establish a diagnosis for patients with NE. In the absence of a collodion membrane, causes other than the relatively non-life-threatening ichthyoses, such as DOI: 10.1111/ddg.14298Diagnostic next generation sequencing in neonatal erythroderma Clinical LetterThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.2 © 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical LetterTable 1 Next generation sequencing outcome of (likely) pathogenic mutations in nine prospective (1–9) and eight retrospective (10–17) patients with neonatal erythroderma.PatientCollodionGeneVariant descriptionProteinStatus of mutationType of mutationClinical significance*Diagnosis (inheritance)1YesABCA12NM_173076: c.6091T>Gp.Trp2031GlyHomMissenseLikely pathogenicHI (AR)2YesALOX12BNM_001139.3: c.1463G>Ap.Arg488HisHomMissensePathogenicSHCB (AR)3YesALOX12BNM_001139: c.1642C>TNM_001139: c.1349G>Ap.Arg548Trpp.Gly450GluHetHetMissenseMissensePathogenicVUSLI* (AR)4YesALOX12BNM_001139: c..467_470dupNM_001139: c. 1562A>Gp.His158fsp.Tyr521CysHetHetFrameshiftMissensePathogenicPathogenicARCI (AR)5NoALOXE3NM_001165960.1: c.2285C>Tp.Pro762LeuHomMissensePathogenicARCI (AR)6YesPNPLA1NM_173676.2: c.488C>Tp.Pro163LeuHomMissensePathogenicARCI (AR)7YesTGM1NM_00359.3: c.877-2A>Gp.(?); (?)HomSplice sitePathogenicARCI (AR)8YesTGM1NM_00359.3: c.968G>Ap.Arg323GlnHomMissenseLikely pathogenicSHCB (AR)9YesTGM1NM_00359.3: c.857G>A; 857G>Ap.Arg286GlnHomMissenseLikely pathogenicSHCB (AR)10NoABCA12NM_173076: c.6440dupNM_173076.2: c.3180-6T>Gp.Gln2149fsp.(?)HetHetFrameshiftSplice sitePathogenicVUSARCI* (AR)11YesALDH3A2NM_000382.3: c.1297_1298delp.Glu433fsHomFrameshiftPathogenicSLS (AR)12YesALOXE3NM_001165960.1: c.1642T>CNM_001165960.1: c.2285C>Tp.Cys548Argp.Pro762LeuHetHetMissenseMissenseLikely pathogenicPathogenicARCI (AR)13NoIL36RNNM_173170.1: c.80T>Cp.Leu27ProHomMissensePathogenicDITRA (AR)14YesKRT10NM_000421.3: c.1468_1473delinsAGTTCCGp.Gly490fsHetFrameshiftLikely pathogenicIchthyosis with confetti (AD)15NoSPINK5NM_006846.3: c.649C>TNM_006846.3: c.724G>Tp.Arg217*p.Glu242*HetHetNonsenseNonsenseLikely PathogenicNS (AR)16YesTGM1NM_00359.3: c.1472C>Tp.Thr491MetHetMissensePathogenicLI* (AR)17NoDSG1NM_001942.2: c.382C>Tp. Arg128*HetNonsensePathogenicSAM* (AR)Abbr.: AD, autosomal dominant; AR, autosomal recessive; ARCI, autosomal recessive congenital ichthyosis; DITRA, deficiency of interleukin receptor-36 antagonist; Het, Heterozygous; HI, Harlequin ichthyosis; Hom, Homozygous; LI, Lamellar ichthyosis; N/A, Not Available; NGS, Next Generation Sequencing; NS, Netherton syndrome; SAM, severe dermatitis, atopic diathesis and metabolic syndrome; SHCB, self-healing collodion baby; SLS, Sjögren-Larsson syndrome.*According to AMCG guidelines 2015 [10]; **Clinically conform diagnosis; ***No genetic diagnosis; ****2nd  mutation (large deletion) was detected elsewhere, but not with current NGS method.3© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical Letterimmunodeficiencies, metabolic disorders or DITRA, are pos-sible. In newborns, these might be detected through genetic evaluations at an earlier stage than onset of clinical signs. Immunodeficiencies such as Omenn syndrome can be present with congenital erythroderma but without typical associated systemic symptoms such as a failure to thrive, infections and fever [9]. These life-threating conditions require immediate and adequate therapy, which can be facilitated by rapid NGS diagnostics. This is now feasible for newborns with NE.AcknowledgmentsThe authors thank all parents who gave informed consent for their children. The authors acknowledge all physicians, dermatologists and pediatricians for their efforts and con-tributions to this study in The Netherlands. This study is part of the Academic Centers of Excellence of Congenital Anatomical Abnormalities and Primary Immunodeficiency Center of the Erasmus MC University Medical Center-So-phia Children’s Hospital and of European Reference Net-work-SKIN-Ichthyosis. The authors are indebted to M. van Geel, MD, PhD, clinical geneticist, Maastricht University Medical Center, the Netherlands, for his contribution in SAM syndrome.FundingThe study was funded by Fonds NutsOhra and Stichting Coolsingel.Conflict of interestNone.Edwin Cuperus1,2, Vigfús Sigurdsson3, Peter C. van den Akker4, Marieke C. Bolling5, Mariëlle E. van Gijn4,6,*, Suzanne G. M. A. Pasmans1(1) Department of Dermatology, Center of Pediatric Dermatology, Erasmus MC University Medical Center Rotterdam-Sophia Children’s Hospital, Rotterdam, The Netherlands(2) Department of Dermatology, St Jansdal Hospital, Harderwijk, The Netherlands(3) Department of Dermatology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands(4) Department of Genetics, University Medical Center, University of Groningen, Groningen, The Netherlands(5) Department of Dermatology, University Medical Center, University of Groningen, Groningen, The Netherlands(6) Department of Genetics, University Medical Center Utrecht and Wilhelmina’s Children Hospital Utrecht, Utrecht, The Netherlands*The last two authors contributed equally to the present article.Correspondence toSuzanne G. M. A. Pasmans, MD, PhDDepartment of DermatologyErasmus MC-Sophia Children’s HospitalUniversity Medical Centre RotterdamWytemaweg 803015 CN Rotterdam, The NetherlandsE-mail: s.pasmans@erasmusmc.nlReferences1 Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Im-munol 2019; 30(3): 259–68.2 Pruzskowski A, Bodemer C, Fraitag S et al. Neonatal and infan-tile erythrodermas. A retrospective study of 51 patients. Arch Dermatol 2000; 136: 875–80.3 Rae W, Ward D, Mattocks C et al. Clinical efficacy of a next-generation sequencing gene panel for primary immunodefi-ciency diagnostics. Clin Genet 2018; 93(3): 647–55.4 Russo R, Andolfo I, Manna F et al. Multi-gene panel testing im-proves diagnosis and management of patients with hereditary anemias. Am J Hematol 2018; 93(5): 672–82.5 Stalke A, Skawran B, Auber B et al. Diagnosis of monogenic liver diseases in childhood by next-generation sequencing. Clin Genet 2018; 93(3): 665–70.6 Cuperus E, Koevoets R, van der Smagt JJ et al. Juvenile inter-leukin-36 receptor antagonist deficiency (DITRA) with c.80T>C (p.Leu27Pro) mutation successfully treated with etanercept and acitretin. JAAD Case Rep 2018; 4(2): 192–5.7 El-Sayed N, Seifeldin NS, Gobrial CKT. High frequency of pri-mary hereditary icthyoses in the North-East region of Cairo, Egypt. Postepy Dermatol Alergol 2018; 35(2): 161–6.8 Youssefian L, Vahidnezhad H, Saeidian AH et al. Autosomal recessive congenital ichthyosis: Genomic landscape and phe-notypic spectrum in a cohort of 125 consanguineous families. Human Mutation 2019; 40: 288–98.9 Cuperus E, van Montfrans JM, van Gijn ME et al. Congenital erythroderma should be considered as an urgent warning sign of immunodeficiency: a case of Omenn syndrome. Eur J Dermatol 2017; 27(3): 313–4.10 Richards S, Aziz N, Bale S et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med 2015; 17(5): 405–24.

van den Akker, Peter C.

Bolling, Marieke C.

van Gijn, Mariëlle E.

Pasmans, Suzanne G.M.A.

NARCIS 

EUR Research Repository

Correspondence Clinical Letter612 © 2021 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2021/1904Dear Editors,The list of differential diagnoses of neonatal erythroderma (NE) is long. Ichthyoses, immunodeficiencies and infections are the most frequent underlying causes while metabolic dis-orders, drugs and more rare causes such as atopic dermati-tis, psoriasis and seborrheic dermatitis are the less frequent [1, 2]. Neonatal erythroderma is often accompanied by a col-lodion membrane. A correct diagnostic approach to neonatal erythroderma is difficult based on the clinical presentation alone. To our knowledge, this is the first report on the ap-plication of next generation sequencing (NGS) in a cohort of patients with NE as main inclusion criterium. This study revealed a variety of genetic diagnoses. Next generation se-quencing was proven to be particularly valuable for detecting life-threatening disorders that are difficult to clinically reco-gnize in the early stages in NE patients without a collodion.To obtain a definite genetic diagnosis in 23 patients, NGS was performed prospectively (September 1, 2014–January 1, 2018) in 15 patients at birth and retrospectively in eight patients born before September 1, 2014 in which a definite diagnosis was not present yet. The NGS panel was regularly updated during the study. The last version of the NGS panel as present on January 1, 2018 was run on patients without a genetic diagnosis earlier in the study. Non-genetic diagnoses such as infections or drug-use were less plausible based on history, laboratory results and clinical characteristics. Infor-med consent was obtained from parents of the patients along with approval of the medical ethics committee.A targeted NGS panel of 60 genes associated with neo-natal erythroderma and collodion membrane was used (see Table S1 in the online supplement), based on extensive lite-rature search. The gene panel comprised uniquely mapped coding regions of 60 genes from the built genome GRCh37/hg19 (www.ncbi.nlm.nih.gov/assembly/2758) as well as 50 bp flanks into intronic regions. The DNA was enriched using the SureSelect XT Target or Human All Exon v5 kit (Agilent Technologies B. V. Netherlands) and sequenced using the HiSeq2500 system on rapid run mode (Illumina, Netherlands) at a mean target depth of 100x. The reads were aligned to hg19 using BWA (BWA-MEM v0.7.5a); variants were called using the GATK haplotype caller (v2.7-2). The correlation between the diagnosis and clinical presentation (erythroderma or collodion) was calculated using the odds ratio and chi-squared tests.A genetic diagnosis was found in 70 % of the cases (16/23) (Table 1); 60 % in the prospective cohorts (9/15) and 88 % (7/8) in the retrospective cohorts, respectively. A col-lodion membrane was present in 14/23 patients (61 %) of which 12 (86 %) had an underlying type of ichthyosis. Muta-tions linked to ichthyoses were found in the genes: TGM 1 (4/14), ALOX12B (3/14), PNPLA1, ABCA12, ALOXE3, KRT10 and ALDH3A2 [1/14 each]. In two collodion pati-ents, no definite genetic diagnosis could be made; variants of unknown significance (VUS) were found in BTD and ALO-X12B, which were unlikely to have contributed to the clini-cal presentation. In patients without a collodion membrane, an underlying diagnosis was made in 67 % of cases (6/9), with an underlying type of ichthyosis in 44 % (4/9). In two patients, mutations were found in IL36RN and SPINK5, defining: Deficiency of Interleukin-36 Receptor Antagonist (DITRA) and Netherton syndrome, respectively. In two pa-tients, no pathogenic mutations could be found, and in one patient, a VUS in C5 was found, which was unlikely to have contributed to the clinical presentation.The obtained diagnostic yield of 60 % in the prospecti-ve group was higher compared to, for instance, NGS panels for other heterogeneous entities like primary immunodefi-ciencies (33–48 %) [3], hereditary anemias (45.8 %) [4] and monogenic liver diseases (17 %) [5]. This confirms the strong genetic etiology of neonatal erythroderma. Along with the genetic heterogeneity this demonstrates the relevance of per-forming NGS for NE.Additionally, our results confirm that a form of ichthyo-sis is the most likely diagnosis in cases of NE accompanied by a collodion. In contrast, in patients without a collodion membrane, other diagnoses are more likely (OR 6, chi-squa-red: 0.03). In the patient with DITRA, the diagnosis resulted in a significant therapeutic change later on [6]. Since results are limited to a Dutch population, genetic differences are possible in other populations [7, 8]. A limitation in this study relates to the use of a targeted NGS panel: since causal genes, such as SULT2B1, were not known as related to ichthyosis and thus not included during the study, a higher yield in di-agnostic outcome in our study population could have been achieved if open exome (WES; Whole Exome Sequencing) analysis had been performed. On the other hand, the patients lacking a genetic diagnosis might not have had a genetic basis for their NE.In conclusion, this study underscores the relevance of the use of NGS to establish a diagnosis for patients with NE. In the absence of a collodion membrane, causes other than the relatively non-life-threatening ichthyoses, such as DOI: 10.1111/ddg.14298Diagnostic next generation sequencing in neonatal erythroderma Clinical LetterThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.Correspondence Clinical Letter613© 2021 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2021/1904Table 1 Next generation sequencing outcome of (likely) pathogenic mutations in nine prospective (1–9) and eight retrospective (10–17) patients with neonatal erythroderma.PatientCollodionGeneVariant descriptionProteinStatus of mutationType of mutationClinical significance*Diagnosis (inheritance)1YesABCA12NM_173076: c.6091T>Gp.Trp2031GlyHomMissenseLikely pathogenicHI (AR)2YesALOX12BNM_001139.3: c.1463G>Ap.Arg488HisHomMissensePathogenicSHCB (AR)3YesALOX12BNM_001139: c.1642C>TNM_001139: c.1349G>Ap.Arg548Trpp.Gly450GluHetHetMissenseMissensePathogenicVUSLI* (AR)4YesALOX12BNM_001139: c..467_470dupNM_001139: c. 1562A>Gp.His158fsp.Tyr521CysHetHetFrameshiftMissensePathogenicPathogenicARCI (AR)5NoALOXE3NM_001165960.1: c.2285C>Tp.Pro762LeuHomMissensePathogenicARCI (AR)6YesPNPLA1NM_173676.2: c.488C>Tp.Pro163LeuHomMissensePathogenicARCI (AR)7YesTGM1NM_00359.3: c.877-2A>Gp.(?); (?)HomSplice sitePathogenicARCI (AR)8YesTGM1NM_00359.3: c.968G>Ap.Arg323GlnHomMissenseLikely pathogenicSHCB (AR)9YesTGM1NM_00359.3: c.857G>A; 857G>Ap.Arg286GlnHomMissenseLikely pathogenicSHCB (AR)10NoABCA12NM_173076: c.6440dupNM_173076.2: c.3180-6T>Gp.Gln2149fsp.(?)HetHetFrameshiftSplice sitePathogenicVUSARCI* (AR)11YesALDH3A2NM_000382.3: c.1297_1298delp.Glu433fsHomFrameshiftPathogenicSLS (AR)12YesALOXE3NM_001165960.1: c.1642T>CNM_001165960.1: c.2285C>Tp.Cys548Argp.Pro762LeuHetHetMissenseMissenseLikely pathogenicPathogenicARCI (AR)13NoIL36RNNM_173170.1: c.80T>Cp.Leu27ProHomMissensePathogenicDITRA (AR)14YesKRT10NM_000421.3: c.1468_1473delinsAGTTCCGp.Gly490fsHetFrameshiftLikely pathogenicIchthyosis with confetti (AD)15NoSPINK5NM_006846.3: c.649C>TNM_006846.3: c.724G>Tp.Arg217*p.Glu242*HetHetNonsenseNonsenseLikely PathogenicNS (AR)16YesTGM1NM_00359.3: c.1472C>Tp.Thr491MetHetMissensePathogenicLI* (AR)17NoDSG1NM_001942.2: c.382C>Tp. Arg128*HetNonsensePathogenicSAM* (AR)Abbr.: AD, autosomal dominant; AR, autosomal recessive; ARCI, autosomal recessive congenital ichthyosis; DITRA, deficiency of interleukin receptor-36 antagonist; Het, Heterozygous; HI, Harlequin ichthyosis; Hom, Homozygous; LI, Lamellar ichthyosis; N/A, Not Available; NGS, Next Generation Sequencing; NS, Netherton syndrome; SAM, severe dermatitis, atopic diathesis and metabolic syndrome; SHCB, self-healing collodion baby; SLS, Sjögren-Larsson syndrome.*According to AMCG guidelines 2015 [10]; **Clinically conform diagnosis; ***No genetic diagnosis; ****2nd  mutation (large deletion) was detected elsewhere, but not with current NGS method.Correspondence Clinical Letter614 © 2021 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2021/1904immunodeficiencies, metabolic disorders or DITRA, are pos-sible. In newborns, these might be detected through genetic evaluations at an earlier stage than onset of clinical signs. Immunodeficiencies such as Omenn syndrome can be present with congenital erythroderma but without typical associated systemic symptoms such as a failure to thrive, infections and fever [9]. These life-threating conditions require immediate and adequate therapy, which can be facilitated by rapid NGS diagnostics. This is now feasible for newborns with NE.AcknowledgmentsThe authors thank all parents who gave informed consent for their children. The authors acknowledge all physicians, der-matologists and pediatricians for their efforts and contribu-tions to this study in The Netherlands. This study is part of the Academic Centers of Excellence of Congenital Anatomical Abnormalities and Primary Immunodeficiency Center of the Erasmus MC University Medical Center-Sophia Children’s Hospital and of European Reference Network-SKIN-Ichthyo-sis. The authors are indebted to M. van Geel, MD, PhD, cli-nical geneticist, Maastricht University Medical Center, the Netherlands, for his contribution in SAM syndrome.Open access funding enabled and organized by Projekt DEAL.FundingThe study was funded by Fonds NutsOhra and Stichting Coolsingel.Conflict of interestNone.Edwin Cuperus1,2, Vigfús Sigurdsson3, Peter C. van den Akker4, Marieke C. Bolling5, Mariëlle E. van Gijn4,6,*, Suzanne G. M. A. Pasmans1(1) Department of Dermatology, Center of Pediatric Dermatology, Erasmus MC University Medical Center Rotterdam-Sophia Children’s Hospital, Rotterdam, The Netherlands(2) Department of Dermatology, St Jansdal Hospital, Harderwijk, The Netherlands(3) Department of Dermatology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands(4) Department of Genetics, University Medical Center, University of Groningen, Groningen, The Netherlands(5) Department of Dermatology, University Medical Center, University of Groningen, Groningen, The Netherlands(6) Department of Genetics, University Medical Center Utrecht and Wilhelmina’s Children Hospital Utrecht, Utrecht, The Netherlands*The last two authors contributed equally to the present article.Correspondence toSuzanne G. M. A. Pasmans, MD, PhDDepartment of DermatologyErasmus MC-Sophia Children’s HospitalUniversity Medical Centre RotterdamWytemaweg 803015 CN Rotterdam, The NetherlandsE-mail: s.pasmans@erasmusmc.nlReferences1 Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Im-munol 2019; 30(3): 259–68.2 Pruzskowski A, Bodemer C, Fraitag S et al. Neonatal and infan-tile erythrodermas. A retrospective study of 51 patients. Arch Dermatol 2000; 136: 875–80.3 Rae W, Ward D, Mattocks C et al. Clinical efficacy of a next-generation sequencing gene panel for primary immunodefi-ciency diagnostics. Clin Genet 2018; 93(3): 647–55.4 Russo R, Andolfo I, Manna F et al. Multi-gene panel testing im-proves diagnosis and management of patients with hereditary anemias. Am J Hematol 2018; 93(5): 672–82.5 Stalke A, Skawran B, Auber B et al. Diagnosis of monogenic liver diseases in childhood by next-generation sequencing. Clin Genet 2018; 93(3): 665–70.6 Cuperus E, Koevoets R, van der Smagt JJ et al. Juvenile inter-leukin-36 receptor antagonist deficiency (DITRA) with c.80T>C (p.Leu27Pro) mutation successfully treated with etanercept and acitretin. JAAD Case Rep 2018; 4(2): 192–5.7 El-Sayed N, Seifeldin NS, Gobrial CKT. High frequency of pri-mary hereditary icthyoses in the North-East region of Cairo, Egypt. Postepy Dermatol Alergol 2018; 35(2): 161–6.8 Youssefian L, Vahidnezhad H, Saeidian AH et al. Autosomal recessive congenital ichthyosis: Genomic landscape and phe-notypic spectrum in a cohort of 125 consanguineous families. Human Mutation 2019; 40: 288–98.9 Cuperus E, van Montfrans JM, van Gijn ME et al. Congenital erythroderma should be considered as an urgent warning sign of immunodeficiency: a case of Omenn syndrome. Eur J Dermatol 2017; 27(3): 313–4.10 Richards S, Aziz N, Bale S et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med 2015; 17(5): 405–24.

   University of GroningenDiagnostic next generation sequencing in neonatal erythrodermaCuperus, Edwin; Sigurdsson, Vigfús; van den Akker, Peter C; Bolling, Marieke C; van Gijn,Mariëlle E; Pasmans, Suzanne G M APublished in:Journal der deutschen dermatologischen gesellschaftDOI:10.1111/ddg.14298IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Cuperus, E., Sigurdsson, V., van den Akker, P. C., Bolling, M. C., van Gijn, M. E., & Pasmans, S. G. M. A.(2021). Diagnostic next generation sequencing in neonatal erythroderma. Journal der deutschendermatologischen gesellschaft, 19(4), 612-614. https://doi.org/10.1111/ddg.14298CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 04-06-2022Correspondence Clinical Letter1© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Dear Editors,The list of differential diagnoses of neonatal erythroderma (NE) is long. Ichthyoses, immunodeficiencies and infections are the most frequent underlying causes while metabolic dis-orders, drugs and more rare causes such as atopic dermati-tis, psoriasis and seborrheic dermatitis are the less frequent [1, 2]. Neonatal erythroderma is often accompanied by a col-lodion membrane. A correct diagnostic approach to neonatal erythroderma is difficult based on the clinical presentation alone. To our knowledge, this is the first report on the ap-plication of next generation sequencing (NGS) in a cohort of patients with NE as main inclusion criterium. This study revealed a variety of genetic diagnoses. Next generation se-quencing was proven to be particularly valuable for detecting life-threatening disorders that are difficult to clinically reco-gnize in the early stages in NE patients without a collodion.To obtain a definite genetic diagnosis in 23 patients, NGS was performed prospectively (September 1, 2014–January 1, 2018) in 15 patients at birth and retrospectively in eight patients born before September 1, 2014 in which a definite diagnosis was not present yet. The NGS panel was regularly updated during the study. The last version of the NGS panel as present on January 1, 2018 was run on patients without a genetic diagnosis earlier in the study. Non-genetic diagnoses such as infections or drug-use were less plausible based on history, laboratory results and clinical characteristics. Infor-med consent was obtained from parents of the patients along with approval of the medical ethics committee.A targeted NGS panel of 60 genes associated with neo-natal erythroderma and collodion membrane was used (see Table S1 in the online supplement), based on extensive lite-rature search. The gene panel comprised uniquely mapped coding regions of 60 genes from the built genome GRCh37/hg19 (www.ncbi.nlm.nih.gov/assembly/2758) as well as 50 bp flanks into intronic regions. The DNA was enriched using the SureSelect XT Target or Human All Exon v5 kit (Agilent Technologies B. V. Netherlands) and sequenced using the HiSeq2500 system on rapid run mode (Illumina, Netherlands) at a mean target depth of 100x. The reads were aligned to hg19 using BWA (BWA-MEM v0.7.5a); variants were called using the GATK haplotype caller (v2.7-2). The correlation between the diagnosis and clinical presentation (erythroderma or collodion) was calculated using the odds ratio and chi-squared tests.A genetic diagnosis was found in 70 % of the cases (16/23) (Table 1); 60 % in the prospective cohorts (9/15) and 88 % (7/8) in the retrospective cohorts, respectively. A col-lodion membrane was present in 14/23 patients (61 %) of which 12 (86 %) had an underlying type of ichthyosis. Muta-tions linked to ichthyoses were found in the genes: TGM 1 (4/14), ALOX12B (3/14), PNPLA1, ABCA12, ALOXE3, KRT10 and ALDH3A2 [1/14 each]. In two collodion pati-ents, no definite genetic diagnosis could be made; variants of unknown significance (VUS) were found in BTD and ALO-X12B, which were unlikely to have contributed to the clini-cal presentation. In patients without a collodion membrane, an underlying diagnosis was made in 67 % of cases (6/9), with an underlying type of ichthyosis in 44 % (4/9). In two patients, mutations were found in IL36RN and SPINK5, defining: Deficiency of Interleukin-36 Receptor Antagonist (DITRA) and Netherton syndrome, respectively. In two pa-tients, no pathogenic mutations could be found, and in one patient, a VUS in C5 was found, which was unlikely to have contributed to the clinical presentation.The obtained diagnostic yield of 60 % in the prospecti-ve group was higher compared to, for instance, NGS panels for other heterogeneous entities like primary immunodefi-ciencies (33–48 %) [3], hereditary anemias (45.8 %) [4] and monogenic liver diseases (17 %) [5]. This confirms the strong genetic etiology of neonatal erythroderma. Along with the genetic heterogeneity this demonstrates the relevance of per-forming NGS for NE.Additionally, our results confirm that a form of ichthyo-sis is the most likely diagnosis in cases of NE accompanied by a collodion. In contrast, in patients without a collodion membrane, other diagnoses are more likely (OR 6, chi-squa-red: 0.03). In the patient with DITRA, the diagnosis resulted in a significant therapeutic change later on [6]. Since results are limited to a Dutch population, genetic differences are possible in other populations [7, 8]. A limitation in this study relates to the use of a targeted NGS panel: since causal genes, such as SULT2B1, were not known as related to ichthyosis and thus not included during the study, a higher yield in di-agnostic outcome in our study population could have been achieved if open exome (WES; Whole Exome Sequencing) analysis had been performed. On the other hand, the patients lacking a genetic diagnosis might not have had a genetic basis for their NE.In conclusion, this study underscores the relevance of the use of NGS to establish a diagnosis for patients with NE. In the absence of a collodion membrane, causes other than the relatively non-life-threatening ichthyoses, such as DOI: 10.1111/ddg.14298Diagnostic next generation sequencing in neonatal erythroderma Clinical LetterThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.2 © 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical LetterTable 1 Next generation sequencing outcome of (likely) pathogenic mutations in nine prospective (1–9) and eight retrospective (10–17) patients with neonatal erythroderma.PatientCollodionGeneVariant descriptionProteinStatus of mutationType of mutationClinical significance*Diagnosis (inheritance)1YesABCA12NM_173076: c.6091T>Gp.Trp2031GlyHomMissenseLikely pathogenicHI (AR)2YesALOX12BNM_001139.3: c.1463G>Ap.Arg488HisHomMissensePathogenicSHCB (AR)3YesALOX12BNM_001139: c.1642C>TNM_001139: c.1349G>Ap.Arg548Trpp.Gly450GluHetHetMissenseMissensePathogenicVUSLI* (AR)4YesALOX12BNM_001139: c..467_470dupNM_001139: c. 1562A>Gp.His158fsp.Tyr521CysHetHetFrameshiftMissensePathogenicPathogenicARCI (AR)5NoALOXE3NM_001165960.1: c.2285C>Tp.Pro762LeuHomMissensePathogenicARCI (AR)6YesPNPLA1NM_173676.2: c.488C>Tp.Pro163LeuHomMissensePathogenicARCI (AR)7YesTGM1NM_00359.3: c.877-2A>Gp.(?); (?)HomSplice sitePathogenicARCI (AR)8YesTGM1NM_00359.3: c.968G>Ap.Arg323GlnHomMissenseLikely pathogenicSHCB (AR)9YesTGM1NM_00359.3: c.857G>A; 857G>Ap.Arg286GlnHomMissenseLikely pathogenicSHCB (AR)10NoABCA12NM_173076: c.6440dupNM_173076.2: c.3180-6T>Gp.Gln2149fsp.(?)HetHetFrameshiftSplice sitePathogenicVUSARCI* (AR)11YesALDH3A2NM_000382.3: c.1297_1298delp.Glu433fsHomFrameshiftPathogenicSLS (AR)12YesALOXE3NM_001165960.1: c.1642T>CNM_001165960.1: c.2285C>Tp.Cys548Argp.Pro762LeuHetHetMissenseMissenseLikely pathogenicPathogenicARCI (AR)13NoIL36RNNM_173170.1: c.80T>Cp.Leu27ProHomMissensePathogenicDITRA (AR)14YesKRT10NM_000421.3: c.1468_1473delinsAGTTCCGp.Gly490fsHetFrameshiftLikely pathogenicIchthyosis with confetti (AD)15NoSPINK5NM_006846.3: c.649C>TNM_006846.3: c.724G>Tp.Arg217*p.Glu242*HetHetNonsenseNonsenseLikely PathogenicNS (AR)16YesTGM1NM_00359.3: c.1472C>Tp.Thr491MetHetMissensePathogenicLI* (AR)17NoDSG1NM_001942.2: c.382C>Tp. Arg128*HetNonsensePathogenicSAM* (AR)Abbr.: AD, autosomal dominant; AR, autosomal recessive; ARCI, autosomal recessive congenital ichthyosis; DITRA, deficiency of interleukin receptor-36 antagonist; Het, Heterozygous; HI, Harlequin ichthyosis; Hom, Homozygous; LI, Lamellar ichthyosis; N/A, Not Available; NGS, Next Generation Sequencing; NS, Netherton syndrome; SAM, severe dermatitis, atopic diathesis and metabolic syndrome; SHCB, self-healing collodion baby; SLS, Sjögren-Larsson syndrome.*According to AMCG guidelines 2015 [10]; **Clinically conform diagnosis; ***No genetic diagnosis; ****2nd  mutation (large deletion) was detected elsewhere, but not with current NGS method.3© 2020 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft. | JDDG | 1610-0379/2020Correspondence Clinical Letterimmunodeficiencies, metabolic disorders or DITRA, are pos-sible. In newborns, these might be detected through genetic evaluations at an earlier stage than onset of clinical signs. Immunodeficiencies such as Omenn syndrome can be present with congenital erythroderma but without typical associated systemic symptoms such as a failure to thrive, infections and fever [9]. These life-threating conditions require immediate and adequate therapy, which can be facilitated by rapid NGS diagnostics. This is now feasible for newborns with NE.AcknowledgmentsThe authors thank all parents who gave informed consent for their children. The authors acknowledge all physicians, dermatologists and pediatricians for their efforts and con-tributions to this study in The Netherlands. This study is part of the Academic Centers of Excellence of Congenital Anatomical Abnormalities and Primary Immunodeficiency Center of the Erasmus MC University Medical Center-So-phia Children’s Hospital and of European Reference Net-work-SKIN-Ichthyosis. The authors are indebted to M. van Geel, MD, PhD, clinical geneticist, Maastricht University Medical Center, the Netherlands, for his contribution in SAM syndrome.FundingThe study was funded by Fonds NutsOhra and Stichting Coolsingel.Conflict of interestNone.Edwin Cuperus1,2, Vigfús Sigurdsson3, Peter C. van den Akker4, Marieke C. Bolling5, Mariëlle E. van Gijn4,6,*, Suzanne G. M. A. Pasmans1(1) Department of Dermatology, Center of Pediatric Dermatology, Erasmus MC University Medical Center Rotterdam-Sophia Children’s Hospital, Rotterdam, The Netherlands(2) Department of Dermatology, St Jansdal Hospital, Harderwijk, The Netherlands(3) Department of Dermatology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands(4) Department of Genetics, University Medical Center, University of Groningen, Groningen, The Netherlands(5) Department of Dermatology, University Medical Center, University of Groningen, Groningen, The Netherlands(6) Department of Genetics, University Medical Center Utrecht and Wilhelmina’s Children Hospital Utrecht, Utrecht, The Netherlands*The last two authors contributed equally to the present article.Correspondence toSuzanne G. M. A. Pasmans, MD, PhDDepartment of DermatologyErasmus MC-Sophia Children’s HospitalUniversity Medical Centre RotterdamWytemaweg 803015 CN Rotterdam, The NetherlandsE-mail: s.pasmans@erasmusmc.nlReferences1 Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Im-munol 2019; 30(3): 259–68.2 Pruzskowski A, Bodemer C, Fraitag S et al. Neonatal and infan-tile erythrodermas. A retrospective study of 51 patients. Arch Dermatol 2000; 136: 875–80.3 Rae W, Ward D, Mattocks C et al. Clinical efficacy of a next-generation sequencing gene panel for primary immunodefi-ciency diagnostics. Clin Genet 2018; 93(3): 647–55.4 Russo R, Andolfo I, Manna F et al. Multi-gene panel testing im-proves diagnosis and management of patients with hereditary anemias. Am J Hematol 2018; 93(5): 672–82.5 Stalke A, Skawran B, Auber B et al. Diagnosis of monogenic liver diseases in childhood by next-generation sequencing. Clin Genet 2018; 93(3): 665–70.6 Cuperus E, Koevoets R, van der Smagt JJ et al. Juvenile inter-leukin-36 receptor antagonist deficiency (DITRA) with c.80T>C (p.Leu27Pro) mutation successfully treated with etanercept and acitretin. JAAD Case Rep 2018; 4(2): 192–5.7 El-Sayed N, Seifeldin NS, Gobrial CKT. High frequency of pri-mary hereditary icthyoses in the North-East region of Cairo, Egypt. Postepy Dermatol Alergol 2018; 35(2): 161–6.8 Youssefian L, Vahidnezhad H, Saeidian AH et al. Autosomal recessive congenital ichthyosis: Genomic landscape and phe-notypic spectrum in a cohort of 125 consanguineous families. Human Mutation 2019; 40: 288–98.9 Cuperus E, van Montfrans JM, van Gijn ME et al. Congenital erythroderma should be considered as an urgent warning sign of immunodeficiency: a case of Omenn syndrome. Eur J Dermatol 2017; 27(3): 313–4.10 Richards S, Aziz N, Bale S et al. 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Diagnostic next generation sequencing in neonatal erythroderma

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