Blau syndrome

Last updated
Blau syndrome
Other namesArthrocutaneouveal granulomatosis [1]
Blau syndrome2.jpg
Coarse facial features in a boy with Blau syndrome
Specialty Dermatology
Multiple, reddish-brown papules coalescing over the right arm in a boy with Blau syndrome Blau syndrome.jpg
Multiple, reddish-brown papules coalescing over the right arm in a boy with Blau syndrome

Blau syndrome is an autosomal dominant genetic inflammatory disorder which affects the skin, eyes, and joints. It is caused by a mutation in the NOD2 (CARD15) gene. [2] and is classified as an inborn error of immunity. [3] Symptoms usually begin before the age of four, and the disease manifests as early onset cutaneous sarcoidosis, granulomatous arthritis, and uveitis.

Contents

Presentation

Blau syndrome classically presents in early childhood as a triad of granulomatous dermatitis, arthritis, and uveitis. Arthritis typically affects peripheral joints mainly wrists, knees, ankles, and proximal interphalangeal (PIP) joints of the hands. Tenosynovitis is another characteristic feature; tendon sheaths appear enlarged on examination; most often the extensor tendons of the wrist, the pes anserinus, peroneal, and flexor tibialis tendon sheaths are affected. Skin rash is typically the first symptom to appear, usually in the first year of life. The most frequent appearance is that of an erythematous maculo-micropapular fine scaly rash on the trunk and extremities. Uveitis presents as an insidious granulomatous iridocyclitis with posterior uveitis in 60–80% of patients. [4]

Cause

The discovery that the gene defect in Blau syndrome involves the CARD15/NOD2 gene has sparked investigation into its function as part of the innate immune system. The innate immune system recognizes pathogen-associated molecular patterns, including bacterial polysaccharides such as muramyl dipeptide, via its pattern recognition receptors, such as NOD2, to induce signaling pathways that activate cytokine responses and protect the organism. In Blau syndrome, the genetic defect seems to lead to overactivation and poor control of the inflammatory response leading to widespread granulomatous inflammation and tissue damage. [5] [6]

Diagnosis

The diagnosis of Blau syndrome is made by the presentation of classical clinical features and can be confirmed by genetic testing and biopsy. Laboratory and imaging studies can be supportive but are usually not diagnostic. [7]

Treatment

History

In 1981, Malleson et al. reported a family that had autosomal dominant synovitis, camptodactyly, and iridocyclitis. [8] One member died of granulomatous arteritis of the heart and aorta.

In 1982, Rotenstein reported a family with granulomatous arteritis, rash, iritis, and arthritis transmitted as an autosomal dominant trait over three generations. [9]

In 1985, Edward Blau, a pediatrician in Marshfield, Wisconsin, reported a family that over four generations had granulomatous inflammation of the skin, eyes and joints. The condition was transmitted as an autosomal dominant trait. In the same year Jabs et al. reported a family that over two generations had granulomatous synovitis, uveitis and cranial neuropathies. [10]

Then in 1990 Pastores et al. reported a kindred with a phenotype very similar to what Blau described and suggested that the condition be called Blau syndrome. They also pointed out the similarities in the families noted above to Blau syndrome but also pointed out the significant differences in the phenotypes. [11]

In 1996 Tromp et al. conducted a genome wide search using affected and non-affected members of the original family. A marker, D16S298, gave a maximum logarithm of odds score of 3.75 and put the Blau syndrome susceptibility locus within the 16p12-q21 interval. Hugot et al. found a susceptibility locus for Crohn disease, a granulomatous inflammation of the bowel, on chromosome 16 close to the locus for BS. Based on the above information Blau suggested in 1998 that the genetic defect in Blau syndrome and Crohn disease might be the same or similar.

Finally in 2001 Miceli-Richard et al. found the defect in Blau syndrome to be in the nucleotide-binding domain of CARD15/NOD2. They commented in their article that mutations in CARD15 had also been found in Crohn disease. Confirmation of the defect in Blau syndrome being in the CARD15 gene was made by Wang et al. in 2002 using the Blau syndrome family and others. [10]

See also

Related Research Articles

<span class="mw-page-title-main">Sarcoidosis</span> Abnormal formation of clumps of inflammatory cells (granulomata)

Sarcoidosis is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph nodes. Less commonly affected are the eyes, liver, heart, and brain, though any organ can be affected. The signs and symptoms depend on the organ involved. Often, no symptoms or only mild symptoms are seen. When it affects the lungs, wheezing, coughing, shortness of breath, or chest pain may occur. Some may have Löfgren syndrome with fever, large lymph nodes, arthritis, and a rash known as erythema nodosum.

<span class="mw-page-title-main">Familial Mediterranean fever</span> Genetic autoinflammatory disease

Familial Mediterranean fever (FMF) is a hereditary inflammatory disorder. FMF is an autoinflammatory disease caused by mutations in the Mediterranean fever (MEFV) gene, which encodes a 781–amino acid protein called pyrin. While all ethnic groups are susceptible to FMF, it usually occurs in people of Mediterranean origin—including Sephardic Jews, Mizrahi Jews, Ashkenazi Jews, Assyrians, Armenians, Azerbaijanis, Druze, Levantines, Kurds, Greeks, Turks and Italians.

<span class="mw-page-title-main">Chronic granulomatous disease</span> Hereditary disease group

Chronic granulomatous disease (CGD), also known as Bridges–Good syndrome, chronic granulomatous disorder, and Quie syndrome, is a diverse group of hereditary diseases in which certain cells of the immune system have difficulty forming the reactive oxygen compounds used to kill certain ingested pathogens. This leads to the formation of granulomas in many organs. CGD affects about 1 in 200,000 people in the United States, with about 20 new cases diagnosed each year.

<span class="mw-page-title-main">Uveitis</span> Inflammation of the uvea of the eye

Uveitis is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and includes the iris, ciliary body, and choroid. Uveitis is described anatomically, by the part of the eye affected, as anterior, intermediate or posterior, or panuveitic if all parts are involved. Anterior uveitis (iridocyclitis) is the most common, with the incidence of uveitis overall affecting approximately 1:4500, most commonly those between the ages of 20–60. Symptoms include eye pain, eye redness, floaters and blurred vision, and ophthalmic examination may show dilated ciliary blood vessels and the presence of cells in the anterior chamber. Uveitis may arise spontaneously, have a genetic component, or be associated with an autoimmune disease or infection. While the eye is a relatively protected environment, its immune mechanisms may be overcome resulting in inflammation and tissue destruction associated with T-cell activation.

Connective tissue disease, also known as connective tissue disorder, or collagen vascular diseases, refers to any disorder that affects the connective tissue. The body's structures are held together by connective tissues, consisting of two distinct proteins: elastin and collagen. Tendons, ligaments, skin, cartilage, bone, and blood vessels are all made of collagen. Skin and ligaments contain elastin. The proteins and the body's surrounding tissues may suffer damage when these connective tissues become inflamed.

<span class="mw-page-title-main">Leflunomide</span> Chemical compound

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<span class="mw-page-title-main">NOD2</span> Protein-coding gene in humans

Nucleotide-binding oligomerization domain-containing protein 2 (NOD2), also known as caspase recruitment domain-containing protein 15 (CARD15) or inflammatory bowel disease protein 1 (IBD1), is a protein that in humans is encoded by the NOD2 gene located on chromosome 16. NOD2 plays an important role in the immune system. It recognizes bacterial molecules (peptidoglycans) and stimulates an immune reaction.

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<span class="mw-page-title-main">NOD-like receptor</span> Class of proteins

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<span class="mw-page-title-main">Cryopyrin-associated periodic syndrome</span> Medical condition

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<span class="mw-page-title-main">Enteropathic arthropathy</span> Medical condition

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<span class="mw-page-title-main">Familial episodic pain syndrome</span> Medical condition

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References

  1. "Blau syndrome | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program". rarediseases.info.nih.gov. Archived from the original on 23 April 2019. Retrieved 23 April 2019.
  2. "Blau syndrome: MedlinePlus Genetics".
  3. Bousfiha A, Moundir A, Tangye SG, Picard C, Jeddane L, Al-Herz W, Rundles CC, Franco JL, Holland SM, Klein C, Morio T, Oksenhendler E, Puel A, Puck J, Seppänen MR, Somech R, Su HC, Sullivan KE, Torgerson TR, Meyts I (October 2022). "The 2022 Update of IUIS Phenotypical Classification for Human Inborn Errors of Immunity". Journal of Clinical Immunology. 42 (7): 1508–1520. doi:10.1007/s10875-022-01352-z. PMID   36198931.
  4. Wouters, Carine; Maes, Anne; Foley, Kevin; Bertin, John; Rose, Carlos (6 August 2014). "Blau Syndrome, the prototypic auto-inflammatory granulomatous disease". Pediatr Rheumatol Online J. 12 (33): 33. doi: 10.1186/1546-0096-12-33 . PMC   4136643 . PMID   25136265. Creative Commons by small.svg  This article incorporates textfrom this source, which is available under the CC BY 4.0 license.
  5. "Blau syndrome". www.ncbi.nlm.nih.gov.
  6. "Blau's Disease / Juvenile Sarcoidosis". www.printo.it.
  7. Kaufman, Katherine; Becker, Mara (9 February 2021). "Distinguishing Blau Syndrome from Systemic Sarcoidosis". Curr Allergy Asthma Rep. 21 (2): 10. doi:10.1007/s11882-021-00991-3. PMC   9762981 . PMID   33560445.
  8. Malleson, P; Schaller, JG; Dega, F; Cassidy, SB; Pagon, RA (September 1981). "Familial arthritis and camptodactyly". Arthritis and Rheumatism. 24 (9): 1199–204. doi:10.1002/art.1780240915. PMID   7306244.
  9. Rotenstein, D; Gibbas, DL; Majmudar, B; Chastain, EA (14 January 1982). "Familial granulomatous arteritis with polyarthritis of juvenile onset". The New England Journal of Medicine. 306 (2): 86–90. doi:10.1056/NEJM198201143060208. PMID   7053492.
  10. 1 2 Wang, X; Kuivaniemi, H; Bonavita, G; Mutkus, L; Mau, U; Blau, E; Inohara, N; Nunez, G; Tromp, G; Williams, CJ (November 2002). "CARD15 mutations in familial granulomatosis syndromes: a study of the original Blau syndrome kindred and other families with large-vessel arteritis and cranial neuropathy". Arthritis and Rheumatism. 46 (11): 3041–5. doi:10.1002/art.10618. PMID   12428248.
  11. Cimaz, Rolando; Lehman, Thomas J. A. (2007). Pediatrics in Systemic Autoimmune Diseases. Elsevier. p. 190. ISBN   9780080553443.

Further reading

PMC   4136643. doi : 10.1186/1546-0096-12-33 Open Access logo PLoS transparent.svg .