A Family With A20 Haploinsufficiency Presenting With Novel Clinical Manifestations and Challenges for Treatment : JCR: Journal of Clinical Rheumatology

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A Family With A20 Haploinsufficiency Presenting With Novel Clinical Manifestations and Challenges for Treatment

Hautala, Timo MD, PhD∗,†; Vähäsalo, Paula MD, PhD; Kuismin, Outi MD, PhD§; Keskitalo, Salla PhD; Rajamäki, Kristiina PhD; Väänänen, Antti MD#; Simojoki, Marja MD∗∗; Säily, Marjaana MD, PhD; Pelkonen, Ilpo MD††; Tokola, Heikki MD, PhD‡‡; Mäkinen, Markus MD, PhD‡‡; Kaarteenaho, Riitta MD, PhD§§; Jartti, Airi MD, PhD∥∥; Hautala, Nina MD, PhD¶¶; Kantola, Saara MD##; Jackson, Päivi MD∗∗∗; Glumoff, Virpi PhD; Saarela, Janna MD, PhD†††; Varjosalo, Markku PhD∥,‡‡‡; Eklund, Kari K. MD, PhD§§§; Seppänen, Mikko R. J. MD, PhD¶,∥∥∥

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JCR: Journal of Clinical Rheumatology 27(8):p e583-e587, December 2021. | DOI: 10.1097/RHU.0000000000001268

Abstract

Background 

Tumor necrosis factor α–induced protein 3 gene (TNFAIP3, also called A20) haploinsufficiency (HA20) leads to autoinflammation and autoimmunity. We have recently shown that a p.(Lys91*) mutation in A20 disrupts nuclear factor κB signaling, impairs protein-protein interactions of A20, and leads to inflammasome activation.

Methods 

We now describe the clinical presentations and drug responses in a family with HA20 p.(Lys91*) mutation, consistent with our previously reported diverse immunological and functional findings.

Results 

We report for the first time that inflammasome-mediated autoinflammatory lung reaction caused by HA20 can be treated with interleukin 1 antagonist anakinra. We also describe severe anemia related to HA20 successfully treated with mycophenolate. In addition, HA20 p.(Lys91*) was found to associate with autoimmune thyroid disease, juvenile idiopathic arthritis, psoriasis, liver disease, and immunodeficiency presenting with specific antibody deficiency and genital papillomatosis.

Conclusions 

We conclude that HA20 may lead to combination of inflammation, immunodeficiency, and autoimmunity. The condition may present with variable and unpredictable symptoms with atypical treatment responses.

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