Fine-mapping the MHC locus in juvenile idiopathic arthritis (JIA) reveals genetic heterogeneity corresponding to distinct adult inflammatory arthritic diseases.

OBJECTIVES: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of diseases, comprising seven categories. Genetic data could potentially be used to help redefine JIA categories and improve the current classification system. The human leucocyte antigen (HLA) region is strongly associated with JIA. Fine-mapping of the region was performed to look for similarities and differences in HLA associations between the JIA categories and define correspondences with adult inflammatory arthritides. METHODS: Dense genotype data from the HLA region, from the Immunochip array for 5043 JIA cases and 14 390 controls, were used to impute single-nucleotide polymorphisms, HLA classical alleles and amino acids. Bivariate analysis was performed to investigate genetic correlation between the JIA categories. Conditional analysis was used to identify additional effects within the region. Comparison of the findings with those in adult inflammatory arthritic diseases was performed. RESULTS: We identified category-specific associations and have demonstrated for the first time that rheumatoid factor (RF)-negative polyarticular JIA and oligoarticular JIA are genetically similar in their HLA associations. We also observe that each JIA category potentially has an adult counterpart. The RF-positive polyarthritis association at HLA-DRB1 amino acid at position 13 mirrors the association in adult seropositive rheumatoid arthritis (RA). Interestingly, the combined oligoarthritis and RF-negative polyarthritis dataset shares the same association with adult seronegative RA. CONCLUSIONS: The findings suggest the value of using genetic data in helping to classify the categories of this heterogeneous disease. Mapping JIA categories to adult counterparts could enable shared knowledge of disease pathogenesis and aetiology and facilitate transition from paediatric to adult services.

Regulation of Extrasynaptic GABAA α4 Receptors by Ethanol-Induced Protein Kinase A, but Not Protein Kinase C Activation in Cultured Rat Cerebral Cortical Neurons.

Ethanol produces changes in GABAA receptor trafficking and function that contribute to ethanol dependence symptomatology. Extrasynaptic γ-aminobutyric acid A receptors (GABAA-R) mediate inhibitory tonic current and are of particular interest because they are potentiated by physiologically relevant doses of ethanol. Here, we isolate GABAA α4δ receptors by western blotting in subsynaptic fractions to investigate protein kinase A (PKA) and protein kinase C (PKC) modulation of ethanol-induced receptor trafficking, while extrasynaptic receptor function is determined by measurement of tonic inhibition and responses evoked by 4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridin-3-ol (THIP). Rat cerebral cortical neurons were grown for 18 days in vitro and exposed to ethanol and/or PKA/PKC modulators. Ethanol exposure (1 hour) did not alter GABAA α4 receptor abundance, but it increased tonic current amplitude, an effect that was prevented by inhibiting PKA, but not PKC. Direct activation of PKA, but not PKC, increased the abundance and tonic current of extrasynaptic α4δ receptors. In contrast, prolonged ethanol exposure (4 hours) reduced α4δ receptor abundance as well as tonic current, and this effect was also PKA dependent. Finally, PKC activation by ethanol or phorbol-12,13-dibutyrate (PdBu) had no effect on extrasynaptic α4δ subunit abundance or activity. We conclude that ethanol alters extrasynaptic α4δ receptor function and expression in cortical neurons in a PKA-dependent manner, but ethanol activation of PKC does not influence these receptors. These results could have clinical relevance for therapeutic strategies to restore normal GABAergic functioning for the treatment of alcohol use disorders.

Human neutrophil adherence to laminin in vitro. Evidence for a distinct neutrophil integrin receptor for laminin.

We used mAbs against polymorphonuclear leukocyte (PMN) surface proteins to investigate the mechanisms by which stimulated human neutrophils (PMNs) adhere in vitro to laminin, the major glycoprotein of mammalian basement membrane. mAb IB4, which is directed against the common beta 2 chain of the CD11/CD18, only partially inhibited the adherence of PMA-stimulated PMNs to both laminin and to subendothelial matrices. In contrast, IB4 completely inhibited PMA-stimulated PMN adherence to gelatin, fibronectin, collagen IV, and endothelial cell monolayers. PMA-stimulated PMNs from a patient with severe congenital CD11/CD18 deficiency also adhered to laminin, but not to gelatin or endothelial cell monolayers. Therefore, PMA-stimulated PMNs adhere to laminin by both CD11/CD18-dependent and CD11/CD18-independent mechanisms. Expression of CD11/CD18-independent adherence to laminin was agonist dependent, occurring after stimulation with the calcium ionophore A23187 and recombinant TNF-alpha, but not with the chemotactic factors FMLP, platelet activating factor, or recombinant human C5a. Expression of CD11/CD18-independent adherence was also divalent cation dependent, occurring in the presence of Mg2+ but not Ca2+ as the sole added divalent cation. The mAbs AIIB2 and 13, which are directed against the beta 1 subunit of the VLA integrins, significantly inhibited the CD11/CD18-independent adherence of normal PMNs to laminin, and completely abolished the adherence of CD11/CD18-deficient PMNs to laminin. Both anti-beta 1 mAbs bound to PMNs, as demonstrated by flow cytometry, and immunoprecipitated a membrane molecule of Mr 130,000 daltons from 125I-labeled, detergent-solubilized PMNs. These data suggest that human PMNs possess beta 1 and beta 2 classes of integrins, and that both mediate PMN adherence.

Connective tissue proteins and phagocytic cell function. Laminin enhances complement and Fc-mediated phagocytosis by cultured human macrophages.

Brief exposure of culture-derived human macrophages to laminin, a glycoprotein component of all mammalian basement membranes that has a molecular weight of 1,000,000, led to enhancement of subsequent macrophage phagocytosis of EAC4b, EAC3bi, and EAIgG (sheep erythrocytes sensitized with IgG anti-Forssman antibody). This effect on macrophage phagocytosis occurred with both substrate-adherent and fluid phase laminin. Preincubation of macrophages, but not of EAC4b, with laminin led to augmentation of phagocytosis, suggesting that interaction with the phagocytic cell, but not with the opsonized particle, was required for laminin's effect. Laminin-stimulated phagocytosis of EAC4b was blocked entirely by a monoclonal antibody to CR1. Direct comparison of the phagocytic ability of macrophages adherent to laminin- and fibronectin-coated glass slides showed that fibronectin had a somewhat greater enhancing effect on phagocytosis. Nonetheless, the phagocytosis-enhancing effect of laminin was not due to contamination of the purified laminin preparation by fibronectin, since the laminin preparation was free of fibronectin, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and enzyme-linked immunosorbent assay; in addition, laminin-enhanced phagocytosis was decreased in the presence of laminin-specific antibodies. Laminin inhibited macrophage adherence and spreading, but selection of a laminin-binding macrophage subpopulation could not account for the laminin-induced increases in phagocytosis. We hypothesize that interaction with extracellular matrix proteins may represent an important activation stimulus both to the macrophages normally present in the extravascular compartment and to the phagocytic cells that have emigrated from the blood-stream into areas of inflammation.

Effects of marine reserves on adjacent fisheries.

Marine reserves have been widely promoted as conservation and fishery management tools. There are robust demonstrations of conservation benefits, but fishery benefits remain controversial. We show that marine reserves in Florida (United States) and St. Lucia have enhanced adjacent fisheries. Within 5 years of creation, a network of five small reserves in St. Lucia increased adjacent catches of artisanal fishers by between 46 and 90%, depending on the type of gear the fishers used. In Florida, reserve zones in the Merritt Island National Wildlife Refuge have supplied increasing numbers of world record-sized fish to adjacent recreational fisheries since the 1970s. Our study confirms theoretical predictions that marine reserves can play a key role in supporting fisheries.

Lack of association between beta 2-adrenergic receptor polymorphisms and juvenile idiopathic arthritis.

OBJECTIVE: Juvenile idiopathic arthritis (JIA) is a chronic autoimmune arthropathy. Beta 2-adrenergic receptors are a link between the sympathetic nervous system and the immune system. Associations between variants in the gene encoding the beta 2-adrenergic receptor (ADRB2) and autoimmune disorders such as rheumatoid arthritis (RA) have been demonstrated. We aimed to investigate ADRB2 variants for association with JIA. METHODS: Genotypes and haplotypes of two ADRB2 variants (G16R and Q27E) were determined in 348 children with JIA and 448 healthy controls by direct molecular haplotyping using melting-curve analysis of a fluorescently labelled loci-spanning probe. Case-control analysis was performed to investigate whether ADRB2 variants were associated with JIA. RESULTS: No association was found between JIA and alleles, genotypes, or haplotypes of ADRB2. Specifically, the haplotype that demonstrated a strong association with RA (R16/Q27) was not associated with JIA. None of the variants demonstrated association after stratification by JIA subtypes or gender. CONCLUSIONS: Our results indicate that ADRB2 variants are not associated with JIA or any of the major JIA subtypes. These observations suggest that, although they share several clinical and pathological features, JIA and RA have unique genetic associations.

Juvenile idiopathic arthritis and exposure to fine particulate air pollution.

OBJECTIVES: Inhalation of fine particulate matter, including particles with an aerodynamic diameter less than or equal to a 2.5-microm cut point (PM2.5), has been associated with systemic inflammation and the clinical presentation of various cardiopulmonary heath events. The urban area along Utah's Wasatch Mountains has high PM2.5 concentrations during periods of stagnant air conditions. Short-term inhalation exposures may trigger inflammatory events presenting as symptom onset in new patients with juvenile idiopathic arthritis (JIA). This study evaluated potential associations between JIA symptom onset and temporal changes in regional air pollution measured by stagnant air conditions and PM2.5 concentrations. METHODS: A case-crossover design was used to analyze associations of regional ambient PM2.5 concentrations with onset date of 338 JIA cases living on Utah's Wasatch Front. Patients were drawn from the Intermountain States Database of Childhood Rheumatic Diseases (1993-2006). Time trends, seasonality, month, and weekday were controlled for by matching. Selected exposure windows of PM2.5 and stagnant air days were used in the model to determine the effect of short term cumulative exposure on JIA symptom onset. RESULTS: Increased concentrations of PM2.5 and stagnant air conditions in the preceding 14 days were associated with significantly elevated risk of JIA onset in preschool aged children (RR=1.60, 95% CI 1.00-2.54) but not older children. Elevated risk was larger in males and in systemic onset JIA. CONCLUSION: Exposure to stagnant polluted air may be an environmental risk factor for JIA in young children, potentially triggered by pollution-induced pulmonary mediated inflammation.

Mechanism of inhibition of immunoglobulin G-mediated phagocytosis by monoclonal antibodies that recognize the Mac-1 antigen.

We have investigated the effects of the monoclonal antibodies against the cell surface molecule Mac-1 on C3bi-mediated rosetting and IgG-mediated rosetting and phagocytosis by human peripheral blood monocytes. Highly purified M1/70 F(ab')2, used in the fluid phase, inhibited both monocyte functions. Half-maximal C3bi rosette inhibition occurred at a concentration of 2 nM F(ab')2 M1/70. An equivalent decrease in IgG-mediated rosetting required 10 nM M1/70 F(ab')2, and 50% inhibition of IgG-mediated phagocytosis required 7 nM antibody. Mo-1 F(ab')2 inhibited EC3bi binding with an ID50 of 0.3 nM, whereas 50% decrease in IgG-mediated rosetting required 70 nM of this antibody. OKM1 did not inhibit rosettes of sheep erythrocytes opsonized with IgG antibody (EA) at all. F(ab')2 M1/70 did not affect the binding of monomeric human IgG to monocytes, but did substantially decrease the binding of IgG aggregates. Half-maximal inhibition of aggregated IgG binding at 0 degrees C occurred at 8 nM F(ab')2 M1/70, very close to the concentration that caused equivalent inhibition of IgG-mediated phagocytosis. Aggregated IgG inhibited the binding of radiolabeled M1/70 to monocytes by approximately 40%, suggesting that some, but not all Mac-1 molecules were associated with IgG receptors under these conditions. When cells were allowed to adhere to surfaces coated with M1/70 or Mo-1 F(ab')2, C3bi-mediated rosetting was inhibited, but IgG mediated-phagocytosis was unaffected. Moreover, the dose response of inhibition of phagocytosis by fluid-phase F(ab')2, of anti-Mac-1 monoclonals was similar on monocytes adherent to albumin-coated and antibody-coated surfaces. Kinetic experiments showed that even prolonged incubation of monocytes on M1/70 coated surfaces did not lead to inhibition of EA binding nor did these incubations alter the dose response for inhibition of EA binding by fluid-phase M1/70 F(ab')2. This suggested that not all molecules recognized by M1/70 are freely mobile in the plasma membrane. Indeed, only approximately 60% of 125I-M1/70-biding sites were lost even after 4 h when monocytes were adherent to M1/70-coated surfaces. We conclude that some anti-Mac-1 antibodies can inhibit EA binding because of their epitope specificity, independent of any direct interaction with monocyte Fc receptors. This interference with IgG-Fc receptor-mediated binding and ingestion apparently occurs because of antibody binding to a subpopulation of Mac-1 molecules which are associated with IgG Fc receptors and remain on the apical membrane of monocytes adherent to anti-Mac-1-coated surfaces. We suggest that there may be two functionally distinct molecules on human monocytes recognized by M1/70 and Mo-1 that can be distinguished by their mobility in the plane of the monocyte membrane. The more mobile form of Mac-1 is involved in C3bi rosettes, and does not affect IgG-mediated phagocytosis. The other antigen recognized by M1/70 does not diffuse within the plane of the membrane; ligation of the latter molecule by antibody is associated with inhibition of IgG-mediated phagocytosis.

Demonstration of defective C3-receptor-mediated clearance by the reticuloendothelial system in patients with acquired immunodeficiency syndrome.

The function of macrophage C3 receptors was assessed in vivo by measuring the clearance of C3-sensitized autologous erythrocytes in seven acquired immunodeficiency syndrome (AIDS) patients, eight healthy homosexual men, eight healthy heterosexual men, and four infected controls. Healthy heterosexual men had an initial clearance of 50.1 +/- 2.0% of the inoculum, with a release of a small portion of these cells (10.9 +/- 1.3%) into the circulation. Healthy homosexual men had a greater initial clearance of 66.0 +/- 4.2% (P less than 0.01) followed by a similar release (14.0 +/- 3.3%). AIDS patients had an initial clearance of 60.6 +/- 7.5% but had a relatively large release of cells (25.6 +/- 3.2%) (P less than 0.005 vs. heterosexuals; P less than 0.05 vs. homosexuals), suggesting a failure of macrophage phagocytosis. Infected controls had an initial clearance of 59.4 +/- 4.9%, with a release of 19.6 +/- 3.8% (P = NS vs. AIDS). These data, in addition to Fc-receptor dysfunction, demonstrate a global reticuloendothelial system dysfunction in AIDS patients. This may contribute to their frequent infections with opportunistic pathogens and inappropriate immune responses against these microorganisms.

Genetic relatedness between group B streptococci originating from bovine mastitis and a human group B Streptococcus type V cluster displaying an identical pulsed-field gel electrophoresis pattern.

Twenty isolates of group B streptococcus (GBS) were recovered from the milk of cows with bovine mastitis on three farms located in the south and south-east of Brazil between 1987 and 1988. These isolates were characterised by molecular methods and compared with a collection of 103 human GBS isolates from colonised and infected patients in the same region between 1980 and 2003. Some of the bovine isolates shared identical or similar pulsed-field gel electrophoresis (PFGE) patterns with a PFGE clone of human GBS type V. In addition, these bovine and human isolates also possessed the same ribotype. Multilocus sequence typing (MLST) of representative isolates confirmed the genetic relationship between the human and bovine GBS isolates with identical PFGE patterns, which clustered in the same ST-26 clonal complex. These data support the hypothesis that some bovine GBS strains are related closely to human isolates and may infect humans, or vice versa. Further comparative genomic analyses of GBS isolates from bovine and human origins are required to investigate this hypothesis further.

Cyclosporine A in juvenile idiopathic arthritis. Results of the PRCSG/PRINTO phase IV post marketing surveillance study.

OBJECTIVE: To investigate the clinical use patterns, clinical effect and safety of cyclosporine A (CSA) in juvenile idiopathic arthritis (JIA) in the setting of routine clinical care. METHODS: An open-ended, phase IV post marketing surveillance study was conducted among members of the Pediatric Rheumatology Collaborative Study Group (PRCSG) and of the Paediatric Rheumatology International Trials Organisation (PRINTO) to identify patients with polyarticular course JIA who had received CSA during the course of their disease. RESULTS: A total of 329 patients, half of whom had systemic JIA, were collected in 21 countries. Data were collected during 1240 routine clinic visits. CSA was started at a mean of 5.8 years after disease onset and was given at a mean dose of 3.4 mg/kg/day. The drug was administered in combination with MTX in 61% and along with prednisone in 65% of the patients who were still receiving CSA. Among patients who were still receiving CSA therapy at the last reported visit, remission was documented in 9% of the patients, whereas in 61% of the patients the disease activity was rated as moderate or severe. The most frequent reason for discontinuation of CSA was insufficient therapeutic effect (61% of the patients); only 10% of the patients stopped CSA because of remission. In 17% of the patients, side effects of therapy was given as the primary reason for discontinuation. CONCLUSION: This survey suggests that CSA may have a less favourable efficacy profile than MTX and etanercept, whereas the frequency of side effects may be similar. The exact place of CSA in the treatment of JIA can only be established via controlled clinical trial.

Purification of the proteinase from group B streptococci that inactivates human C5a.

We previously reported that group B streptococci (GBS) possess a cell-associated activity that inactivates the chemotactic activity generated in zymosan-activated serum by cleaving a specific site within the carboxy termini of C5a and C5adesarg. This inactivates the major chemoattractants for neutrophils that are generated when serum complement is activated. We now report the isolation of the enzyme responsible for the proteolytic cleavage of C5a. Treatment of GBS with mutanolysin, an endo-N-acetyl muramidase, released activity from GBS which destroyed the functional activity of C5a. The soluble activity was purified to homogeneity by hydroxyapatite, ion-exchange and gel-filtration chromatography. Analysis by SDS-PAGE showed that the enzyme (GBS C5a-ase) has an Mr of approx. 120,000. The GBS C5a-ase appears to be a serine esterase on the basis of its sensitivity to di-isopropyl fluorophosphate. This enzyme is distinct from the C5a-cleaving enzyme produced by group A streptococci, since the two bacterial products migrate differently on SDS-PAGE, and lack antigenic cross reactivity. This enzyme may play a role in the pathogenesis of group B streptococcal disease through its ability to rapidly inactivate the potent neutrophil agonist, C5a, at sites of infection.

Aberrant glycosylation of L-selectin on the lymphocytes of chronic lymphocytic leukemia.

Abnormal trafficking of chronic lymphocytic leukemia (CLL) cells may account for the differences in accumulation of malignant lymphocytes within the bone marrow and lymphoid tissues of this lymphoproliferative disorder. We therefore hypothesized that CLL cells aberrantly express one or more receptors involved in lymphocyte trafficking. Leukemia cells from patients with B-cell CLL showed no quantitative difference in surface expression of L-selectin, LFA-1, or CD44 by flow cytometry compared to normal B cells. Analysis of L-selectin by dodecyl sulfate/polyacrylamide gel electrophoresis (SDS-PAGE) and Western blot, however, demonstrated a consistent, reproducible approximately 3.7 kDa decrease in the M(r) of L-selectin on CLL cells compared to normal B cells. In contrast, Western blot analysis revealed no obvious qualitative abnormality in either CD11a (the alpha-chain of LFA-1) or CD44 on CLL cells. Analysis of L-selectin cDNA by polymerase chain reaction revealed identically sized products for both normal and CLL cells, suggesting that the abnormality in M(r) does not result from a difference in primary structure. Inhibition of N-linked glycosylation by tunicamycin resulted in the production of identical-sized nascent L-selectin by normal and CLL cells. These studies demonstrate that L-selectin on CLL cells is aberrantly glycosylated compared to normal peripheral blood lymphocytes. The functional importance of this aberrant glycosylation is unclear, however, since L-selectin is shed normally from phorbol myristate acetate (PMA)-stimulated CLL cells and since normal and CLL lymphocytes bind equally well in vitro to high endothelial venules. Understanding the mechanism that accounts for the aberrance may provide important insights into the molecular basis of CLL.

Mechanisms of beta 1 integrin-dependent adherence of granulocytic HL60 to fibronectin.

We investigated the mechanism of beta 1 integrin-mediated adherence of stimulated granulocytic HL60 cells to fibronectin using a monoclonal antibody (15/7) that recognizes beta 1 integrins only when the receptors are active for ligand binding. Phorbol myristate acetate (PMA) stimulated expression of the 15/7 epitope on granulocytic HL60 by nearly fivefold but had an insignificant effect on the expression of the epitope on undifferentiated HL60 cells. These results paralleled the effect of PMA on HL60 and granulocytic HL60 adhesion to fibronectin, indicating that activation of beta 1 integrins is important for beta 1-mediated adherence of granulocytic HL60 cells to fibronectin. Agonists that stimulate alpha 5 beta 1-dependent human polymorphonuclear leukocyte (PMN) adhesion to fibronectin (C5a and PMA) also upregulated the 15/7 epitope on purified human PMNs. Although PMA rapidly induces increased levels of filamentous actin (F-actin) in granulocytic HL60 cells and a decrease in F-actin levels in undifferentiated HL60 cells, depolymerization of the actin cytoskeleton with cytochalasin B did not affect increased expression of the 15/7 epitope on granulocytic HL60 cells. Cytochalasin B did, however, inhibit granulocytic HL60 adherence to fibronectin by 50%, demonstrating that actin polymerization is important for optimal beta 1-dependent granulocytic adherence.

Induction of cyclooxygenase-2 by human monocytes exposed to group B streptococci.

Group B streptococcal (GBS) infections are associated with high morbidity and mortality. The molecular pathways mediating the pathophysiological events in GBS infection are not fully delineated. Cyclooxygenases (COX) are the enzymes that convert arachidonate to active eicosanoids. To identify the effects of GBS on eicosanoid metabolism and regulatory mechanisms, we exposed human monocytes to GBS and found that they secreted prostaglandin E2, prostacyclin, and thromboxane A2. Exposure to GBS caused monocytes to express COX-2 mRNA and protein in both a time- and concentration-dependent manner that correlated with eicosanoid production. COX-1 protein was unchanged. Addition of the anti-inflammatory cytokines interleukin (IL)-4 or IL-10 markedly attenuated GBS-induced COX-2 protein accumulation after GBS exposure, as did inhibition of p38 MAPK. Our experiments are the first to show that exposure of monocytes to a gram-positive bacterium (GBS) results in induction of functional COX-2, suggesting that eicosanoids may play important roles in the pathogenesis of GBS infections.

Evidence for a conformational change in human fibronectin which occurs between 4 and 37 degrees C.

The effects of temperatures between 4 and 37 degrees C on the structure of human fibronectin (Fn) using monoclonal antibodies (MAb) with specificity for Fn have been studied. Three MAb bound to Fn in solution better at 4 than at 37 degrees C, assessed by both ELISA and immunoprecipitation. These MAb detected temp-dependent conformational changes in Fn which were not associated with a major refolding of the Fn molecule, since the S20,w of Fn and the binding of Fn to polyclonal anti-Fn were unchanged by temp shifts from 4 to 37 degrees C. Fn also was adhered directly to ELISA plates at 4 and at 37 degrees C, and then probed with MAb, with detergents, and with trypsin. One MAb bound better to surface adherent Fn when the Fn had bound to the surface at 4 rather than 37 degrees C. Both SDS and polyoxyethylene (20) sorbitan monolaurate (Tween-20) caused the release of more adherent Fn from surfaces to which it had adhered at 4 degrees C. Finally, trypsin released Fn fragments more rapidly and more completely from surfaces coated at 4 than at 37 degrees C. It is concluded that Fn has different conformations at 4 and 37 degrees C in solution and after adherence to surfaces, as reflected by MAb binding, detergent sensitivity and protease susceptibility. This conformational difference is not associated with alterations in the physiochemical properties of the molecule and is thus a result of a less extensive intramolecular rearrangement than the conformational changes resulting from manipulations of ionic strength or pH, and from binding to collagen or hydrophobic surfaces. Nonetheless, the more subtle conformational change demonstrated here may be important for the biological properties of Fn.

Distal arthrogryposis type 1: clinical analysis of a large kindred.

We describe the clinical findings of 15 individuals in a large kindred affected with distal arthrogryposis type 1A (DA1A). The most consistent findings among individuals were overlapping fingers at birth, abnormal digital flexion creases, and foot deformities, including talipes equinovarus and vertical talus. There was marked intrafamilial variation in the expression of DA1A. Linkage mapping of the locus for DA1A suggests that the use of strict diagnostic criteria excludes unaffected individuals rigorously, but can produce incomplete ascertainment of affected individuals. In the context of an affected family, the range of phenotypes consistent with a diagnosis of DA1A needs to be expanded.

Clinical analysis of a variant of Freeman-Sheldon syndrome (DA2B).

We describe the clinical characteristics of a provisionally unique form of distal arthrogryposis. The anomalies observed in affected individuals are more severe than those in distal arthrogryposis type 1 and are similar to but less dramatic than those described in distal arthrogryposis type 2A (Freeman-Sheldon syndrome). Consequently, we label this disorder distal arthrogryposis type 2B (DA2B). Affected individuals have vertical talus, ulnar deviation, severe camptodactyly, and a distinctive face characterized by a triangular shape, prominent nasolabial folds, downslanting palpebral fissures, small mouth, and a prominent chin. A gene for DA2B maps to chromosome 11p15.5. We suggest that DA2B is partly responsible for the clinical variability observed in Freeman-Sheldon syndrome.

Growth failure, intracranial calcifications, acquired pancytopenia, and unusual humoral immunodeficiency: a genetic syndrome?

We report on two children who may represent a novel syndrome consisting of a deficiency of immunoglobulin-bearing B lymphocytes and serum antibody, deficient intrauterine and/or postnatal growth, intracranial calcifications, and acquired pancytopenia. Poor growth, intracranial calcifications, developmental delay, and hematological abnormalities are common manifestations of congenital infection. However, humoral immunodeficiency is not characteristic in these infections, and no infection was found on extensive evaluation. Rare genetic syndromes may mimic intrauterine infections and may also include immunodeficiency. However the children reported here lack important characteristics or share distinctive manifestations not described in these disorders. Infants presenting with apparent congenital infections in whom a specific infectious cause cannot be identified should be followed carefully with immunological evaluations since this disorder may be progressive and considerable morbidity is attributable to hematological and immunological manifestations.