Proposal of a new diagnostic algorithm for adult-onset Still's disease.

OBJECTIVE: This study was performed to develop a new diagnostic algorithm for adult-onset Still's disease (AOSD). METHODS: We conducted a multicenter prospective nationwide case-control study in tertiary Internal Medicine, Rheumatology, and Infectious Diseases departments, to include successively patients with suspected AOSD based on the presence of two or more major criteria of Yamaguchi and/or Fautrel classifications. Patients were classified as AOSD or controls according to a predefined procedure. A receiving operating characteristic curve was used to determine the best cutoff value of the points-based score for disease classification. A diagnostic algorithm was developed to help the physician in the diagnostic approach. RESULTS: A total of 160 patients were included, 80 patients with AOSD and 60 controls with different diagnoses. Twenty patients with incomplete data were excluded. In the multivariate analysis, 6 items remained independently associated with AOSD diagnosis: typical rash (OR: 24.01, 3 points), fever ≥ 39 °C (OR: 17.34, 3 points), pharyngitis (OR: 10.23, 2 points), arthritis (OR: 9.01, 2 points), NLR ≥ 4 (OR: 11.10, 2 points), and glycosylated ferritin ≤ 20% (OR: 1.59, 1 point). AOSD should be considered if the patient satisfies 7 points with a sensitivity of 92.5%, specificity of 93.3%, and accuracy of 92.8% (area under the curve (AUC): 0.97 [95% CI: 0.94-0.99]). The present points-based score was more accurate and sensitive than the Yamaguchi classification (78.8%, 92.5%, p = 0.01) and Fautrel classification (76.3%, 92.5%, p = 0.004). A typical rash associated with a points-based score ≥ 7 points leads to a very likely disease. CONCLUSION: The proposed new algorithm could be a good diagnostic tool for adult-onset Still's disease in clinical practice and research. Key Points • A diagnostic algorithm was performed to help the physician in the diagnostic approach of AOSD. • The points-based score included in this algorithm had a high sensitivity and accuracy. • This diagnostic algorithm can be useful in the clinical research.

Validation of the neutrophil-to-lymphocyte ratio as a new simple biomarker of adult onset Still's disease: A STROBE-Compliant prospective observational study.

This study was performed to investigate the role of neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of adult onset Still disease (AOSD) and its performance to improve the sensitivity of the classifications criteria (Yamaguchi and Fautrel Classifications). We conducted a multicenter prospective nationwide case-control study in Internal medicine, Rheumatology and Infectious disease departments, to include successively patients with suspected AOSD (2 or more major criteria of Yamaguchi or Fautrel classifications). All clinical and biological features were collected in a consensual and standardized clinical assessment at baseline and during follow-up. A receiving operating characteristic (ROC) curve was used to reassess the cutoff value of NLR. After determination of the cutoff value for NLR by ROC curve, 2 composite sets (Yamaguchi classification + NLR as a major criterion and Fautrel classification + NLR as a major criterion) were performed and evaluated. One hundred sixty patients were included, 80 patients with AOSD and 60 controls with different diagnoses. Twenty patients with incomplete data were excluded. The cutoff value for NLR equals 4 (area under the curve, AUC: 0.82). The NLR was ≥ 4 in 93.7% (75/80) of AOSD patients with a sensitivity of 93.8% and specificity of 61.7%. The association of NLR as a major criterion with the classification of Yamaguchi or Fautrel improved their sensitivity, respectively for Fautrel (76.3% to 92.5%, P = .004) and Yamaguchi (78.8% to 90%, P = .05). This study validates the NLR as a good simple biomarker of AOSD with a cutoff value of 4 and high sensitivity (93.8%). The addition of NLR (NLR ≥ 4) as a major criterion to the classifications (Yamaguchi and Fautrel) improved significantly their sensitivity and accuracy.

Reconsidering vitamin D optimal values based on parathyroid hormone levels in a North Algerian cohort: stratification by gender and season.

"Health-based threshold value" is used to define the optimal cutoff of vitamin D. This approach is based on the hypothesis of a secondary hyperparathyroidism associated with hypovitaminosis D. We define the optimal values in a North Algerian population. The optimal value is 25.0 ng/ml in men and 30.0 ng/ml in women. PURPOSE/INTRODUCTION: There is no consensus defining the vitamin D optimal values. The aim of this study is to establish vitamin D optimal values in the Northern Algerian population, based on its skeletal effects as represented by the inverse relationship between 25-hydroxy vitamin D (25(OH) D) and parathyroid hormone (PTH). METHODS: 451 healthy volunteers of both genders, aged 19 to 79 years, were enrolled in a cross-sectional study conducted at the medical analysis laboratory of the University Hospital of Blida, Algeria. 25(OH) D was assessed by a sequential competitive immuno-fluoroassay technique. Determination of vitamin D optimal values was performed based on the kinetic relationship between 25(OH) D and PTH, as explored by inverse nonlinear regression on a spline plots curve. The optimal value represents the 25(OH) D level at which PTH ceases to increase and reaches a virtual plateau. RESULTS: In men and women, respectively, the 25 (OH) D thresholds are estimated at 25.0 ng/ml and 30 ng/ml, above this value, PTH stabilizes in a virtual plateau, estimated at 22.3 pg/ml and 26.8 pg/ml. In warm and cold seasons, respectively, the 25 (OH) D cut-offs are estimated at 30.0 ng/ml and 25.0 ng/ml, from these values, the PTH stabilizes in a virtual plateau, estimated at 21.5 pg/ml and 27.7 pg/ml. CONCLUSION: In this study, the optimal values of 25(OH) D were defined for the first time in a North Algerian adult population. The optimal value is 25.0 ng/ml in men and 30.0 ng/ml in women.

Diversity of the Genes Implicated in Algerian Patients Affected by Usher Syndrome.

Usher syndrome (USH) is an autosomal recessive disorder characterized by a dual sensory impairment affecting hearing and vision. USH is clinically and genetically heterogeneous. Ten different causal genes have been reported. We studied the molecular bases of the disease in 18 unrelated Algerian patients by targeted-exome sequencing, and identified the causal biallelic mutations in all of them: 16 patients carried the mutations at the homozygous state and 2 at the compound heterozygous state. Nine of the 17 different mutations detected in MYO7A (1 of 5 mutations), CDH23 (4 of 7 mutations), PCDH15 (1 mutation), USH1C (1 mutation), USH1G (1 mutation), and USH2A (1 of 2 mutations), had not been previously reported. The deleterious consequences of a missense mutation of CDH23 (p.Asp1501Asn) and the in-frame single codon deletion in USH1G (p.Ala397del) on the corresponding proteins were predicted from the solved 3D-structures of extracellular cadherin (EC) domains of cadherin-23 and the sterile alpha motif (SAM) domain of USH1G/sans, respectively. In addition, we were able to show that the USH1G mutation is likely to affect the binding interface between the SAM domain and USH1C/harmonin. This should spur the use of 3D-structures, not only of isolated protein domains, but also of protein-protein interaction interfaces, to predict the functional impact of mutations detected in the USH genes.

A novel biallelic splice site mutation of TECTA causes moderate to severe hearing impairment in an Algerian family.

Congenital deafness is certainly one of the most common monogenic diseases in humans, but it is also one of the most genetically heterogeneous, which makes molecular diagnosis challenging in most cases. Whole-exome sequencing in two out of three Algerian siblings affected by recessively-inherited, moderate to severe sensorineural deafness allowed us to identify a novel splice donor site mutation (c.5272+1G > A) in the gene encoding α-tectorin, a major component of the cochlear tectorial membrane. The mutation was present at the homozygous state in the three affected siblings, and at the heterozygous state in their unaffected, consanguineous parents. To our knowledge, this is the first reported TECTA mutation leading to the DFNB21 form of hearing impairment among Maghrebian individuals suffering from congenital hearing impairment, which further illustrates the diversity of the genes involved in congenital deafness in the Maghreb.

IL36RN Mutations Affect Protein Expression and Function: A Basis for Genotype-Phenotype Correlation in Pustular Diseases.

Homozygous or compound heterozygous IL36RN gene mutations underlie the pathogenesis of psoriasis-related pustular eruptions including generalized pustular psoriasis, palmoplantar pustular psoriasis, acrodermatitis continua of Hallopeau, and acute generalized exanthematous pustular eruption. We identified two unreported IL36RN homozygous mutations (c.41C>A/p.Ser14X and c.420_426del/p.Gly141MetfsX29) in patients with familial generalized pustular psoriasis. We analyzed the impact of a spectrum of IL36RN mutations on IL-36 receptor antagonist protein by using site-directed mutagenesis and expression in HEK293T cells. This enabled us to differentiate null mutations with complete absence of IL-36 receptor antagonist (the two previously unreported mutations, c.80T>C/p.Leu27Pro, c.28C>T/p.Arg10X, c.280G>T/p.Glu94X, c.368C>G/p.Thr123Arg, c.368C>T/p.Thr123Met, and c.227C>T/p.Pro76Leu) from mutations with decreased (c.95A>G/p.His32Arg, c.142C>T/p.Arg48Trp, and c.308C>T/p.Ser113Leu) or unchanged (c.304C>T/p.Arg102Trp and c.104A>G/p.Lys35Arg) protein expression. Functional assays measuring the impact of mutations on the capacity to repress IL-36-dependent activation of the NF-κB pathway showed complete functional impairment for null mutations, whereas partial or no impairment was observed for other mutations considered as hypomorphic. Finally, null mutations were associated with severe clinical phenotypes (generalized pustular psoriasis, acute generalized exanthematous pustular eruption), whereas hypomorphic mutations were identified in both localized (palmoplantar pustular psoriasis, acrodermatitis continua of Hallopeau) and generalized variants. These results provide a preliminary basis for genotype-phenotype correlation in patients with deficiency of the IL-36Ra (DITRA), and suggest the involvement of other factors in the modulation of clinical expression.

The CD2 isoform of protocadherin-15 is an essential component of the tip-link complex in mature auditory hair cells.

Protocadherin-15 (Pcdh15) is a component of the tip-links, the extracellular filaments that gate hair cell mechano-electrical transduction channels in the inner ear. There are three Pcdh15 splice isoforms (CD1, CD2 and CD3), which only differ by their cytoplasmic domains; they are thought to function redundantly in mechano-electrical transduction during hair-bundle development, but whether any of these isoforms composes the tip-link in mature hair cells remains unknown. By immunolabelling and both morphological and electrophysiological analyses of post-natal hair cell-specific conditional knockout mice (Pcdh15ex38-fl/ex38-fl Myo15-cre+/-) that lose only this isoform after normal hair-bundle development, we show that Pcdh15-CD2 is an essential component of tip-links in mature auditory hair cells. The finding, in the homozygous or compound heterozygous state, of a PCDH15 frameshift mutation (p.P1515Tfs*4) that affects only Pcdh15-CD2, in profoundly deaf children from two unrelated families, extends this conclusion to humans. These results provide key information for identification of new components of the mature auditory mechano-electrical transduction machinery. This will also serve as a basis for the development of gene therapy for deafness caused by PCDH15 defects.

IFN-γ and TNF-α are involved during Alzheimer disease progression and correlate with nitric oxide production: a study in Algerian patients.

Alzheimer's disease (AD) is a neurodegenerative disease leading to a progressive and irreversible loss of mental functions. It is characterized by 3 stages according to the evolution and the severity of the symptoms. This disease is associated with an immune disorder, which appears with significant rise in the inflammatory cytokines and increased production of free radicals such as nitric oxide (NO). Our study aims to investigate interferon (IFN)-γ and tumor necrosis factor-α (TNF-α) involvement in NO production, in vivo and ex vivo, in peripheral blood mononuclear cells from Algerian patients (n=25), according to the different stages of the disease (mild Alzheimer's, moderate Alzheimer's, and severe Alzheimer's) in comparison to mild cognitive impairment (MCI) patients. Interestingly, we observed that in vivo IFN-γ and TNF-α levels assessed in patients with AD in mild and severe stages, respectively, are higher than those observed in patients with moderate stage and MCI. Our in vivo and ex vivo results show that NO production is related to the increased levels of IFN-γ and TNF-α, in mild and severe stages of AD. Remarkably, significant IFN-γ level is only detected in mild stage of AD. Our study suggests that NO production is IFN-γ dependent both in MCI and mild Alzheimer's patients. Further, high levels of NO are associated with an elevation of TNF-α levels in severe stage of AD. Collectively, our data indicate that the proinflammatory cytokine production seems, in part, to be involved in neurological deleterious effects observed during the development of AD through NO pathway.

EPS8, encoding an actin-binding protein of cochlear hair cell stereocilia, is a new causal gene for autosomal recessive profound deafness.

BACKGROUND: Almost 90% of all cases of congenital, non-syndromic, severe to profound inherited deafness display an autosomal recessive mode of transmission (DFNB forms). To date, 47 causal DFNB genes have been identified, but many others remain to be discovered. We report the study of two siblings born to consanguineous Algerian parents and affected by isolated, profound congenital deafness. METHOD: Whole-exome sequencing was carried out on these patients after a failure to identify mutations in the DFNB genes frequently involved. RESULTS: A biallelic nonsense mutation, c.88C > T (p.Gln30*), was identified in EPS8 that encodes epidermal growth factor receptor pathway substrate 8, a 822 amino-acid protein involved in actin dynamics. This mutation predicts a truncated inactive protein or no protein at all. The mutation was also present, in the heterozygous state, in one clinically unaffected sibling and in both unaffected parents, and was absent from the other two unaffected siblings. It was not found in 120 Algerian normal hearing control individuals or in the Exome Variant Server database. EPS8 is an F-actin capping and bundling protein. Mutant mice lacking EPS8 (Eps8-/- mice), which is present in the hair bundle, the sensory antenna of the auditory sensory cells that operate the mechano-electrical transduction, are also profoundly deaf and have abnormally short hair bundle stereocilia. CONCLUSION: This new DFNB form is likely to arise from abnormal hair bundles resulting in compromised detection of physiological sound pressures.

[Preliminary evaluation of the antioxidant trace elements in an Algerian patient with type 2 diabetes: special role of manganese and chromium]. / Évaluation primaire du statut antioxydant oligominéral chez le patient diabétique de type 2 algérien : intérêt particulier du manganèse et du chrome.

In type 2 diabetes, the relationship between antioxidants and insuline-like trace elements is very complex during oxidative stress, being mediated by hyperglycemia, dyslipidemia and inflammation. We investigated the antioxidant status, particularly Mn and Cr on the diabetes metabolic control, and their interaction with the metabolic syndrome (MS) parameters. The study was undertaken on 278 Algerian diabetic subjects who were divided in 2 groups according to glycated hemoglobin (HbA(1c)) <7% or >7% value, attesting for a good or poor metabolic control of diabetes, respectively. The MS was defined according to NCEP-ATPIII. Insulin resistance was evaluated by HOMA-IR model. The plasma manganese concentrations was significantly increased in both diabetics groups, independently of metabolic control. However, chromium (Cr) seems to play a determinant action in metabolic control, as shown by better values of insulin resistance (HOMA-IR) and HbA(1c). The selenium status was positively correlated with glutathion peroxidase activity. Copper and zinc plasma levels in the diabetic patients were similar to those of control subjects. In conclusion, our results suggest that Mn play a crucial role in antioxidant capacity and we hypothesize that antioxidant defense is preserved in the cytosol (superoxide dismutase Cu/Zn -SOD), whereas it is impaired in mitochondria (Mn-SOD), which makes this cell organelle a true therapeutic target in diabetes.

Polymorphisms in NAT2 gene and atherosclerosis in an Algerian population.

BACKGROUND AND AIMS: The etiology of atherosclerosis is multifactorial. Genetic and environmental factors are involved in the development of atherosclerosis. Human arylamine N-acetyltransferase 2 (NAT2) is an important metabolizing enzyme that exhibits genetic polymorphisms and modifies individual response and/or toxicity to many xenobiotics. We undertook this study to investigate the NAT2 polymorphisms in patients with atherosclerosis. METHODS: Genotyping for NAT2 alleles was performed using polymerase chain reaction-restriction fragment-length polymorphism (PCR-RFLP) in 285 Algerian patients with atherosclerosis and 286 controls. RESULTS: There was no association between NAT2 polymorphisms and atherosclerosis risk. However, the haplotype NAT2(*)5F decreased susceptibility to the disease (p = 0.005, OR = 0.55, 95% CI = 0.37-0.84). The frequency of the slow acetylator phenotype was approximately 50% in both cases and controls. CONCLUSIONS: These results suggest that NAT2 polymorphisms may not be involved in the pathogenesis of atherosclerosis.

Molecular screening of deafness in Algeria: high genetic heterogeneity involving DFNB1 and the Usher loci, DFNB2/USH1B, DFNB12/USH1D and DFNB23/USH1F.

A systematic approach, involving haplotyping and genotyping, to the molecular diagnosis of non-syndromic deafness within 50 families and 9 sporadic cases from Algeria is described. Mutations at the DFNB1 locus (encompassing the GJB2 and GJB6 genes) are responsible for more than half of autosomal recessive prelingual non-syndromic deafness in various populations. A c.35delG mutation can account for up to 85% of GJB2 mutations and two large deletions del(GJB6-D13S1830) and del(GJB6-D13S1854) have also been reported in several population groups. In view of the genetic heterogeneity a strategy was developed which involved direct analysis of DFNB1. In negative familial cases, haplotype analysis was carried out, where possible, to exclude DFNB1 mutations. Following this, haplotype analysis of five Usher syndrome loci, sometimes involved in autosomal non-syndromic hearing loss, was carried out to identify cases in which Usher gene sequencing was indicated. When homozygosity was observed at a locus in a consanguineous family, the corresponding gene was exhaustively sequenced. Pathogenic DFNB1 genotypes were identified in 40% of the cases. Of the 21 cases identified with 2 pathogenic mutations, c.35delG represented 76% of the mutated alleles. The additional mutations were one nonsense, two missense and one splicing mutation. Four additional patients were identified with a single DFNB1 mutation. None carried the large deletions. Three families with non-syndromic deafness carried novel unclassified variants (UVs) in MYO7A (1 family) and CDH23 (2 families) of unknown pathogenic effect. Additionally, molecular diagnosis was carried out on two Usher type I families and pathogenic mutations in MYO7A and PCDH15 were found.

A predominantly neolithic origin for Y-chromosomal DNA variation in North Africa.

We have typed 275 men from five populations in Algeria, Tunisia, and Egypt with a set of 119 binary markers and 15 microsatellites from the Y chromosome, and we have analyzed the results together with published data from Moroccan populations. North African Y-chromosomal diversity is geographically structured and fits the pattern expected under an isolation-by-distance model. Autocorrelation analyses reveal an east-west cline of genetic variation that extends into the Middle East and is compatible with a hypothesis of demic expansion. This expansion must have involved relatively small numbers of Y chromosomes to account for the reduction in gene diversity towards the West that accompanied the frequency increase of Y haplogroup E3b2, but gene flow must have been maintained to explain the observed pattern of isolation-by-distance. Since the estimates of the times to the most recent common ancestor (TMRCAs) of the most common haplogroups are quite recent, we suggest that the North African pattern of Y-chromosomal variation is largely of Neolithic origin. Thus, we propose that the Neolithic transition in this part of the world was accompanied by demic diffusion of Afro-Asiatic-speaking pastoralists from the Middle East.

Mutations in COL6A3 cause severe and mild phenotypes of Ullrich congenital muscular dystrophy.

Ullrich congenital muscular dystrophy (UCMD) is an autosomal recessive disorder characterized by generalized muscular weakness, contractures of multiple joints, and distal hyperextensibility. Homozygous and compound heterozygous mutations of COL6A2 on chromosome 21q22 have recently been shown to cause UCMD. We performed a genomewide screening with microsatellite markers in a consanguineous family with three sibs affected with UCMD. Linkage of the disease to chromosome 2q37 was found in this family and in two others. We analyzed COL6A3, which encodes the alpha3 chain of collagen VI, and identified one homozygous mutation per family. In family I, the three sibs carried an A-->G transition in the splice-donor site of intron 29 (6930+5A-->G), leading to the skipping of exon 29, a partial reduction of collagen VI in muscle biopsy, and an intermediate phenotype. In family II, the patient had an unusual mild phenotype, despite a nonsense mutation, R465X, in exon 5. Analysis of the patient's COL6A3 transcripts showed the presence of various mRNA species-one of which lacked several exons, including the exon containing the nonsense mutation. The deleted splice variant encodes collagen molecules that have a shorter N-terminal domain but that may assemble with other chains and retain a functional role. This could explain the mild phenotype of the patient who was still ambulant at age 18 years and who showed an unusual combination of hyperlaxity and finger contractures. In family III, the patient had a nonsense mutation, R2342X, causing absence of collagen VI in muscle and fibroblasts, and a severe phenotype, as has been described in patients with UCMD. Mutations in COL6A3 are described in UCMD for the first time and illustrate the wide spectrum of phenotypes which can be caused by collagen VI deficiency.