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Abstract Number: 032

From Bedside to Bench and Back: Discovery of a Novel Missense Variant in NLRP3 Causing Atypical Cryopyrin-Associated Periodic Syndromes with Hearing Loss as the Primary Presentation, Responsive to Anti-IL1 Therapy

Merav Birk-Bachar1, Hadar Cohen2, Yoel Levinsky3, rotem tal4, Gil Amarilyo5, Meirav Sokolov6, Efrat Sofrin-Drucker7, Naama Orenstein7, Gabriel Lidzbarsky7, Liora Kornreich8, Eyal Raveh6, Nesya Kropach-Gilad7, Motti Gerlic2 and Liora Harel9, 1Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel, 2Sackler Faculty of Medicine, Immunology Department, Tel Aviv University, Tel Aviv, Israel, 3Schneider Children's Medical Center of Israel, Tel Aviv University, Petach Tikva, Israel, 4Schneider Children's Medical Center of Israel, Petach Tikva, Israel, 5Schneider Children's Medical Center of Israel, Petach Tikva, Israel, 6Pediatric Ear Nose and Throat Unit Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel, 7Recanati Genetic Institute, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel, 8Pediatric Imaging Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel, 9Scheiders Children Medical Center of Israel, Petah-Tiqva, Israel

Meeting: 2023 Pediatric Rheumatology Symposium

Keywords: Autoinflammatory diseases, Biologicals, Inflammasome, Innate Immunity Rheumatic Disease

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Session Information

Date: Friday, March 31, 2023

Title: Poster Breakout 5 - Autoinflammatory/Vasculitis: STAT3, NLRP3, KD and MIS-C

Session Type: Breakout Session

Session Time: 4:30PM-5:00PM

Background/Purpose: Cryopyrin-associated periodic syndromes (CAPS) are a spectrum of rare autoinflammatory diseases caused by gain-of-function mutations inthe NLRP3 gene. These mutations cause inflammasome hyperactivity and subsequent uncontrolled release of Interleukin-1β (IL-1β). CAPS patients may develop progressive sensorineural hearing loss (SNHL) due to cochlear autoinflammation, initially affecting the high-ultrahigh frequency ranges. In rare instances this may be the sole presenting symptom. A Jewish Ashkenazi family presented with autosomal dominant SNHL, a novel missense variant of unknown significance in the NLRP3 gene 001079821:c.1790G >A p.Ser597Asn, however they did not fulfill CAPS classification criteria. In order to establish the suspected diagnosis of atypical CAPS causing SNHL, and enable initiation of Anti-IL1 therapy, we performed functional studies of the inflammasome to evaluate whether the variant leads to inflammasome hyperactivity.

Methods: Our prospective study included 15 family members (10 known carriers, 5 age-group matched non-carriers who served as controls). We conducted clinical and hearing assessments along with ex-vivo functional studies of inflammasome activity. Secreted levels of IL-1β from peripheral-blood mononuclear cells (PBMCs) in carriers versus controls, were measured under 3 main conditions: basal state, in response to priming signal alone (LPS- lipopolysaccharide or LPS+CaCl2), and in response to priming signal along with specific inflammasome inhibitor (MCC950).

Results: Of the 10 known carriers spanning 3 generations, 7 suffered from SNHL. Although most presented progressive deterioration classically associated with CAPS, some suffered from sudden episodes of unilateral SNHL as well. The severity of hearing impairment ranged from moderate, involving the high-ultrahigh frequency, to severe hearing loss requiring cochlear implant. Functional assessment of the inflammasome in carriers vs. non carriers (controls) revealed that although basal levels of secreted IL-1β were not significantly different, PBMCs isolated from NLRP3 variant carriers primed with either LPS or LPS+CaCl2 showed significantly higher secretion of IL-1β than healthy subjects. Inflammasome inhibition with MCC950 prior to addition of LPS+CaCl2 resulted in relative suppression of IL-1β secretion (Fig. 1). This evidence of NLRP3 inflammasome hyperactivity confirmed the suspected diagnosis of atypical CAPS. Indeed, administration of Anakinra therapy resulted in substantial clinical improvement, particularly among pediatric patients who exhibited near resolution of hearing impairment within 1-3 months of treatment (Fig. 2).

Conclusion: Our study revealed a novel pathogenic variant in NLRP3, causing atypical CAPS with a primary presentation of SNHL- responsive to Anti IL1 therapy. These findings highlight the crucial role of early diagnosis and subsequent treatment in reversing cochlear damage. Auditory assessment of the high and ultrahigh frequency range is important and can detect early subclinical SNHL. Incorporating functional inflammasome assessment as part of the clinical evaluation could establish the diagnosis in inconclusive cases.

Supporting image 1Ex Vivo NLRP3 Inflammasome Functional Assessment

Supporting image 2 Pure-tone audiometry Pre and Post Anakinra Treatment


Disclosures: M. Birk-Bachar: None; H. Cohen: None; Y. Levinsky: None; r. tal: None; G. Amarilyo: None; M. Sokolov: None; E. Sofrin-Drucker: None; N. Orenstein: None; G. Lidzbarsky: None; L. Kornreich: None; E. Raveh: None; N. Kropach-Gilad: None; M. Gerlic: None; L. Harel: None.

To cite this abstract in AMA style:

Birk-Bachar M, Cohen H, Levinsky Y, tal r, Amarilyo G, Sokolov M, Sofrin-Drucker E, Orenstein N, Lidzbarsky G, Kornreich L, Raveh E, Kropach-Gilad N, Gerlic M, Harel L. From Bedside to Bench and Back: Discovery of a Novel Missense Variant in NLRP3 Causing Atypical Cryopyrin-Associated Periodic Syndromes with Hearing Loss as the Primary Presentation, Responsive to Anti-IL1 Therapy [abstract]. Arthritis Rheumatol. 2023; 75 (suppl 4). https://acrabstracts.org/abstract/from-bedside-to-bench-and-back-discovery-of-a-novel-missense-variant-in-nlrp3-causing-atypical-cryopyrin-associated-periodic-syndromes-with-hearing-loss-as-the-primary-presentation-responsive-to-ant/. Accessed .
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