In a recent report, the cellular receptor CD55 was identified as a molecule essential for the invasion of human erythrocytes by Plasmodium falciparum, the causal agent of the most severe form of malaria. As this invasion process represents a critical step during infection with the parasite, it was hypothesized that genetic variants in the gene could affect severe malaria (SM) susceptibility. We performed high-resolution variant discovery of rare and common genetic variants in the human CD55 gene. Association testing of these variants in over 1700 SM cases and unaffected control individuals from the malaria-endemic Ashanti Region in Ghana, West Africa, were performed on the basis of single variants, combined rare variant analyses, and reconstructed haplotypes. A total of 26 genetic variants were detected in coding and regulatory regions of CD55. Five variants were previously unknown. None of the single variants, rare variants, or haplotypes showed evidence for association with SM or P. falciparum density. Here, we present the first comprehensive analysis of variation in the CD55 gene in the context of SM and show that genetic variants present in a Ghanaian study group appear not to influence susceptibility to the disease.

The genetic basis of congenital heart disease remains unknown in most of the cases. Recently, a novel mouse model shed new light on the role of CCN1/CYR61, a matricellular regulatory factor, in cardiac morphogenesis. In a candidate gene approach, we analyzed a cohort of 143 patients with atrial septal defects (ASD) by sequencing the coding exons of CCN1. In addition to three frequent polymorphisms, we identified an extremely rare novel heterozygous missense mutation (c.139C > T; p.R47W) in one patient with severe ASD. The mutation leads to an exchange of residues with quite different properties in a highly conserved position of the N-terminal insulin-like growth factor binding protein module. Further bioinformatic analysis, exclusion of known ASD disease genes as well as the exclusion of the mutation in a very high number of ethnically matched controls (more than 1,000 individuals) and in public genetic databases, indicates that the p.R47W variant is a probable disease-associated mutation. The report about ASD in mice in heterozygous Ccn 1 +/- animals strongly supports this notion. Our study is the first to suggest a relationship between a probable CCN1 mutation and ASD. Our purpose here was to draw attention to CCN1, a gene that we believe may be important for genetic analysis in patients with congenital heart disease.

Sickle cell disease is among hereditary diseases with evidence that early diagnoses and treatment improves the clinical outcome. So far sickle cell disease has not been included in the German newborn screening program despite immigration from countries with populations at risk. To determine the birth prevalence we tested 17,018 newborns. High pressure liquid chromatography and subsequent molecular-genetic testing were used for the detection and confirmation of hemoglobin variants. The frequency of sickle cell disease-consistent genotypes was one in 2,385 newborns. Duffy-blood group typing showed evidence that affected children were likely of Sub-Saharan ancestry. An inclusion of sickle cell disease into the German newborn screening seems reasonable.

Our results suggest that there are at least two different underlying mechanisms of malaria anaemia, uncomplicated anaemia characterized by a slow and continuous development towards a deficit of red blood cells, and anaemia with complications characterized by a rapid and substantial loss of red blood cells. The uncomplicated form appears to be caused by chronic systemic inflammatory processes rather than malaria episodes or parasite densities, similar to what is found in other forms of anaemia of chronic disease (ACD).

Background:Malaria transmission is heterogeneous. Villages close to each other may have very different transmission characteristics. The presence and abundance of malaria vectors is governed by local ecology and microclimate. Knowledge of the dynamics of transmission is important for planning and evaluation of malaria control strategies. This study investigated the heterogeneity of malaria transmission in preparation for a vaccine trial and offers insights into dynamics of malaria incidence in the forest zone of Ghana.Methods:Malaria transmission was assessed in four villages with different micro-ecological features in the forest zone of the Akwapim-Mampong Range in Ghana, water shed with rivers flowing north to Lake Volta in the south. Human landing catches (HLC) of mosquitoes were conducted and Plasmodium falciparum circumsporozoite rates were assessed by ELISA. Sporozoite prevalence, annual biting rates (ABR) and entomological inoculation rates (EIR) from the four study sites were compared with climatological and ecological data. Regression analysis was used to compare transmission data and blood parasite prevalence, parasite density (PD) and malaria episodes from children in the study area. Additionally we examined trends in confirmed clinical malaria incidence from 2005 -2012.Results:In total 1307 Anopheles gambiae s.l. and 54 An. funestus females were caught by HLC from November 2003 to August 2005. Sporozoites in Anopheles vectors in four villages ranged from 4.0 to 10.2%, ABR from 371 to 1890 and EIR from 40 to 158. Linear regression on parasitological and clinical data of children from the villages revealed that the ABR significantly influenced the parasite density (PD) of P. falciparum.Conclusion:Malaria transmission was intense and heterogeneous and corresponded to the micro-ecological differences. Malaria transmission in the early evening hours before people went to sleep was enough to sustain stable malaria. Scaling up preventive measures to reduce exposure to vectors will be effective in reducing parasitemia in children. Variations in transmission intensity must be considered when evaluating impact of control strategies and interventions such as the vaccine trials.

BACKGROUND:β-Thalassemia is a disorder caused by mutations at the hemoglobin β-gene (HBB) locus. Its most important manifestation, the major form, is characterized by severe hypochromic and hemolytic anemia and is inherited in an autosomal recessive mode. In Gaza Strip, Palestine 0.02% of the population has been identified as β-thalassemia major. DESIGN AND METHODS:An assessment of mutations was performed in 49 transfusion dependent patients with β-thalassemia major and in 176 β-thalassemia carriers diagnosed with a mean erythrocyte cell volume (MCV) <80fl and a proportion of HbA2>3.5%. In addition 39 individuals suspicious for β-thalassemia carrier status due to a reduced MCV (<80fl) but a normal HBA2 were screened. RESULTS:By screening with three hybridization assays a proportion of 80% of the thalassemic chromosomes from patients and carriers was identified to carry five different mutations of the hemoglobin (Hb) β-gene. Subsequent DNA sequencing confirmed these and revealed further 9% of the chromosomes to be affected by other mutations. In addition six chromosomes from suspicious carriers were detected to carry β-thalassemia mutations. Of the 15 different HBB mutations identified the variant IVS-I-110 G>A was the most frequent mutation identified in 34% of the thalassemic chromosomes, followed by IVS-I-1 G>A, IVS-I-6 T>C, Codon 39 C>T, and Codon 37 G>A. Three novel HBB variants were discovered by direct sequencing of the gene: 5' UTR-50 (-/G), 5' UTR-43 C>T, and IVS-II-26 T>G. CONCLUSIONS:The spectrum of HBB mutations described is of the Mediterranean type whereby the allele frequencies of the most common mutations differ from those, which were previously described for the population of the Gaza Strip and other Palestinian populations. The data presented may promote the introduction of molecular testing to the Palestinian premarital screening program for β-thalassemia in Gaza Strip, which will improve the screening protocol and genetic counseling in the future.

Familial Mediterranean fever (FMF) is an autoinflammatory disease and belongs to the heterogeneous group of hereditary recurrent fever syndromes (HRFs). Aims: The aims of the study were to determine the incidence of FMF in Germany and to describe the spectrum of pyrin mutations and the clinical characteristics in children. A prospective surveillance of children with HRF including FMF was conducted in Germany during a time period of 3 years by the German paediatric surveillance unit for rare paediatric diseases (ESPED). Monthly inquiries were sent to 370 children’s hospitals (Clinic-ESPED, n1) and to 23 laboratories (Laboratory-ESPED, n2). Inclusion criteria were children ≤16 years of age, disease-associated pyrin mutations, and more than three self-limiting episodes of fever >38.5 °C with increased inflammation markers. In n1, 122 patients with FMF and 225 pyrin mutations were identified. Ninety-two of 122 (75 %) children were of Turkish origin. The minimum incidence of FMF was estimated to be 3 (95 % CI: 2.48–3.54) per 106 person-years in the whole children population and 55 (95 % CI: 46–66) per 106 person-years in Turkish children living in Germany. N1 U n2 amounted to 593 asymptomatic and symptomatic carriers of 895 mutations (overlap of 73 cases with 134 mutations). p.Met694Val (45 %), p.Met680Ile (14 %), p.Val726Ala (12 %), and p.Glu148Gln (11.5 %) were the most common pyrin mutations. Conclusions: Despite FMF being the most frequent of the HRFs, its incidence in Germany is low. Twenty-five to 50 FMF patients ≤16 years are newly diagnosed per year. The disease is most commonly observed in individuals of Turkish ancestry.

Zusammenfassung Das familiäre Mittelmeerfieber (FMF), Hyper-IgD-Syndrom (HIDS) und das Tumornekrosefaktor(TNF)-Rezeptor-1-assoziierte periodische Syndrom (TRAPS) sind monogene Krankheiten, die unter dem Begriff der hereditären Fiebersyndrome zusammengefasst werden. Sie sind durch rezidivierende Episoden mit Fieber und Entzündungszeichen gekennzeichnet und werden von Mutationen in Genen verursacht, denen eine Funktion bei der angeborenen Immunität zukommt. Die vorliegende Übersichtsarbeit befasst sich mit dem klinischen Erscheinungsbild und der Genetik der hereditären Fiebersyndrome. Sie sind für die humangenetische Beratung von Bedeutung.

genome-wide association study in Ghana, West Africa, to identify genetic variants associated with malaria pathogenesis reveals two previously unknown loci on chromosomes 1 and 16.

Autoinflammatory diseases (AIDs) are characterized by recurrent, self-limiting systemic inflammation. Disorders include hereditary recurrent fever (HRF) syndromes such as hyperimmunoglobulinemia D and periodic fever syndrome (HIDS). To determine the incidence of HIDS and report clinical and genetic characteristics together with the underlying MVK genotypes in German children, a prospective active surveillance was conducted in Germany during a period of 3 years. Monthly inquiries were sent to 370 children’s hospitals by the German Paediatric Surveillance Unit (Clinic-ESPED, n1) and to two laboratories (Laboratory-ESPED, n2) performing genetic analyses. Inclusion criteria were a MVK mutation–positive patient ≤16 years of age with more than three self-limiting episodes of fever >38.5°C associated with increased inflammation markers. Clinical, epidemiological, and genetic data were assessed via questionnaires. Eight out of 16 patients were identified in Clinic-ESPED (n1) and 15 of 16 in Laboratory-ESPED (n2). Clinical and laboratory surveys overlapped in 7 of 16 cases. Incidence of HIDS was estimated to be 0.39 (95% CI: 0.22, 0.64) per 106 person-years. HIDS symptoms generally started in infancy with recurrent fever episodes lasting 3–12 (median, 4.5) days and recurring every 1–12 weeks. Fever was accompanied by abdominal pain, vomiting, diarrhea, cervical lymphadenopathy, and sometimes by headache, skin and joint symptoms. The patients carried 11 different MVK mutations mostly in compound heterozygosity (75%, 12 out of 16). The most frequent mutation was p.Val377Ile (81%, 13 out of 16). In Germany, the incidence of HIDS is very low with 0.39 per 106 person-years.

Paternity and maternity investigations in immigration procedures are frequently done in Germany. Since mostly only one parent and one or more children are investigated, the occurrence of possible mutational events has to be interpreted with great care and the analysis of as many STRs as possible is recommended. The new Powerplex® ESX17 and Powerplex® ESI17 kits from Promega comprising both eleven established STRs and additionally the loci D1S1656, D2S441, D10S1248, D12S391, and D22S1045 (in different order) are potential tools in such paternity or maternity analyses, but only few allele frequency data for the five new loci exist. Here, we provide allele frequencies for the five additional STRs from three different populations from Africa. In addition, we present two maternity cases and one paternity case in which a clear inclusion or exclusion of the alleged parent could only be achieved by the additional application of the new Powerplex® ESX17 kit.

Human genetics and immune responses are considered to critically influence the outcome of malaria infections including life-threatening syndromes caused by Plasmodium falciparum. An important role in immune regulation is assigned to the apoptosis-signaling cell surface receptor CD95 (Fas, APO-1), encoded by the gene FAS. Here, a candidate-gene association study including variant discovery at the FAS gene locus was carried out in a case-control group comprising 1,195 pediatric cases of severe falciparum malaria and 769 unaffected controls from a region highly endemic for malaria in Ghana, West Africa. We found the A allele of c.−436C>A (rs9658676) located in the promoter region of FAS to be significantly associated with protection from severe childhood malaria (odds ratio 0.71, 95% confidence interval 0.58–0.88, pempirical = 0.02) and confirmed this finding in a replication group of 1,412 additional severe malaria cases and 2,659 community controls from the same geographic area. The combined analysis resulted in an odds ratio of 0.71 (95% confidence interval 0.62–0.80, p = 1.8×10−7, n = 6035). The association applied to c.−436AA homozygotes (odds ratio 0.47, 95% confidence interval 0.36–0.60) and to a lesser extent to c.−436AC heterozygotes (odds ratio 0.73, 95% confidence interval 0.63–0.84), and also to all phenotypic subgroups studied, including severe malaria anemia, cerebral malaria, and other malaria complications. Quantitative FACS analyses assessing CD95 surface expression of peripheral blood mononuclear cells of naïve donors showed a significantly higher proportion of CD69+CD95+ cells among persons homozygous for the protective A allele compared to AC heterozygotes and CC homozygotes, indicating a functional role of the associated CD95 variant, possibly in supporting lymphocyte apoptosis.

To the Editor: Schnitzler syndrome is a rare, enigmatic disorder characterized by chronic urticarial rashes and a monoclonal IgM gammopathy, variably combined with intermittent fever, arthralgia or arthritis, lymphadenopathy, hepatomegaly and/or splenomegaly, leukocytosis, and an elevated erythrocyte sedimentation rate.1Lipsker D. Veran Y. Grunenberger F. Cribier B. Heid E. Grosshans E. The Schnitzler's syndrome: four new cases and review of the literature.Medicine. 2001; 80: 37-44Crossref PubMed Scopus (232) Google Scholar Patients have an excess risk for Waldenström macroglobulinemia and amyloidosis.2de Koning H.D. Bodar E.J. van der Meer J.W.M. Simon A. Schnitzler's Syndrome Study GroupSchnitzler's syndrome: beyond the case reports: review and follow-up of 94 patients with an emphasis on prognosis and treatment.Semin Arthritis Rheum. 2007; 37: 137-148Crossref PubMed Scopus (214) Google Scholar Both increased secretion of the proinflammatory cytokine IL-1 from PBMCs and efficacy of anakinra (soluble IL-1 receptor antagonist) treatment suggest an important role of IL-1 in the disease process. However, the cause of increased IL-1 secretion has remained obscure.2de Koning H.D. Bodar E.J. van der Meer J.W.M. Simon A. Schnitzler's Syndrome Study GroupSchnitzler's syndrome: beyond the case reports: review and follow-up of 94 patients with an emphasis on prognosis and treatment.Semin Arthritis Rheum. 2007; 37: 137-148Crossref PubMed Scopus (214) Google Scholar, 3Ryan J.G. de Koning H.D. Beck L.A. Booty M.G. Kastner D.L. Simon A. IL-1 blockade in Schnitzler's syndrome: ex vivo findings correlate with clinical remission.J Allergy Clin Immunol. 2008; 121: 260-262Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Here, we report on a gain-of-function mutation (V198M) of a gene (nucleotide-binding domain protein and leucine-rich repeat containing gene family, pyrin domain containing 3 [NLRP3], also known as CIAS1) predisposing for excessive IL-1β secretion in a patient with Schnitzler syndrome. To our knowledge, this is the first report on a NLRP3 gene mutation found in this disease. We diagnosed Schnitzler syndrome in a 52-year-old woman who was admitted to our department because of an 18-month history of chronic urticaria with annular erythematous and maculopapular lesions, periodic fever, polyarthralgia, night sweats, and 10-kg weight loss starting days after a clinically diagnosed respiratory infection that had not been further investigated. Skin eruptions initially occurred at mechanically stressed regions but generalized within 2 months, sparing the neck and face. At presentation, leukocytosis (12.100/μL), and elevated erythrocyte sedimentation rate (54 mm/h) and C-reactive protein (23 mg/L) were present. Mild anemia (hemoglobin 10.5 g/dL) was noted. The thrombocyte count was within the normal range. Serum IgM levels were markedly increased (7.8 g/L; normal range, 0.4-2.3) with a monoclonal IgMκ component. The rheumatoid factor was elevated (46 U/L; threshold ≥20 U/L). Other autoantibodies (antinuclear antibodies, antibodies to extractable nuclear antigens, antineutrophil cytoplasmic autoantibodies) and cryoglobulins were not detected. Complement, IgG, IgA, IgD, IgE, C1 esterase inhibitor, and tryptase levels were normal. A skin biopsy disclosed neutrophilic urticaria vasculitis. Chronic infections (Helicobacter pylori, HIV, hepatitis B and C), occult cancer, leukemia, multiple myeloma, Waldenström macroglobulinemia, and lymphoma were excluded by laboratory tests, sonographic examination, chest radiograph, magnetic resonance imaging of the abdomen, endoscopy of the upper and lower gastrointestinal tract, and bone marrow analysis. Splenomegaly and lytic bone lesions were not present. The patient responded to high-dose prednisolone treatment, but attempts to taper the dose below 40 mg/d were followed by reoccurrence of urticaria, fever, polyarthralgia, and an increase of the erythrocyte sedimentation rate. However, addition of the soluble IL-1 receptor antagonist anakinra (100 mg/d subcutaneously) resulted in complete clinical remission within 1 day. Remission has been sustained and prednisolone discontinued with daily anakinra injections on follow-up for >2 years. An attempt by the patient to taper down anakinra to injections every other day was followed by a recurrence of the skin lesions, which rapidly disappeared after reintroduction of daily application. Considering the hypothesis of autoinflammation and the pivotal role of IL-1 in Schnitzler syndrome,2de Koning H.D. Bodar E.J. van der Meer J.W.M. Simon A. Schnitzler's Syndrome Study GroupSchnitzler's syndrome: beyond the case reports: review and follow-up of 94 patients with an emphasis on prognosis and treatment.Semin Arthritis Rheum. 2007; 37: 137-148Crossref PubMed Scopus (214) Google Scholar sequencing of the NLRP3 gene from PBMCs of our patient was performed. The V198M mutation was disclosed (Fig 1), which has been known as one of the gain-of-function mutations causing the so-called cryopyrin-associated periodic syndromes (cryopyrinopathies) in infants.4Hoffman H.M. Mueller J.L. Broide D.H. Wanderer A.A. Kolodner R.D. Mutation of a new gene encoding a putative pyrin-like protein causes familial cold autoinflammatory syndrome and Muckle-Wells syndrome.Nat Genet. 2001; 29: 301-305Crossref PubMed Scopus (1343) Google Scholar, 5Aksentijevich I. Putnam C.D. Remmers E.F. Mueller J.L. Le J. Kolodner R.D. et al.The clinical continuum of cryopyrinopathies: novel CIAS1 mutations in north American patients and a new cryopyrin model.Arthritis Rheum. 2007; 56: 1273-1285Crossref PubMed Scopus (324) Google Scholar NLRP3 encodes neuronal apoptosis inhibitory protein, MHC class II transcription activator, HET-E and telomerase-associated protein [NACHT], leucine-rich repeat [LRR] and pyrin containing-domain protein 3 (NALP3), also called cryopyrin, an intracellular pattern-recognition receptor mediating monocyte and macrophage IL-1β secretion in response to a heterogeneous group of exogenous and host danger signals including microbial and host DNA, amyloid-β, adenosine triphosphate, and monosodium urate and calcium pyrophosphate dehydrate crystals.6Pétrilli V. Dostert C. Muruve D.A. Tschopp J. The inflammasome: a danger sensing complex triggering innate immunity.Curr Opin Immunol. 2007; 19: 615-622Crossref PubMed Scopus (596) Google Scholar, 7Muruve D.A. Pétrilli V. Zaiss A.K. White L.R. Clark S.A. Ross J.P. et al.The inflammasome recognizes cytosolic microbial and host DNA and triggers an innate immune response.Nature. 2008; 452: 103-107Crossref PubMed Scopus (778) Google Scholar, 8Halle A. Hornung V. Petzold G.C. Stewart C.R. Monks B.G. Reinhenkel T. et al.The NALP3 inflammasome is involved in the innate immune response to amyloid-β.Nat Immunol. 2008; 9: 857-865Crossref PubMed Scopus (1884) Google Scholar On sensing danger signals, NALP3 is activated by postulated unfolding from an autorepressed form, then forming oligomers, and recruiting caspase-1 via adaptor molecules (apoptosis-associated speck-like protein containing a CARD [ASC], CARD inhibitor of NFkB-activating ligands [CARDINAL]). The activated caspase-1 in this oligomer-complex coined NALP3 inflammasome cleaves pro–IL-1β to convert it into active IL-1β.6Pétrilli V. Dostert C. Muruve D.A. Tschopp J. The inflammasome: a danger sensing complex triggering innate immunity.Curr Opin Immunol. 2007; 19: 615-622Crossref PubMed Scopus (596) Google Scholar To study IL-1β secretion in our patient, PBMCs were isolated from blood obtained at the end of a voluntary 60-hour interval between anakinra doses. At that time, a relapse of urticaria had occurred, which rapidly resolved within hours after resuming anakinra treatment. Fractionation of PBMCs by CD14 positivity (a marker of monocytes) was performed by using CD14 microbeads (Miltenyi Biotec, Bergisch-Gladbach, Germany) as described by the manufacturer. The spontaneous IL-1α and IL-1β secretion from both CD14-positive and CD14-negative PBMCs of the patient was below the limit of determination of the ELISA (<1 pg/mL, Quantikine; R&D Systems, Wiesbaden, Germany). Both IL-1α and IL-1β secretion strongly increased after stimulation of PBMCs by LPS (Sigma Aldrich, Taufkirchen, Germany; 0.1 μg/mL for 14 hours). Comparing patient cells to PBMCs from a matched healthy control, there was no difference in the increment of IL-1α secretion after LPS stimulation. However, IL-1β secretion from the patient's PBMCs was much stronger in response to LPS as compared to LPS-stimulated IL-1β secretion from PBMCs from the control (>55-fold larger increment from CD14-positive PBMCs; >10-fold larger increment from CD14-negative PBMCs). The results support a crucial role of IL-1β in this patient with Schnitzler syndrome and are in line with a possible functional role of the detected mutation as a genetic predisposition for increased IL-1β secretion in this case. The cryopyrin-associated periodic syndromes—familial cold autoinflammatory syndrome, Muckle-Wells syndrome, and neonatal-onset multisystem inflammatory disease, also known as chronic infantile neurologic, cutaneous, articular syndrome—are caused by autosomal-dominant gain-of-function mutations of the NLRP3 gene. The mutations result in spontaneous NALP3 activation and oligomerization in the absence of a ligand with subsequent IL-1β procession and secretion. As a proof of principle, cryopyrinopathies respond dramatically to treatment with IL-1 receptor antagonists. Although originally classified as distinct disorders, cryopyrinopathies are now thought to reflect a spectrum of 1 disease, with familial cold autoinflammatory syndrome being the mildest and neonatal-onset multisystem inflammatory disease the most severe. They are characterized by recurrent episodes of systemic inflammatory attacks affecting serosal, synovial, and cutaneous interfaces as well as other tissues in the absence of infection. An urticarial skin rash is a key symptom of all 3 diseases.4Hoffman H.M. Mueller J.L. Broide D.H. Wanderer A.A. Kolodner R.D. Mutation of a new gene encoding a putative pyrin-like protein causes familial cold autoinflammatory syndrome and Muckle-Wells syndrome.Nat Genet. 2001; 29: 301-305Crossref PubMed Scopus (1343) Google Scholar, 5Aksentijevich I. Putnam C.D. Remmers E.F. Mueller J.L. Le J. Kolodner R.D. et al.The clinical continuum of cryopyrinopathies: novel CIAS1 mutations in north American patients and a new cryopyrin model.Arthritis Rheum. 2007; 56: 1273-1285Crossref PubMed Scopus (324) Google Scholar Intriguingly, Schnitzler syndrome and cryopyrin-associated periodic syndromes share common pathophysiological (ie, pivotal role of IL-1) and clinical features (eg, chronic urticaria, fever, rapid response to anakinra). Our patient had not experienced symptoms of cryopyrin-associated periodic syndromes during childhood. Although thorough investigation did not disclose clinically affected relatives, genetic screening (with previous written consent of each subject) identified 4 asymptomatic family members in 3 generations carrying the same mutation (Fig 2). None of these asymptomatic individuals showed a monoclonal gammopathy. Incomplete penetrance of the V198M NLRP3 mutation has been shown before with single asymptomatic carriers identified at a frequency of 0.0074.5Aksentijevich I. Putnam C.D. Remmers E.F. Mueller J.L. Le J. Kolodner R.D. et al.The clinical continuum of cryopyrinopathies: novel CIAS1 mutations in north American patients and a new cryopyrin model.Arthritis Rheum. 2007; 56: 1273-1285Crossref PubMed Scopus (324) Google Scholar The low prevalence of the mutation together with the rareness of Schnitzler syndrome—less than 100 case reports have recently been found in the literature2de Koning H.D. Bodar E.J. van der Meer J.W.M. Simon A. Schnitzler's Syndrome Study GroupSchnitzler's syndrome: beyond the case reports: review and follow-up of 94 patients with an emphasis on prognosis and treatment.Semin Arthritis Rheum. 2007; 37: 137-148Crossref PubMed Scopus (214) Google Scholar—make a pure coincidence of both findings in our patient highly unlikely. Thus, the detection of the V198M NLRP3 gene mutation provides evidence for a possible genetic predisposition for IL-1–mediated inflammation in Schnitzler syndrome. In our patient, a second factor (possibly the preceding infection) could have been important for triggering disease manifestation in a genetically predisposed individual. The possible genetic linkage of Schnitzler syndrome described here is so far the result of the observation of only 1 patient and requires confirmation. Earlier studies failed to demonstrate NLRP3 gene mutations in 2 other patients.3Ryan J.G. de Koning H.D. Beck L.A. Booty M.G. Kastner D.L. Simon A. IL-1 blockade in Schnitzler's syndrome: ex vivo findings correlate with clinical remission.J Allergy Clin Immunol. 2008; 121: 260-262Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar, 9Martinez-Taboada V.M. Fontalba A. Blanco R. Fernández-Luna J.L. Successful treatment of refractory Schnitzler's syndrome with anakinra: comment on the article by Hawkins et al.Arthritis Rheum. 2005; 52: 2226-2227Crossref PubMed Scopus (93) Google Scholar However, novel relevant mutations continue to be described in patients with cryopyrinopathies, and almost 50% of the clinically diagnosed cases of the most severe form (neonatal-onset multisystem inflammatory disease) still lack an identified genetic basis.5Aksentijevich I. Putnam C.D. Remmers E.F. Mueller J.L. Le J. Kolodner R.D. et al.The clinical continuum of cryopyrinopathies: novel CIAS1 mutations in north American patients and a new cryopyrin model.Arthritis Rheum. 2007; 56: 1273-1285Crossref PubMed Scopus (324) Google Scholar The mutation identified in our patient might be 1 of several background mutations affecting IL-1 procession. Because a number of proteins including the other components of the NLRP3 inflammasome are involved in IL-1 generation and trafficking, unknown mutations in the corresponding genes could likewise be important as predisposing factors for disease manifestation in Schnitzler syndrome. Although the influence of the monoclonal gammopathy (or the underlying monoclonal lymphocyte disorder) remains unknown, we suggest that the pathogenesis of Schnitzler syndrome at least in some individuals involves the appearance of a second factor triggering IL-1 secretion on the basis of a genetically determined susceptibility to a hyperactive response.

The cause of death of the Egyptian pharoah Tutankhamun has now for decades been matter of speculation and various hypotheses. A recent article in the Journal of the American Medical Association (JAMA) provided new evidence and suggested malaria, together with Köhler’s disease, as the most probable cause of death of the boy king. We are sceptical towards this elucidation of the cause of death of King Tut and discuss alternative and differential diagnoses, among them, in particular, sickle cell disease and Gauche’s disease.

To the Editor: In their study, Dr Hawass and colleagues reported ancient DNA data from 11 royal Egyptian mummies and used microsatellites to ascertain kinship among specimens. We question the reliability of the genetic data presented in this study and therefore the validity of the authors’ conclusions. Furthermore, we urge a more critical assessment of the ancient DNA data in the context of DNA degradation and contamination. The long-term survival of DNA is determined by the environmental history of the samples, and Gilbert et al argued in reference to mitochondrial DNA that “in most, if not all, ancient Egyptian remains, [ancient DNA] does not survive to a level that is currently retrievable.” The age of the mummies (more than 3300 years before the present) coupled with their preservation history suggests that DNA survival is highly unlikely. Longterm survival of nuclear DNA sequences, as accessed by Hawass et al, is even less likely than mitochondrial DNA, given lower copy numbers per cell. Success in the retrieval of putative nuclear DNA sequences is also surprising given the use of traditional polymerase chain reaction techniques rather than newly developed capture approaches coupled with second-generation sequencing that allow for successful capture of degraded (shorter) DNA sequences. Contamination is a major obstacle in human ancient DNA research. Although laboratory members involved in the study were genotyped, no persons handling the specimens prior to the study were included, raising a question of the reliability of the microsatellite profiles. Precautions such as genotyping of associated nonhuman remains and including information on the microsatellite allele frequencies in presentday Egypt would have clarified the issue of modern contamination. Another cause for concern is the lack of reported quality control measures in the genotyping of microsatellites. Potential genotyping errors include allelic stutters, allelic dropout, short allele dominance, and null alleles, all of which can result in the incorrect identification of alleles. Even small error rates (0.01 per allele) can lead to high error rates in downstream applications, such as false paternity exclusion in kinship testing.

Background: Cryopyrin-associated periodic syndromes (CAPS) are rare disorders belonging to the group of hereditary periodic fever (HPF) syndromes. These auto-inflammatory diseases (AID) are characterized by recurrent episodes of inflammation with attacks of fever variably associated with serosal, synovial and/or cutaneous inflammation, usually in a self-limiting manner, and with a mostly monogenic origin. The aims were to determine the incidence of CAPS and the spectrum of mutations in the NLRP3 (formerly = CIAS1) gene and to describe the clinical manifestations.Patients and methods: A prospective surveillance of children with CAPS was conducted in Germany during a time period of 3 years (2003-2006). Monthly inquiries were sent to 370 children's hospitals by the German Paediatric Surveillance Unit (Clinic-ESPED, n1) and to 2 laboratories (Laboratory-ESPED, n2). Inclusion criteria were children <= 16 years of age, disease-associated NLRP3 mutation, more than 3 self-limiting episodes of fever > 38.5 degrees C, and increased inflammation markers. Clinical, epidemiological and genetic data were evaluated via questionnaires.Findings: 6 out of 14 patients were identified in Clinic-ESPED (n1) and 13/14 in Laboratory-ESPED (n2). Clinical and laboratory surveys overlapped in 5 of 14 cases. The incidence of CAPS in German children was estimated to be 3.43 per 10(7) person-years. The patients carried 11 different NLRP3 mutations and were classified as MWS (n=6), CINCA (n=4), FCAS (n=1) and undefined CAPS (n=3).Interpretation: The incidence of CAPS in Germany is very low and corresponds to 2-7 newly diagnosed patients <= 16 years per year.

Background: Cryopyrin-associated periodic syndromes (CAPS) are rare disorders belonging to the group of hereditary periodic fever (HPF) syndromes. These auto-infl ammatory diseases (AID) are characterized by recurrent episodes of infl ammation with attacks of fever variably as- sociated with serosal, synovial and / or cutaneous infl ammation, usually in a self-limiting manner, and with a mostly monogenic origin. The aims were to determine the incidence of CAPS and the spectrum of mutations in the NLRP3 (for- merly = CIAS1) gene and to describe the clinical manifestations. Patients and methods: A prospective sur- veillance of children with CAPS was conducted in Germany during a time period of 3 years (2003 - 2006). Monthly inquiries were sent to 370 children ' s hospitals by the German Paedia- tric Surveillance Unit (Clinic-ESPED, n1) and to 2 laboratories (Laboratory-ESPED, n2). Inclu- sion criteria were children ≤ 16 years of age, disease-associated NLRP3 mutation, more than 3 self- limiting episodes of fever > 38.5 ° C, and increased infl ammation markers. Clinical, epide- miological and genetic data were evaluated via ques tionnaires. Findings: 6 out of 14 patients were identifi ed in Clinic-ESPED (n1) and 13 / 14 in Laboratory-ESPED (n2). Clinical and laboratory surveys overlapped in 5 of 14 cases. The incidence of CAPS in Ger- man children was estimated to be 3.43 per 10 7 person-years. The patients carried 11 diff erent NLRP3 mutations and were classifi ed as MWS (n = 6), CINCA (n = 4), FCAS (n = 1) and undefi ned CAPS (n = 3). Interpretation: The incidence of CAPS in Ger- many is very low and corresponds to 2 - 7 newly diagnosed patients ≤ 16 years per year. Zusammenfassung ▼

Periodic episodes of fever and inflammation can have a genetic origin. Nowadays, the identification of the causative genetic variants in the majority of cases allows molecular genetic confirmation of the clinical diagnosis, which enables approaches with specific drug treatment and improves patient compliance as well as genetic counseling. Besides a detailed clinical examination a medical history including family history and an assessment of the ethnic origin are required. In order to make genetic testing straightforward and cost effective an iterative procedure should be followed which should include, in addition to clinical data, the frequencies of causative mutations in the various gene segments involved.