Background and objective Majeed syndrome is an autosomal recessive disorder characterised by the triad of chronic recurrent multifocal osteomyelitis, congenital dyserythropoietic anaemia and a neutrophilic dermatosis that is caused by mutations in LPIN2. Long-term outcome is poor. This is the first report detailing the treatment of Majeed syndrome with biological agents and demonstrates clinical improvement with IL-1blockade. Methods We describe the clinical presentation, genetic analysis, cytokine profiles and response to biological therapy in two brothers with Majeed syndrome. Results Both boys were homozygous for a novel 2-base pair deletion in LPIN2 (c.1312_1313delCT; p.Leu438fs+16X), confirming the diagnosis. Their bone disease and anaemia were refractory to treatment with corticosteroids. Both siblings had elevated proinflammatory cytokines in their serum, including tumour necrosis factor α (TNF-α), however a trial of the TNF inhibitor etanercept resulted in no improvement. IL-1 inhibition with either a recombinant IL-1 receptor antagonist (anakinra) or an anti-IL-1β antibody (canakinumab) resulted in dramatic clinical and laboratory improvement. Conclusions The differential response to treatment with TNF-α or IL-1 blocking agents sheds light into disease pathogenesis; it supports the hypothesis that Majeed syndrome is an IL-1β dependent autoinflammatory disorder, and further underscores the importance of IL-1 in sterile bone inflammation.

Staphylococcus aureus secretes the SSL7 protein as part of its immune evasion strategy. The protein binds both complement C5 and IgA, yet it is unclear whether SSL7 cross-links these two proteins and, if so, what purpose this serves the pathogen. We have isolated a stable IgA-SSL7-C5 complex, and our crystal structure of the C5-SSL7 complex confirms that binding to C5 occurs exclusively through the C-terminal β-grasp domain of SSL7 leaving the OB domain free to interact with IgA. SSL7 interacts with C5 >70 Å from the C5a cleavage site without inducing significant conformational changes in C5, and efficient inhibition of convertase cleavage of C5 is shown to be IgA dependent. Inhibition of C5a production and bacteriolysis are all shown to require C5 and IgA binding while inhibition of hemolysis is achieved by the C5 binding SSL7 β-grasp domain alone. These results provide a conceptual and structural basis for the development of a highly specific complement inhibitor preventing only the formation of the lytic membrane attack complex without affecting the important signaling functions of C5a. Complement activation triggers cleavage of the three homologous 185-to 200-kDa proteins C3, C4, and C5. Three activation pathways converge on C3 cleavage to C3b (6). Activation by the alternative pathway (AP) results from spontaneous hydrolysis of an internal thioester bond in C3 or by deposition of properdin on an appropriate surface (7), whereas the classical pathway (CP) and lectin-mediated pathways are activated by surface-bound immune complexes or mannan binding lectins/ficolins, respectively. Activation of the CP or the lectin pathway generates the surface-bound C3 convertase (a proteolytic enzyme cleaving C3) C4b2a, whereas the AP generates the C3 convertase C3bBb. Both may recruit an additional C3b molecule to form the CP C5 convertase C4b2a3b or the AP C5 convertase C3bBb3b (8, 9), which cleaves C5 to generate the large fragment C5b and the anaphylatoxin C5a. This binds with high affinity to the C5a receptor (CD88) on myeloid cells triggering G protein (Gα I and Gα 16 )-mediated cell activation, chemotaxis, respiratory burst, and release of proinflammatory mediators (10). C5b quickly associates with C6, C7, C8, and multiple molecules of C9 to form the membrane attack complex (MAC) that results in rapid cell lysis (11). Elevated levels of C5a are implicated in a wide range of inflammatory disorders, such as rheumatoid arthritis, ischemia/reperfusion injury, sepsis, and fibrotic conditions (12). MAC deposition through C5b on erythrocytes results in destruction of these cells in the hemolytic disease paroxysmal nocturnal hemoglobinuria (PNH) (13). In addition, excessive MAC formation is linked with the pathophysiology of conditions such as antibody-mediated transplant rejection (14), inflammatory neuropathies (15) and multiple sclerosis (16).Given its importance to innate immune clearance, pathogens have developed many strategies to prevent complement activation (17). The Staphylococcal Superantigen-Like protein 7 (SSL7)...

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Level of inflammation, assessed by interleukin-6 and procalcitonin, was independently associated with increased mortality with the highest discriminative value obtained 24 hours after out-of-hospital cardiac arrest. Interventions aiming at decreasing level of inflammation as a way to improve outcome may be investigated in future studies.

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