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Molecular Genetic Dissection of Inflammatory Linear Verrucous Epidermal Naevus Leads to Successful Targeted Therapy

  • Author Footnotes
    10 These authors contributed equally to this work.
    Melissa Riachi
    Footnotes
    10 These authors contributed equally to this work.
    Affiliations
    Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, United Kingdom

    Mosaicism and Precision Medicine Laboratory, The Francis Crick Institute, London, United Kingdom
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  • Author Footnotes
    10 These authors contributed equally to this work.
    Satyamaanasa Polubothu
    Footnotes
    10 These authors contributed equally to this work.
    Affiliations
    Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, United Kingdom

    Mosaicism and Precision Medicine Laboratory, The Francis Crick Institute, London, United Kingdom

    Paediatric Dermatology, Great Ormond Street Hospital for Children, London, United Kingdom
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  • Author Footnotes
    10 These authors contributed equally to this work.
    Paulina Stadnik
    Footnotes
    10 These authors contributed equally to this work.
    Affiliations
    Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
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  • Connor Hughes
    Affiliations
    Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, United Kingdom

    Mosaicism and Precision Medicine Laboratory, The Francis Crick Institute, London, United Kingdom
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  • Sara Barberan Martin
    Affiliations
    Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, United Kingdom

    Mosaicism and Precision Medicine Laboratory, The Francis Crick Institute, London, United Kingdom
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  • Carolyn R. Charman
    Affiliations
    Dermatology, Royal Devon and Exeter Hospital, Exeter, United Kingdom
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  • Iek Leng Cheng
    Affiliations
    Pharmacy, Great Ormond Street Hospital for Children, London, United Kingdom
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  • Karolina Gholam
    Affiliations
    Paediatric Dermatology, Great Ormond Street Hospital for Children, London, United Kingdom
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  • Olumide Ogunbiyi
    Affiliations
    Paediatric Pathology, Department of Histopathology, Great Ormond Street Hospital for Children, London, United Kingdom
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  • David G. Paige
    Affiliations
    Dermatology, Royal London Hospital, London, United Kingdom
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  • Neil J. Sebire
    Affiliations
    Paediatric Pathology, Department of Histopathology, Great Ormond Street Hospital for Children, London, United Kingdom
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  • Alan Pittman
    Affiliations
    Bioinformatics, St George’s University of London, London, United Kingdom
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  • Wei-Li Di
    Affiliations
    Immunobiology Section, Infection, Immunity and Inflammation Programme, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
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  • Veronica A. Kinsler
    Correspondence
    Corresponding author
    Affiliations
    Genetics and Genomic Medicine, University College London Great Ormond Street Institute of Child Health, London, United Kingdom

    Mosaicism and Precision Medicine Laboratory, The Francis Crick Institute, London, United Kingdom

    Paediatric Dermatology, Great Ormond Street Hospital for Children, London, United Kingdom
    Search for articles by this author
  • Author Footnotes
    10 These authors contributed equally to this work.
Open AccessPublished:June 07, 2021DOI:https://doi.org/10.1016/j.jid.2021.02.765

      Abbreviations:

      ILVEN (inflammatory linear verrucous epidermal naevus), KC (keratinocyte)
      To the Editor
      Inflammatory linear verrucous epidermal naevus (ILVEN) is a rare skin condition. Classically, it presents at birth or within the first year of life, frequently progressing during early childhood. Diagnostic criteria are erythematous verrucous hyperkeratosis in a fine and whorled Blaschko-linear pattern, intense pruritus, early age of onset, histological features, and resistance to treatment (
      • Morag C.
      • Metzker A.
      Inflammatory linear verrucous epidermal nevus: report of seven new cases and review of the literature.
      ). The cause of ILVEN has been unknown; however, a single case of mosaicism in gene GJA1 has recently been reported (
      • Umegaki-Arao N.
      • Sasaki T.
      • Fujita H.
      • Aoki S.
      • Kameyama K.
      • Amagai M.
      • et al.
      Inflammatory linear verrucous epidermal nevus with a postzygotic GJA1 mutation is a mosaic erythrokeratodermia variabilis et progressiva.
      ). We sought to investigate the genetics of ILVEN with a view to new therapeutic angles.
      A total of 15 children with ILVEN and six normal controls (from surgery where excess normal skin was available) were recruited with written informed consent by their parents or guardians and Research Ethics Committee approval from the Great Ormond Street Hospital Research and Development office. The patients’ parents/guardians consented to the publication of the patients' images. DNA and RNA were extracted from skin biopsies of the affected tissue, DNA was extracted from blood by standard methods and affected skin keratinocytes (KCs) were cultured and immortalized where possible (Lenti-HPV-16 E6/E7 Virus). Deep whole-exome sequencing of blood and affected skin was performed on patient samples, and data were analyzed using an optimized bioinformatic pathway for the detection of low-level somatic variants as previously published (
      • Al-Olabi L.
      • Polubothu S.
      • Dowsett K.
      • Andrews K.A.
      • Stadnik P.
      • Joseph A.P.
      • et al.
      Mosaic RAS/MAPK variants cause sporadic vascular malformations which respond to targeted therapy.
      ). Pathogenic GJA1 variants were not found in any patient. The clinical and histological features of patients 1 and 2 are shown in Figures 1 and 2a and b and Supplementary Table S1.
      Figure thumbnail gr1
      Figure 1Clinical features of CARD14 mosaic ILVEN and dramatic response to targeted therapy in one patient. Patient 1 pre-treatment (ac) and 3 months post commencing Ustekinumab (df), showing dramatic reduction in erythema and hyperkeratosis. Patient 2 pre-treatment showing predominantly left-sided Blaschko-linear inflammatory and hyperkeratotic skin lesions at 1 year (g, i) and 4 years (h, j). The patients’ parents/guardians consented to the publication of the patients' images.
      Figure thumbnail gr2
      Figure 2Histological features and mosaic genetic variants in CARD14 ILVEN. (a, c, e) Patient 1 and (b, d, f, g, h, i, j, k, l, m, n) patient 2. (a, b) Histology demonstrating alternating orthokeratosis (white arrow) and parakeratosis (black arrow) in patient 1, with generalized disruption of cornification in patient 2. Histological variability between ILVEN samples (from clinical diagnosis) was found to be very broad. (c, d) Whole-exome sequencing visualized in the Integrative Genomics Viewer (Broad Institute, Cambridge, MA) shows mosaic CARD14 missense variants c. 356T > A, p. (M119K) (for patient 1 in c) and c.277A > G, p.(K93E) (for patient 2 in d). (e, f) Sanger sequencing chromatograms confirm the variants. Cultured patient KCs and SVK14 cells transfected with a mutant CARD14 construct express increased IL12 and IL23 at mRNA and protein level, proliferate faster than controls, and show variable activity of NF-κB p65. (g, h) QRT-PCR demonstrating a significant increase in IL-12A and IL-23A in cultured KCs from the affected skin from patient 2 and in SVK14 cells transfected with the mutant CARD14 construct in comparison to control patient KCs (n = 3) and SVK14 cells transfected with the wild-type CARD14 construct, respectively. Mean relative gene expression of five replicates per patient sample and duplicates per SVK14 sample was calculated with SD. (i, j) WST-1 proliferation assay showing a proliferation increase in KCs cultured from patient 2 and in SVK14 cells transfected with the mutant CARD14 construct compared to control patient KCs (n = 3) and SVK14 cells transfected with the wild-type CARD14 construct, respectively, measured at 450 nm after 2 and 4 hours. The KCs were cultured for 8 days before proliferation measurement. The mean absorbance of five replicates is shown with SD. (k) Nuclear extracts from patient 2 KCs do not show a difference in NF-κB p65 activity when compared to control patient KCs (n = 6). (l) Nuclear extracts from SVK14 cells transfected with the mutant CARD14 construct show an increase in NF-κB p65 activity when compared with SVK14 cells transfected with the wild-type CARD14 construct. The mean absorbance of triplicates for patient/control KCs and positive control is shown with SD. (m, n) Patient 2 KCs and SVK14 cells transfected with the mutant CARD14 construct have significantly increased levels of IL-12 and IL-23 secreted in the supernatant compared to control KC cell lines (n = 4) and SVK14 cells transfected with the wild-type CARD14 construct, respectively. The mean absorbance of triplicates is shown with SD. All P-values were calculated by Students t-test using Prism, version 7.0 (GraphPad Software, San Diego, CA). Asterisks indicate a P-value < 0.05. (o) Immunofluorescent anti-HA staining of SVK14 cells transfected with CARD14 wild-type and mutant pcDNA3.1-HA constructs with Sanger-sequencing validation. Bar = 400 um. HA, hemagglutinin; ILVEN, inflammatory linear verrucous epidermal naevus; KC, keratinocyte; QRT-PCR, quantitative real-time reverse transcriptase‒PCR.
      Heterozygous missense variants in gene CARD14 were detected in 2 of 15 patients (Figure 2c and d). In both patients, the allelic load was compatible with that of a mosaic variant. In patient 1, the variant was present at 20% in both the blood and DNA extracted directly from a whole punch biopsy of the affected skin (c.356T > A, p. (M119K)); and in patient 2, it was present at 1% from DNA extracted directly from the epidermis of the affected skin and it was undetectable in the blood (4/313 reads in skin, c.277A>G, p.(K93E)). We had intended that whole-exome sequencing of the epidermis in patient 2 might have increased the mutant allele load; however, this was not the case, and the 1% load may have been due to mainly cornified epidermis being sequenced. However, both variants were convincing on whole-exome sequencing raw data, and both were clearly confirmed by Sanger sequencing (Figure 2e and f). The missense variant in patient 1 affects the same codon as one previously published in a non-mosaic state causing pityriasis rubra pilaris (
      • Lwin S.M.
      • Hsu C.K.
      • Liu L.
      • Huang H.Y.
      • Levell N.J.
      • McGrath J.A.
      Beneficial effect of ustekinumab in familial pityriasis rubra pilaris with a new missense mutation in CARD14.
      ), supporting its likely pathogenicity in vivo and also supported by in silico predictions (SIFT Tolerated, Polyphen2 Benign, Mutation Taster Disease Causing, PROVEAN Neutral, CONDEL Neutral, combined annotation‒dependent depletion score 22.6). The variant in patient 2 is predicted overall likely pathogenic in silico (SIFT Tolerated, Polyphen2 Probably Damaging, Mutation Taster Disease Causing, PROVEAN Neutral, CONDEL Deleterious, combined annotation‒dependent depletion score 24.1), and since it was to our knowledge previously unreported, we went on to characterize its functional effects. Cultured patient KCs from patient 2 were used to model the variant in the most biologically similar manner. In addition, the patient 2 variant was modeled in a KC cell line (SVK14) that was transfected (Lipofectamine 2000) with CARD14 wild-type and mutant (c.277A > G) pcDNA3.1-HA constructs (Figure 2o). The culture of KCs from patient 1 unfortunately failed, and it was not deemed ethical to take further biopsies from a child for this purpose only.
      Quantitative real-time reverse transcription–PCR showed a significant increase in IL-12A and IL-23A in cultured patient KCs and SVK14 cells transfected with the mutant CARD14 construct compared to identically–handled KCs from grouped normal controls (Figure 2g) and SVK14 cells transfected with the wild-type CARD14 construct (Figure 2h). This was further validated at the protein level by IL-12/IL-23 p40 ELISA (Figure 2m and n) (Invitrogen, Waltham, CA). In addition, WST-1 assay (Sigma-Aldrich, St. Louis, MO) showed a significant increase in proliferation rate in patient KCs and SVK14 cells transfected with the mutant CARD14 construct (Figure 2i and j). A significant increase in NF-κB p65 subunit activity was shown by ELISA in nuclear extracts from SVK14 cells transfected with the mutant CARD14 construct (Figure 2l) but not in patient KC nuclear extracts (Figure 2k) (Abcam, Cambridge, United Kingdom), potentially owing to the less physiological model of overexpression in the cell line model.
      Inherited (nonmosaic) heterozygous mutations in CARD14 were recently described as rare causes of psoriasis (
      • Jordan C.T.
      • Cao L.
      • Roberson E.D.
      • Duan S.
      • Helms C.A.
      • Nair R.P.
      • et al.
      Rare and common variants in CARD14, encoding an epidermal regulator of NF-kappaB, in psoriasis.
      ) and pityriasis rubra pilaris (
      • Fuchs-Telem D.
      • Sarig O.
      • van Steensel M.A.
      • Isakov O.
      • Israeli S.
      • Nousbeck J.
      • et al.
      Familial Pityriasis rubra pilaris is caused by mutations in CARD14.
      ). Variants affecting certain domains of CARD14 were initially described as leading to the activation of NF-κB in the skin (
      • Fuchs-Telem D.
      • Sarig O.
      • van Steensel M.A.
      • Isakov O.
      • Israeli S.
      • Nousbeck J.
      • et al.
      Familial Pityriasis rubra pilaris is caused by mutations in CARD14.
      ). However, differences between wild-type and variant CARD14 effects on NF-κB are modest (
      • Li Q.
      • Jin Chung H.
      • Ross N.
      • Keller M.
      • Andrews J.
      • Kingman J.
      • et al.
      Analysis of CARD14 polymorphisms in Pityriasis rubra pilaris: activation of NF-κB.
      ), and not all pathogenic variants increase the activation of NF-κB (
      • Bertin J.
      • Wang L.
      • Guo Y.
      • Jacobson M.D.
      • Poyet J.L.
      • Srinivasula S.M.
      • et al.
      CARD11 and CARD14 Are Novel Caspase Recruitment Domain (CARD)/membrane-associated guanylate kinase (MAGUK) Family Members that InterAct with BCL10 and Activate NF-kappa B.
      ). This includes some of those located in the CARD domain (amino acid sequences 15‒107) (
      • Israel L.
      • Mellett M.
      Clinical and genetic heterogeneity of CARD14 mutations in psoriatic skin disease.
      ) such as that in patient 2. Treatment of patients with germline CARD14 variants with Ustekinumab has been highly successful (
      • Eytan O.
      • Sarig O.
      • Sprecher E.
      • van Steensel M.A.
      Clinical response to ustekinumab in familial pityriasis rubra pilaris caused by a novel mutation in CARD14.
      ;
      • Lwin S.M.
      • Hsu C.K.
      • Liu L.
      • Huang H.Y.
      • Levell N.J.
      • McGrath J.A.
      Beneficial effect of ustekinumab in familial pityriasis rubra pilaris with a new missense mutation in CARD14.
      ); however, direct measurement of the effect of CARD14 variants on IL-12 and IL-23 expression has not previously been performed (
      • Teng M.W.
      • Bowman E.P.
      • McElwee J.J.
      • Smyth M.J.
      • Casanova J.L.
      • Cooper A.M.
      • et al.
      IL-12 and IL-23 cytokines: from discovery to targeted therapies for immune-mediated inflammatory diseases.
      ). Our findings suggest that IL-12 and IL-23 could be increased by CARD14 variants in a non‒NF-κB‒dependent manner.
      Patient 1 had been resistant to multiple therapies (cyclosporine, acitretin, oral prednisolone), and she had faltering growth (height and weight below the 0.4th centile by age 3 years; birth weight 50th–75th percentile). With hospital drug and therapeutics committee approval, we started treatment at the age of 6 years with Ustekinumab (0.75 mg/kg/ dose at 0 and 1 months and 3 monthly thereafter, as per psoriasis protocol). She has had a dramatic and sustained improvement in her skin, now 20 months into treatment, but has required an increase to 8-weekly dosing to maintain effect between doses. She also exhibited catch-up growth, with height and weight improving from the <0.4th to 2–9th percentile within 3 months (Figure 1d and f) and no adverse effects. Patient 2 is younger and less symptomatic (Figure 1g and j) and has not required treatment.
      Historically, there has been debate about the clinical and histopathological similarities of ILVEN to congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome and to psoriasis (
      • Happle R.
      Child naevus is not ILVEN.
      ;
      • Ito M.
      • Shimizu N.
      • Fujiwara H.
      • Maruyama T.
      • Tezuka M.
      Histopathogenesis of inflammatory linear verrucose epidermal naevus: histochemistry, immunohistochemistry and ultrastructure.
      ;
      • Moss C.
      • Burn J.
      CHILD + ILVEN = PEN or PENCIL.
      ;
      • Welch M.L.
      • Smith K.J.
      • Skelton H.G.
      • Frisman D.M.
      • Yeager J.
      • Angritt P.
      • et al.
      Immunohistochemical features in inflammatory linear verrucous epidermal nevi suggest a distinctive pattern of clonal dysregulation of growth. Military Medical Consortium for the Advancement of Retroviral Research.
      ). We consider that these debates are likely the result of genetic heterogeneity in ILVEN and that the term ILVEN is a clinical description rather than a single histopathological or genetic entity.
      We identify in this study that heterozygous missense variants in CARD14 are a recurrent cause of this phenotype, leading to successful targeted medical therapy in one patient. Indications for treatment should be made on an individual patient basis. Genetic counseling should be considered in ILVEN as in these cases, it could be passed on as pityriasis rubra pilaris or psoriasis. These findings underline the power of molecular genetic characterization of rare diseases alongside clinical and histopathological phenotyping.

       Data availability statement

      No datasets were generated or analyzed during this study.

      ORCIDs

      Satyamaanasa Polubothu: http://orcid.org/0000-0001-7195-5670

      Conflict of Interest

      The authors state no conflict of interest.

      Acknowledgments

      We gratefully acknowledge the participation of patients and families in this study and the research coordination by Jane White. VAK was funded by the Wellcome Trust (award number WT104076MA). PS was funded by University College London Technology Fund (award number W1140). SP was funded by the National Institute for Health Research Biomedical Research Centre at the University College London Great Ormond Street Institute of Child Health (award number 17BN22). MR and SBM were funded by the Great Ormond Street Hospital Children's Charity Livingstone Skin Research Centre. The work was supported by the United Kingdom National Institute for Health Research through the Biomedical Research Centre at Great Ormond St Hospital for Children National Health Service Foundation Trust and the University College London Great Ormond Street Institute of Child Health. This research was funded in whole or in part by the Wellcome Trust (WT104076MA). For the purpose of Open Access, the author has applied a Creative Common by public copyright licence to any Author Accepted Manuscript version arising from this submission.

      Author Contributions

      Conceptualization: VAK; Formal Analysis: VAK, MR, SP, PS; Investigation: SP, PS, MR; Resources: VAK, SP, PS, MR, SBM, CRC, OO, ILC, DGP, NJS, WLD, AP; Visualization: SP, MR, PS; Writing - Original Draft Preparation: VAK, SP, MR; Writing - Review and Editing: MR, SP, PS, CH, SBM, CRC, ILC, KG, OO, DGP, NJS, AP, WLD, VAK

      Supplementary Materials

      Supplementary Table S1Detailed Clinical Features of Patients 1 and 2
      Clinical FeaturesPatient 1Patient 2
      Age of onset11 mo1 y
      Lesion typeBlaschko-linear erythematous, hyperkeratotic, pruriticBlaschko-linear erythematous, hyperkeratotic
      Lesion distributionGeneralizedAppeared on left thumb at ages 4‒6 wk
      Lesion extentFacial, truncal, and all limbsFacial, truncal, all limbs
      Unilateral / BilateralBilateralInitially unilateral on the left side but progressed to bilateral
      Palmoplantar involvement (Y/N) and which typeDiffuse palmoplantar keratodermaLinear palmoplantar keratoderma in continuity with arm lesions
      Abbreviations: N, no; Y, yes.

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