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Genetic Analysis of MPO Variants in Four Psoriasis Subtypes in Patients from Germany

2021; Elsevier BV; Volume: 141; Issue: 8 Linguagem: Inglês

10.1016/j.jid.2021.01.017

1523-1747

Stefan Haskamp, J Horowitz, Vinzenz Oji, Sandra Philipp, Michael Sticherling, Knut Schäkel, Sarah Schuhmann, Jörg C. Prinz, Harald Burkhardt, Frank Behrens, Beate Böhm, Michaela Köhm, Jürgen Rech, David Simón, Georg Schett, Kirsten Steinz, Sascha Gerdes, G. Aßmann, Ali Nimeh, Volker Schuster, Arnd Jacobi, Ansgar J. Weyergraf, André Reis, Steffen Uebe, Dagmar Wilsmann‐Theis, Rotraut Mößner, Ulrike Hüffmeier,

Autoimmune and Inflammatory Disorders Research

Psoriasis is a common inflammatory skin disorder with a strong impact on patients' QOL. The most common psoriasis form, psoriasis vulgaris (PsV), is characterized by demarcated, erythematous, raised plaques along with silvery scales. Up to 30% of patients with PsV develop an inflammatory joint disease named psoriatic arthritis (PsA) (Mease et al., 2013Mease P.J. Gladman D.D. Papp K.A. Khraishi M.M. Thaçi D. Behrens F. et al.Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics.J Am Acad Dermatol. 2013; 69: 729-735Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar; Reich et al., 2009Reich K. Krüger K. Mössner R. Augustin M. Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasis.Br J Dermatol. 2009; 160: 1040-1047Crossref PubMed Scopus (273) Google Scholar). PsV and PsA are genetically complex diseases with >65 susceptibility loci identified in one or both psoriatic subtypes (Tsoi et al., 2017Tsoi L.C. Stuart P.E. Tian C. Gudjonsson J.E. Das S. Zawistowski M. et al.Large scale meta-analysis characterizes genetic architecture for common psoriasis associated variants.Nat Commun. 2017; 8: 15382Crossref PubMed Scopus (125) Google Scholar). In contrast to PsV and PsA, pustular psoriatic subtypes—palmoplantar pustular psoriasis or palmoplantar pustulosis (PPP) and generalized pustular psoriasis (GPP)—are rarer. PPP is characterized by localized epidermal neutrophil pustules, whereas more generalized pustules in severe multisystemic inflammation are typical for GPP. The genetic etiology of PPP is unsolved; discrepant results related to association with IL36RN (encoding the IL-36 receptor antagonist) variants were reported in British patients (Twelves et al., 2019Twelves S. Mostafa A. Dand N. Burri E. Farkas K. Wilson R. et al.Clinical and genetic differences between pustular psoriasis subtypes.J Allergy Clin Immunol. 2019; 143: 1021-1026Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar) versus in German and Estonian patients (Mössner et al., 2018Mössner R. Wilsmann-Theis D. Oji V. Gkogkolou P. Löhr S. Schulz P. et al.The genetic basis for most patients with pustular skin disease remains elusive.Br J Dermatol. 2018; 178: 740-748Crossref PubMed Scopus (43) Google Scholar). Conversely, IL36RN has been acknowledged as a major gene for GPP (Marrakchi et al., 2011Marrakchi S. Guigue P. Renshaw B.R. Puel A. Pei X.Y. Fraitag S. et al.Interleukin-36-receptor antagonist deficiency and generalized pustular psoriasis.N Engl J Med. 2011; 365: 620-628Crossref PubMed Scopus (623) Google Scholar), although further factors contribute to the pathogenesis of GPP, and oligogenic inheritance is discussed (Mössner et al., 2018Mössner R. Wilsmann-Theis D. Oji V. Gkogkolou P. Löhr S. Schulz P. et al.The genetic basis for most patients with pustular skin disease remains elusive.Br J Dermatol. 2018; 178: 740-748Crossref PubMed Scopus (43) Google Scholar). Patients diagnosed with syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis exhibit different combinations of inflammatory skin and bone diseases considerably overlapping with common psoriatic subtypes and pustular psoriasis; the genetic basis of syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis is largely unknown. Recently, we and others identified MPO as an additional major susceptibility gene in GPP (Haskamp et al., 2020Haskamp S. Bruns H. Hahn M. Hoffmann M. Gregor A. Löhr S. et al.Myeloperoxidase modulates inflammation in generalized pustular psoriasis and additional rare pustular skin diseases.Am J Hum Genet. 2020; 107: 527-538Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar; Vergnano et al., 2020Vergnano M. Mockenhaupt M. Benzian-Olsson N. Paulmann M. Grys K. Mahil S.K. et al.Loss-of-function myeloperoxidase mutations are associated with increased neutrophil counts and pustular skin disease.Am J Hum Genet. 2020; 107: 539-543Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar). The deficiency of neutrophilic enzyme MPO impairs phagocytosis of dying neutrophils and increases the activity of IL-36 activating proteases, thereby driving inflammation in pustules (Haskamp et al., 2020Haskamp S. Bruns H. Hahn M. Hoffmann M. Gregor A. Löhr S. et al.Myeloperoxidase modulates inflammation in generalized pustular psoriasis and additional rare pustular skin diseases.Am J Hum Genet. 2020; 107: 527-538Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar). In addition, patients with GPP with MPO variants are more likely to have PPP, tongue manifestations, and a positive family history of psoriasis than those without MPO variants (Haskamp et al., 2020Haskamp S. Bruns H. Hahn M. Hoffmann M. Gregor A. Löhr S. et al.Myeloperoxidase modulates inflammation in generalized pustular psoriasis and additional rare pustular skin diseases.Am J Hum Genet. 2020; 107: 527-538Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar); an increased serum amount of MPO has been detected in patients with PsV and PsA, suggesting a potentially protective role of MPO variants in common psoriatic manifestations (Cretu et al., 2018Cretu D. Gao L. Liang K. Soosaipillai A. Diamandis E.P. Chandran V. Differentiating psoriatic arthritis from psoriasis without psoriatic arthritis using novel serum biomarkers.Arthritis Care Res (Hoboken). 2018; 70: 454-461Crossref PubMed Scopus (26) Google Scholar). These findings prompted us to investigate the role of MPO variants in other psoriatic subtypes. This study was approved by the ethical committee of the Friedrich-Alexander-Universität Erlangen-Nürnberg (Erlangen, Germany) and the ethical committees of the further involved universities. Written informed consent was obtained from each affected and control individual before enrolment. We analyzed the segregation of MPO, IL36RN, and CARD14 variants in available family members of seven patients with GPP and one patient with acute generalized exanthematous pustulosis, previously identified to carry MPO variants (Figure 1). On the basis of self-reported diagnoses, 14 of those family members were affected by PsV, 2 were affected by inflammatory joint disease, and 1 was affected by PPP. Overall, 6 of the 12 analyzed family members with PsV (50%) and 8 of the 13 analyzed healthy family members (62%) carried a heterozygous MPO variant. When the families were analyzed on the basis of associated enzyme activity of MPO variants, from complete to partial MPO deficiency in the homozygous state (Supplementary Table S1), the proportion of patients with PsV with MPO variants associated with complete deficiency was slightly higher (6 of 10, 60%) but was similar to the one in healthy family members (7 of 11, 64%). In two families with IL36RN variants in addition to the ones in MPO (pedigrees VI and VII, Figure 1), double heterozygous individuals were healthy, whereas the two individuals who were heterozygous or compound heterozygous only for IL36RN presented with PsV (family VI) or PsV and PPP (pedigree VII). Because these findings were based on a limited number of individuals and we could neither establish nor exclude a role of MPO variants in susceptibility to PsV, we investigated MPO variants in larger study groups of patients with psoriasis. We genotyped 3,663 individuals (1,105 with PsV; 1,313 with PsA; 271 with PPP; 52 with syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis; and 922 control individuals) for seven of the most common functionally relevant MPO variants (Supplementary Table S1) (Haskamp et al., 2020Haskamp S. Bruns H. Hahn M. Hoffmann M. Gregor A. Löhr S. et al.Myeloperoxidase modulates inflammation in generalized pustular psoriasis and additional rare pustular skin diseases.Am J Hum Genet. 2020; 107: 527-538Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar) using global screening array and single SNP genotyping assays (Supplementary Materials and Methods including Supplementary Figure S2, Supplementary Tables S7 and S8). We extensively validated the genotyping quality with several approaches, including repeated genotyping with different assays and Sanger sequencing in individuals with MPO variants and randomly selected genotypes (Supplementary Materials and Methods). We determined the cumulative frequency of all variants in patients with psoriatic subtypes and in control individuals as described before (Haskamp et al., 2020Haskamp S. Bruns H. Hahn M. Hoffmann M. Gregor A. Löhr S. et al.Myeloperoxidase modulates inflammation in generalized pustular psoriasis and additional rare pustular skin diseases.Am J Hum Genet. 2020; 107: 527-538Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar) (Table 1). Whereas the frequencies of all MPO variants were similar between two control groups and comparable in PsV; PsA; and syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis, we observed evidence for marginal significant association of PPP with MPO variants (P = 0.015). Analyses at the single variant level pointed to a prominent contribution of variant c.995C>T/p.(Ala332Val), associated with partial MPO deficiency, in PPP (P = 0.008; Supplementary Table S1).Table 1Allele Numbers and Frequencies of Rare MPO Variants in 1,105 Patients with PsV, 1,313 Patients with PsA, 271 Patients with PPP, 52 Patients with SAPHO Syndrome, 922 German Control Indivs., and 64,591 NFE Indivs. of gnomADVariant at Nucleotide and Protein LevelPsoriasis SubtypesControl Indivs.PsV, n (%)PsA, n (%)PPP, n (%)SAPHO Syndrome, n (%)Control Indivs., n (%)NFE Indivs., n (%)c.752T>C/p.(Met251Thr)27 (1.22)38 (1.45)8 (1.48)2 (1.92)25 (1.36)1,735 (1.34)c.995C>T/p.(Ala332Val)33 (1.49)38 (1.45)19 (3.51)1 (0.96)34 (1.84)2,314 (1.79)c.1555_1568del/ p.(Met519Profs∗21)6 (0.27)6 (0.23)2 (0.37)1 (0.96)2 (0.11)0 (.15)c.1642C>T/p.(Arg548Trp)0 (0)0 (0)0 (0)0 (0)1 (0.05)67 (0.05)c.1705C>T/p.(Arg569Trp)6 (0.27)6 (0.23)3 (0.55)1 (0.96)3 (0.16)370 (0.29)c.1768C>T/p.(Arg590Cys)0 (0)0 (0)0 (0.00)0 (0.00)0 (0)9 (0.01)c.2031-2A>C15 (0.68)15 (0.57)4 (0.74)1 (0.96)11 (0.6)936 (0.72)Σ mutant alleles87 (3.94)103 (3.92)36 (6.64)6 (5.77)Σ 5,696 (4.35)Σ WT alleles2,123 (96.06)2,523 (96.08)506 (93.36)98 (94.23)Σ 125,330 (95.65)P-valuen.s. (0.399)n.s. (0.333)0.015n.s. (0.464)——Abbreviations: indivs., individuals; n, number of patients; NFE, non-Finnish European; no., number; n.s., not significant; PPP, palmoplantar pustulosis; PsA, psoriatic arthritis; PsV, psoriasis vulgaris; SAPHO, syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis; WT, wild type.Σ indicates sum.Cumulative frequency distributions of missense or splice variants in patient and control groups were compared using Fisher's exact test with P-values not adjusted for the no. of tests (four psoriatic subtypes).Source from Karczewski et al., 2020Karczewski K.J. Francioli L.C. Tiao G. Cummings B.B. Alföldi J. Wang Q. et al.The mutational constraint spectrum quantified from variation in 141,456 humans [published correction appears in Nature 2021;590:E53].Nature. 2020; 581: 434-443Crossref PubMed Scopus (1605) Google Scholar. Open table in a new tab Abbreviations: indivs., individuals; n, number of patients; NFE, non-Finnish European; no., number; n.s., not significant; PPP, palmoplantar pustulosis; PsA, psoriatic arthritis; PsV, psoriasis vulgaris; SAPHO, syndrome of synovitis, acne, pustulosis, hyperostosis, osteitis; WT, wild type. Σ indicates sum. Cumulative frequency distributions of missense or splice variants in patient and control groups were compared using Fisher's exact test with P-values not adjusted for the no. of tests (four psoriatic subtypes). Source from Karczewski et al., 2020Karczewski K.J. Francioli L.C. Tiao G. Cummings B.B. Alföldi J. Wang Q. et al.The mutational constraint spectrum quantified from variation in 141,456 humans [published correction appears in Nature 2021;590:E53].Nature. 2020; 581: 434-443Crossref PubMed Scopus (1605) Google Scholar. At the genotype level when considering the combination of two MPO variants, we observed mainly combinations resulting in partial MPO deficiency and estimated loss in enzyme activity of 65‒90% in patients (Supplementary Table S2) (Haskamp et al., 2020Haskamp S. Bruns H. Hahn M. Hoffmann M. Gregor A. Löhr S. et al.Myeloperoxidase modulates inflammation in generalized pustular psoriasis and additional rare pustular skin diseases.Am J Hum Genet. 2020; 107: 527-538Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar; Marchetti et al., 2004Marchetti C. Patriarca P. Solero G.P. Baralle F.E. Romano M. Genetic characterization of myeloperoxidase deficiency in Italy.Hum Mutat. 2004; 23: 496-505Crossref PubMed Scopus (23) Google Scholar; Nauseef et al., 1994Nauseef W.M. Brigham S. Cogley M. Hereditary myeloperoxidase deficiency due to a missense mutation of arginine 569 to tryptophan.J Biol Chem. 1994; 269: 1212-1216Abstract Full Text PDF PubMed Google Scholar). Although the percentage of patients with psoriasis with two variants was increased 1.5-fold compared with that of control individuals owing to higher percentages in PsV and PPP (0.54% and 0.74%, respectively, vs. 0.27%), we did not observe a significant difference in the overall numbers of MPO variants (Supplementary Table S3). Similar results were found when combining MPO genotype data with IL36RN variants (Supplementary Table S4). By investigating the relationships of MPO variants with the age of onset (Supplementary Figure S1), the severity of disease (Supplementary Table S5), and positive family history (Supplementary Table S6), we obtained negative findings, with a tendency to a negative correlation regarding the severity of disease (P = 0.09). Our study found a marginally significant association of MPO variants with intermediate effect size with PPP, although the P-value indicating association did not withstand correction for multiple testing most probably owing to the size of our patient cohort. We found no association with both PsV and PsA. This might be due to the rarity of these alleles, limiting the power of our study. Previous GWASs in psoriasis did not describe MPO as a susceptibility locus (Tsoi et al., 2017Tsoi L.C. Stuart P.E. Tian C. Gudjonsson J.E. Das S. Zawistowski M. et al.Large scale meta-analysis characterizes genetic architecture for common psoriasis associated variants.Nat Commun. 2017; 8: 15382Crossref PubMed Scopus (125) Google Scholar). Because our analyses focused on German patients, we cannot exclude a potential role in patients of other ethnic backgrounds. Nevertheless, individuals carrying two MPO variants may be more susceptible to psoriasis, because the proportion of patients with psoriasis with two variants (PPP and PsV) was nominally higher than that in controls. These findings require independent replication but point to a situation where other genetic factors largely increase susceptibility to the four psoriasis subtypes. Overall, our findings differentiate the genetic etiology of GPP from those of the other psoriasis subtypes. Relevant data generated and/or analyzed are available in this manuscript and its supplementary file. Stefan Haskamp: http://orcid.org/0000-0003-3760-9074 Joseph Simon Horowitz: http://orcid.org/0000-0002-4456-6984 Vinzenz Oji: http://orcid.org/0000-0003-1380-4828 Sandra Philipp: http://orcid.org/0000-0002-9421-5461 Michael Sticherling: http://orcid.org/0000-0001-9396-3938 Knut Schäkel: http://orcid.org/0000-0001-6344-7799 Sarah Schuhmann: http://orcid.org/0000-0002-6775-3547 Jörg C. Prinz: http://orcid.org/0000-0002-8857-5495 Harald Burkhardt: http://orcid.org/0000-0002-6261-3131 Frank Behrens: http://orcid.org/0000-0001-8750-7186 Beate Böhm: http://orcid.org/0000-0001-5823-1184 Michaela Köhm: http://orcid.org/0000-0002-3579-5574 Jürgen Rech: http://orcid.org/0000-0002-2569-2029 David Simon: http://orcid.org/0000-0001-8310-7820 Georg Schett: http://orcid.org/0000-0001-8740-9615 Kirsten Morrison: http://orcid.org/0000-0002-5308-0249 Sascha Gerdes: http://orcid.org/0000-0002-6667-7757 Gunter Assmann: http://orcid.org/0000-0002-3216-9340 Ali Nimeh: http://orcid.org/0000-0003-0912-4758 Volker Schuster: http://orcid.org/0000-0001-5735-1838 Arnd Jacobi: http://orcid.org/0000-0002-0684-3426 Ansgar Weyergraf: http://orcid.org/0000-0001-5221-2492 André Reis: http://orcid.org/0000-0002-6301-6363 Steffen Uebe: http://orcid.org/0000-0002-4819-7637 Dagmar Wilsmann-Theis: http://orcid.org/0000-0002-5594-7192 Rotraut Mößner: http://orcid.org/0000-0003-2476-7647 Ulrike Hüffmeier: http://orcid.org/0000-0001-6448-4671 JSH is employed in the psychiatric department of Klinik am Europakanal, Erlangen, Germany. MS is involved in clinical studies on anti‒IL-36 antibody in generalized pustular psoriasis and palmoplantar pustulosis by Boehringer Mannheim. The remaining authors state no conflict of interest. We are grateful to the patients and controls who participated in this study. We thank Anne Gerschütz, Valentina Rabinovich, and Iris Kerker for excellent technical assistance. We thank Peter Morrison, PhD (Department of Dermatology, Førde Sentralsjukehus, Førde, Norway) for proofreading this manuscript. This project was funded by grants to UH from the Deutsche Forschungsgemeinschaft (CRC1181, project A05; HU 2163/1-1), by a grant to UH from the Dr. Pfleger-Stiftung, and by grants to AR and UH from the Federal Ministry of Education and Research (Metarthros 01EC1407A) and a grant to UH from the Interdisciplinary Centre for Clinical Research Erlangen (Project A85). Conceptualization: UH; Investigation: JSH, UH; Formal Analysis: SH, JSH, SU, UH; Resources: VO, SP, MS, KS, SS, JCP, HB, FB, BB, MK, JR, DS, GS, KM, SG, GA, AN, VS, AJ, AW, DWT, RM, UH; Writing - Original Draft Preparation: SH, UH; Writing - Review and Editing: SH, JSH, VO, SP, MS, KS, SS, JCP, HB, FB, BB, MK, JR, DS, GS, KM, SG, GA, AN, VS, AJ, AW, AR, SU, DWT, RM, UH Download .pdf (.62 MB) Help with pdf files Supplementary File