Tofacitinib relieves symptoms of stimulator of interferon genes (STING)–associated vasculopathy with onset in infancy caused by 2 de novo variants in TMEM173
Authors: Jieun Seo, Jung-Ah Kang, Dong In Suh, Eun-Byeol Park, Cho-Rong Lee, Sun Ah Choi, Soo Yeon Kim, Yeji Kim, Sang-Heon Park, Michael Ye, Soon-Hak Kwon, June Dong Park, Byung Chan Lim, Dong Hun Lee, Suk-Jo Kang, Murim Choi, Sung-Gyoo Park, Jong-Hee Chae
Journal: Journal of Allergy and Clinical Immunology (2016)

Stimulator of interferon genes (STING), which is encoded by transmembrane protein 173 (TMEM173), is an important mediator in initiating innate immune responses by detecting aberrant DNA species or cyclic di-GMP-AMP (cGAMP) in the cytosol and driving synthesis of type I interferon.1Barber G.N. STING: infection, inflammation and cancer.Nat Rev Immunol. 2015; 15: 760-770Crossref PubMed Scopus (682) Google Scholar, 2Jeremiah N. Neven B. Gentili M. Callebaut I. Maschalidi S. Stolzenberg M.C. et al.Inherited STING-activating mutation underlies a familial inflammatory syndrome with lupus-like manifestations.J Clin Invest. 2014; 124: 5516-5520Crossref PubMed Scopus (56) Google Scholar, 3Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (159) Google Scholar cGAMP molecules, which are produced by cyclic GMP-AMP synthase, bind to STING homodimers embedded in the endoplasmic reticulum membrane and eventually cause phosphorylation of interferon regulatory factor 3 by activating Tank-binding kinase 1 (TBK1). Patients with activating mutations of STING display early onset of chronic inflammation and vasculopathy caused by increased type I interferon signaling, a condition termed STING-associated vasculopathy with onset in infancy (SAVI).2Jeremiah N. Neven B. Gentili M. Callebaut I. Maschalidi S. Stolzenberg M.C. et al.Inherited STING-activating mutation underlies a familial inflammatory syndrome with lupus-like manifestations.J Clin Invest. 2014; 124: 5516-5520Crossref PubMed Scopus (56) Google Scholar, 3Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (159) Google Scholar Improved understanding of STING's function and its implications in disease pathogenesis has suggested new potential avenues of disease treatment options through modulating STING signaling pathway components. A 9-year-old Korean boy presented with systemic hyperinflammatory symptoms, including skin lesions, brain infarctions, and pulmonary dysfunction. From 6 months of age, he experienced recurrent infections, including acute otitis media, pneumonia, and gastroenteritis. Telangiectatic skin mottling on both the hands and feet was evident from 12 months of age, which progressed to the extremities and face over time (Fig 1, A, and see Fig E1 in this article's Online Repository at www.jacionline.org). At 5 years of age, he was hospitalized because of pneumococcal meningitis, and brain magnetic resonance imaging and magnetic resonance angiography revealed evidence of infarction in the right parietal area. Chest computed tomography at 8 years of age showed evidence of obliterative bronchiolitis with peribronchial inflammation (Fig 1, B). Consequently, the patient experienced sudden left leg weakness and headache. Brain magnetic resonance imaging revealed acute infarction in the right anterior watershed area and subarachnoid hemorrhages, and magnetic resonance angiography showed diffuse advanced luminal irregularities throughout the cerebral arteries (Fig 1, C). At 9 years of age, a low nasal bridge was apparent and likely caused by a perforated nasal septum (Fig 1, D). Generalized telangiectatic rashes on the cheeks, nose, arms, legs, hands, and feet, with gangrenous lesions, were associated with his recurrent infections. He had slight dyspnea, which worsened on physical exertion but needed continuous supplemental oxygen of 1 L/min or more to maintain an oxygen saturation measured by pulse oximetry of between 90% and 95%. Wheezing and crackles were audible in both lower lung fields. Trio-based whole-exome sequencing was performed (Fig 1, E, and see Table E1 in this article's Online Repository at www.jacionline.org) to search for variants that were specifically found in the patient. Among the candidates, 2 de novo variants of TMEM173 appeared to be the most promising based on known disease associations with the patient's phenotype (Fig 1, F, and see Table E2 and Figs E2 and E3 in this article's Online Repository at www.jacionline.org). To determine whether the 2 variants occurred in the same chromosome (in cis) or on different chromosomes (in trans), we amplified a 3.8-kb fragment of TMEM173 that encompasses both variants, sequenced it using the PacBio sequencing platform, and found that both variants occurred in the paternal chromosome (see Fig E2). The variants were not observed in any of the public (1000 Genomes and ExAC) or private (1060 healthy Koreans) databases, and the corresponding amino acid residues are strongly conserved among vertebrate orthologs (Fig 1, G). The changes were predicted to be damaging by using variant effect prediction software, and the amino acids are located on the transmembrane (p.Ser102Pro) and cytoplasmic domains (p.Phe279Leu), which are involved in homodimerization and are distant from previously reported pathogenic mutations on exon 5 (Fig 1, H, and see Tables E2 and E3 in this article's Online Repository at www.jacionline.org). Analysis of the protein structure reveals that Phe279 is located on the N-terminus of the fourth α-helix, which converges physically with the N-terminus of the first α-helix, possibly affecting nearby amino acids, including Asn154 and Val155, which were found to be mutated in patients with SAVI (Fig 1, I). Analysis of Ser102 was unavailable, although a recent study suggests that Ser103 is important for maintaining proper subcellular localization.4Surpris G. Chan J. Thompson M. Ilyukha V. Liu B.C. Atianand M. et al.Cutting edge: novel Tmem173 allele reveals importance of STING N terminus in trafficking and type I IFN production.J Immunol. 2016; 196: 547-552Crossref PubMed Scopus (15) Google Scholar Based on the known functions of STING, we investigated further the functional consequences of the STING variants. First, patient-derived fibroblasts displayed increased expression of IFN-β, helping to explain the increased inflammatory responses in the patient (Fig 2, A). To understand the molecular basis for increased IFN-β expression, we monitored IFN-β promoter activity by expressing the various mutant STING proteins in HEK293T cells (Fig 2, B). As the cGAMP concentration increases, cells expressing the mutant STING proteins had increased IFN-β promoter activity compared with cells expressing the wild-type STING but with 2 notable differences from previous observations. First, the double-mutant STING (S102P + F279L) showed stronger activity than the STING with a single mutation (S102P or F279L), implying an additive mode of action by the 2 variants. Second, at a baseline level, the mutant STING proteins barely displayed any IFN-β promoter activity, whereas the V147L mutation showed increased activity even without cGAMP (Fig 2, B and C). This observation reflects the patient's delayed onset of disease at 6 months of age, whereas patients with the p.Val147Leu variant presented with infantile onset (see Table E3). Also, the patient is heterozygous for the p.Arg71His-p.Gly230Ala-p.Arg293Gln (HAQ) allele, which is known to confer an approximately 5-fold reduction in IFN-β promoter activity when unstimulated, partially explaining the patient's low basal promoter activity (see Fig E2).5Yi G. Brendel V.P. Shu C. Li P. Palanathan S. Cheng Kao C. Single nucleotide polymorphisms of human STING can affect innate immune response to cyclic dinucleotides.PLoS One. 2013; 8: e77846Crossref PubMed Scopus (31) Google Scholar Subsequent immunoprecipitation analyses revealed that the degree of homodimerization of STING was not altered in the presence or absence of cGAMP (Fig 2, D), but the 2 variants cooperatively conferred increased binding with the downstream factor TBK1, which was slightly increased by the individual mutation alone (Fig 2, E). Previous analyses of patients with SAVI revealed decreased CD4+ T-cell populations and normal CD14+ monocyte levels within the population of PBMCs,3Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (159) Google Scholar whereas our patient had slightly decreased CD4+ T-cell and increased CD14+ monocyte populations. Furthermore, phosphorylated STAT1 (p-STAT1) expression increased dramatically in patients' monocytes (Fig 2, F and G), demonstrating a distinct immunologic response compared with previous patients.2Jeremiah N. Neven B. Gentili M. Callebaut I. Maschalidi S. Stolzenberg M.C. et al.Inherited STING-activating mutation underlies a familial inflammatory syndrome with lupus-like manifestations.J Clin Invest. 2014; 124: 5516-5520Crossref PubMed Scopus (56) Google Scholar, 3Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (159) Google Scholar It has been reported that monocytes from patients with rheumatoid arthritis and systemic lupus erythematosus are more sensitive to IFN-γ signaling for STAT1 phosphorylation than monocytes from healthy donors.6Karonitsch T. von Dalwigk K. Steiner C.W. Bluml S. Steiner G. Kiener H.P. et al.Interferon signals and monocytic sensitization of the interferon-gamma signaling pathway in the peripheral blood of patients with rheumatoid arthritis.Arthritis Rheum. 2012; 64: 400-408Crossref PubMed Scopus (28) Google Scholar Our patient displayed enhanced IFN-γ–secreting CD4+ T-cell and serum IFN-γ levels (see Fig E4 in this article's Online Repository at www.jacionline.org), which were also different from the previously reported patients with SAVI.3Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (159) Google Scholar Thus IFN-γ signaling sensitization in monocytes from our patient possibly contributed to the increased p-STAT1 level in monocytes. The distinct immunologic alterations might be partially contributed by a different genetic background.3Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (159) Google Scholar No agent directly targets STING, but tofacitinib controls the interferon signaling pathway by inhibiting Janus kinases and therefore is used in a number of disease models.3Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (159) Google Scholar, 7Boyle D.L. Soma K. Hodge J. Kavanaugh A. Mandel D. Mease P. et al.The JAK inhibitor tofacitinib suppresses synovial JAK1-STAT signalling in rheumatoid arthritis.Ann Rheum Dis. 2015; 74: 1311-1316Crossref PubMed Scopus (195) Google Scholar After treating the patient with tofacitinib (5 mg/d Xeljanz; Pfizer, New York, NY), the level of p-STAT1 in monocytes decreased rapidly and the monocyte population increased gradually to levels seen in healthy donors by the 21st day (Fig 2, F and G). In addition, the initial ratio of CD4+ to CD8+ cells in lymphocytes (0.61) was lower than that of healthy donors (1.12), and tofacitinib treatment further decreased this ratio (0.39 at day 1), but eventually, the ratio became comparable with that of healthy donors by the 62nd day (1.08; see Fig E5 in this article's Online Repository at www.jacionline.org). Also, inflammatory cytokine levels decreased rapidly (Fig 2, H, and see Fig E4, Fig E5, Fig E6 in this article's Online Repository at www.jacionline.org). Three months of tofacitinib treatment improved the patient's telangiectatic skin lesions (Fig 2, I and J). However, the patient's pulmonary defect remained unchanged, perhaps because his bronchial damage persisted during the critical period of lung growth. Here we report a patient with SAVI caused by 2 genetic changes in STING successfully treated with the Janus kinase inhibitor tofacitinib, which improved the patient's skin lesions. Recent studies have revealed the genetic mechanisms underlying Mendelian forms of autoimmune disorders caused by monogenic defects.8Melki I. Crow Y.J. Novel monogenic diseases causing human autoimmunity.Curr Opin Immunol. 2015; 37: 1-5Crossref PubMed Scopus (16) Google Scholar For example, we characterized and treated a patient with cytotoxic T lymphocyte–associated protein 4 haploinsufficiency with autoimmune infiltration with the cytotoxic T lymphocyte–associated protein 4 mimetic abatacept to augment protein function and demonstrated improved clinical signatures.9Lee S. Moon J.S. Lee C.R. Kim H.E. Baek S.M. Hwang S. et al.Abatacept alleviates severe autoimmune symptoms in a patient carrying a de novo variant in CTLA-4.J Allergy Clin Immunol. 2016; 137: 327-330Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar As the genetic causes underlying idiopathic autoimmune diseases are uncovered more efficiently by using genome sequencing, more successful cases of drug repositioning to readily alleviate disease symptoms will become more commonplace. We thank the patient and his family for their willing and active participation during the study. Written informed consent was obtained from the patient and his family for this study. All samples were collected for research purposes after approval by the Institutional Review Board of Seoul National University Children's Hospital (H-1406-081-588). To understand the genetic basis of the clinical manifestations, we performed whole-exome sequencing (WES) of the patient and his parents. Preparation of genomic DNA, whole-exome capture with the NimbleGen V4 array, sequencing by using the Illumina HiSeq, read alignment, variant calling and filtering, and de novo variant calling procedures were described previously.E1Choi M. Scholl U.I. Ji W. Liu T. Tikhonova I.R. Zumbo P. et al.Genetic diagnosis by whole exome capture and massively parallel DNA sequencing.Proc Natl Acad Sci U S A. 2009; 106: 19096-19101Crossref PubMed Scopus (1004) Google Scholar, E2Seo J. Choi I.H. Lee J.S. Yoo Y. Kim N.K. Choi M. et al.Rare cases of congenital arthrogryposis multiplex caused by novel recurrent CHRNG mutations.J Hum Genet. 2015; 60: 213-215Crossref PubMed Scopus (11) Google Scholar Raw sequence reads were generated by Theragen Etex Co, Ltd (Suwon, Korea). All the called variants were filtered according to the predicted effect on the protein and population frequencies (Table E2). PCR amplification of 2 de novo variants was performed by using standard methods with specific primers (Table E4). The PCR condition included 1 cycle of predenaturation at 95°C for 2 minutes, 35 cycles of denaturation at 95°C for 20 seconds, annealing at 57°C for 40 seconds, elongation at 72°C for 40 seconds, and 1 cycle of postelongation at 72°C for 5 minutes. The products of PCR amplification were purified and sequenced by using the Sanger DNA sequencing method. Full-length orthologous protein sequences among the vertebrates were identified by means of a BLAST search of human TMEM173, and sequences were extracted from GenBank. Orthologs were confirmed based on BLAST searches of the protein sequence against the human protein sequence, with the requirement that human TMEM173 be the top hit and that protein sequences were aligned with the ClustalW algorithm.E3Sievers F. Wilm A. Dineen D. Gibson T.J. Karplus K. Li W. et al.Fast, scalable generation of high-quality protein multiple sequence alignments using Clustal Omega.Mol Syst Biol. 2011; 7: 539Crossref PubMed Scopus (9095) Google Scholar GenBank accession numbers for TMEM173 included NP_938023.1 (Homo sapiens), NP_082537.1 (Mus musculus), XP_002710295.1 (Oryctolagus cuniculus), NP_001039822.1 (Bos taurus), XP_001232171.2 (Gallus gallus), NP_001106445.2 (Xenopus tropicalis), and NP_001265766.1 (Danio rerio). STING secondary structures were identified by means of a UniProt search of human TMEM173 and visualized proteoforms and annotated variants by using Protter (http://wlab.ethz.ch/protter/start/). STING C-terminal Domain 3D structure was extracted from the RCSB database (no. 4F5D) and analyzed by using PyMOL (https://www.pymol.org/). Isolated fibroblasts from skin tissue of the patient or a healthy donor were stimulated with 100 ng/mL cGAMP for 24 hours, and the IFNB mRNA expression level was analyzed by means of quantitative RT-PCR analysis with specific primers (Table E4). HEK293T cells, which are known to be devoid of STING,E4Burdette D.L. Monroe K.M. Sotelo-Troha K. Iwig J.S. Eckert B. Hyodo M. et al.STING is a direct innate immune sensor of cyclic di-GMP.Nature. 2011; 478: 515-518Crossref PubMed Scopus (1005) Google Scholar were transfected with pIFNβ-lucE5Fitzgerald K.A. McWhirter S.M. Faia K.L. Rowe D.C. Latz E. Golenbock D.T. et al.IKKepsilon and TBK1 are essential components of the IRF3 signaling pathway.Nat Immunol. 2003; 4: 491-496Crossref PubMed Scopus (2068) Google Scholar and pRenilla (Promega, Madison, Wis), and the STING expression vectors were cloned out from Jurkat cells. This STING clone does not carry the HAQ allele.E6Yi G. Brendel V.P. Shu C. Li P. Palanathan S. Cheng Kao C. Single nucleotide polymorphisms of human STING can affect innate immune response to cyclic dinucleotides.PLoS One. 2013; 8: e77846Crossref PubMed Scopus (153) Google Scholar Twenty-four hours after the transfection, cells were treated with the indicated concentration of cGAMP. After 24 hours, cells were lysed in 1× passive lysis buffer, and cellular debris was removed by means of centrifugation at 14,000 rpm for 5 minutes at 4°C. Firefly luciferase and Renilla luciferase activities were measured with 20 μL of lysate from each sample. The "fold stimulation" was calculated for each sample by dividing the luciferase activity in the sample normalized to Renilla luciferase activity by the activity of the sample containing empty expression vector. STING expression vector was constructed by inserting the STING open reading frame into the pcDNA3 expression vector. A QuickChange II XL site-directed mutagenesis kit (Agilent Technologies, Santa Clara, Calif) was used to mutate pcDNA3-Myc-STING to generate pcDNA3-Myc-STING (S102P), pcDNA3-Myc-STING (F279L), pcDNA3-Myc-STING (S102P/F279L), and pcDNA3pCMV-Myc-STING (V147L). For binding analysis between the various STING constructs, HEK293T cells were transfected with pcDNA3-HA-STING and pcDNA3-Myc-STING and immunoprecipitated with anti–hemagglutinin (HA) antibody. Then immunoprecipitated proteins were analyzed by means of immune blot analysis with anti-HA or anti-Myc antibodies. For binding analysis between STING and TBK1, HEK293T cells were transfected with pcDNA3-Myc-STING and pcDNA3-FLAG-TBK1 and immunoprecipitated with anti-HA antibody; immunoprecipitated proteins were subsequently analyzed by means of immune blot analysis with anti-Myc or anti-FLAG antibodies. Serum cytokines, including IL-17, IFN-γ, TNF-α, IL-10, IL-6, IL-4, and IL-2, in the patient's or healthy donors' serum were measured with the Cytokine Bead Array (BD Biosciences, San Jose, Calif) by using Canto II flow cytometer (BD Biosciences). Serum IFN-β levels were analyzed by means of ELISA (eBioscience, San Diego, Calif), according to the manufacturer's instructions. PBMCs were isolated from the patient's peripheral venous blood, collected with a Hickman catheter, and purified by means of density gradient centrifugation with Ficoll-Paque PLUS (GE Healthcare Life Sciences, Pittsburgh, Pa). Isolated cells were stained with the indicated fluorochrome-conjugated antibodies and analyzed with the LSR II flow cytometer (BD Biosciences). For intracellular staining, permeabilization solution (eBioscience) was used. The collected data were analyzed with FlowJo software (FlowJo, Ashland, Ore). Peridinin-chlorophyll-protein complex (PerCP)–cy5.5–conjugated anti-human CD3, allophycocyanin-conjugated anti-human CD19, Alexa Fluor 488–conjugated anti-human CD4, PerCP-cy5.5–conjugated anti-human CD8, allophycocyanin-eFluor 780–conjugated anti-human CD14, phycoerythrin-conjugated phosphor specific anti-human STAT1, Percp-cy5.5-conjugated anti-human IFN-γ, and phycoerythrin-conjugated anti-human IL-4 antibodies were purchased from eBioscience.Fig E2Long read sequencing result confirming the 2 cis de novo variants in TMEM173. A, The proband has a heterozygous common single nucleotide polymorphism (rs7380824; East Asian frequency 0.4205 from ExAC) inherited from the mother. B, Sanger sequence traces confirming the rs7380824 inheritance in the family. C, PacBio SMRT sequencing result of a 3.8-kb fragment from TMEM173, including rs7380824 and 2 de novo variants. D, Both de novo TMEM173 variants occurred in the paternal chromosome (in cis). E, Genotype of rs11554776 (p.Arg71His). The variant positions are represented by the asterisks.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig E3Sanger sequence traces confirming other variants from Table E1. The variant positions are represented by the asterisks.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig E4Cytokine levels from the patient's serum. **P < .01, Student t test. †P < .01, 1-way ANOVA.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig E5PBMC population analysis. A, Lymphocytes were gated on forward scatter/side scatter scattergrams, and CD19+ and CD3+ cells were analyzed. B, Lymphocytes were gated on forward scatter/side scatter scattergrams, and CD4+ and CD8+ cells were analyzed. Numbers in parentheses indicate ratios of CD4+ cells to CD8+ cells. C, Lymphocytes were gated on forward scatter/side scatter scattergrams, and CD4+ cells were gated. After gating, IL-4– and IFN-γ–secreting cells were analyzed. In this analysis isolated cells were stimulated with phorbol 12-myristate 13-acetate (50 ng/mL) and ionomycin (500 ng/mL) in the presence of GolgiPlug (BD PharMingen, San Jose, Calif) for 6 hours.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig E6p-STAT levels from CD4+ T cells, CD8+ T cells, and CD19+ B cells after gating lymphocytes based on forward and side scatter.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table E1Exome run quality summaryPatientPatientMotherFatherRead length (bp)2 × 742 × 742 × 74No. of reads (M)75.265.758.8Median coverage depth (X)595146Mean coverage depth (X)72.563.957.0Percentage of reads on genome91.491.591.5Percentage of reads on target63.263.763.5Percentage of bases covered at least 4×97.997.797.4Percentage of bases covered at least 8×96.495.694.9Percentage of bases covered at least 20×88.484.982.4Per-base error rate (%)0.430.420.43Percentage of duplicated reads4.74.74.6 Open table in a new tab Table E2Protein-altering, rare, and patient-specific variantsTypeGeneChromosome: position (hg19)Nucleotide substitutionZygosityEffect on proteinAmino acid changeAmino acid location/protein lengthExAC frequencySIFTPolyPhen-2Coverage (alternative allele/total)ProbandMomDadDe novoTMEM1735:138860851A>GHeterozygousMissensep.Ser102Pro102/37900.220.73513/340/330/21De novoTMEM1735:138857025A>GHeterozygousMissensep.Phe279Leu279/39700.120.92624/580/470/49De novoMYO18A17:27419362G>AHeterozygousMissensep.Ala1729Val1729/205400.200.24210/170/250/28De novoBBS111:66283399C>THeterozygousMissensep.Arg196Trp196/5932/120,9520.001.00046/1080/1080/103De novoMMP1311:102825204A>THeterozygousMissensep.Ile165Asn165/47100.000.22229/680/430/41Rare hemizygousBRWD3X: 79943575C>THemizygousMissensep.Gly1286Glu1286/18020NA0.62777/7759/1310/52 Open table in a new tab Table E3Comparison with previous reportsPatient IDLiu et al, 2014E7Liu Y. Jesus A.A. Marrero B. Yang D. Ramsey S.E. Montealegre Sanchez G.A. et al.Activated STING in a vascular and pulmonary syndrome.N Engl J Med. 2014; 371: 507-518Crossref PubMed Scopus (810) Google ScholarJeremiah et al, 2014E8Jeremiah N. Neven B. Gentili M. Callebaut I. Maschalidi S. Stolzenberg M.C. et al.Inherited STING-activating mutation underlies a familial inflammatory syndrome with lupus-like manifestations.J Clin Invest. 2014; 124: 5516-5520Crossref PubMed Scopus (336) Google ScholarMunoz et al, 2015E9Munoz J. Rodiere M. Jeremiah N. Rieux-Laucat F. Oojageer A. Rice G.I. et al.Stimulator of interferon genes-associated vasculopathy with onset in infancy: a mimic of childhood granulomatosis with polyangiitis.JAMA Dermatol. 2015; 151: 872-877Crossref PubMed Scopus (81) Google ScholarChia et al, 2016E10Chia J. Eroglu F.K. Ozen S. Orhan D. Montealegre-Sanchez G. de Jesus A.A. et al.Failure to thrive, interstitial lung disease, and progressive digital necrosis with onset in infancy.J Am Acad Dermatol. 2016; 74: 186-189Abstract Full Text Full Text PDF PubMed Scopus (50) Google ScholarCurrent studyN1N2N3N4N5N6J1J2J3J4A1--Inheritance patternUnrelatedFamilial---Sex (M/F)MFMFFMMMMFMMMVariant originDe novoNAInheritedDe novo-De novo (two)Variantc.439G>C, p.Val147Leuc.461A>G, p.Asn154Serc.463G>A, p.Val155Metc.463G>A, p.Val155Metc.439G>C, p.Val147Leuc.461A>G, p.Asn154Serc.304T>C, p.Ser102Pro & c.835T>C, p.Phe279LeuAge of onsetInfancy (8 wk)AdulthoodTeenagerTeenagerInfancyInfancyInfancyChildhood (3 years)Status at last follow-upAliveAliveAliveAliveDeadDeadAliveDeadAliveAliveAliveAliveAliveRash or Tachypnea++++++−++++++Gangrene of finger/toe4/6NA+++Lung disease5/6−++++++CNS vessel involvementNot reportedNot reportedNot reportedNot reported+F, Female; M, male; NA, data not available. Open table in a new tab Table E4Primers used in this studyPrimer namePrimer sequencesPrimer namePrimer sequencesTMEM173_S102P_F5′-AGGAGGATGTTCAGTGCCTG-3′TMEM173_S102P_R5′-GGGTATCCAACGTGTGTCAC-3′TMEM173_F279L_F5′-ATCAACCCCTCACCCTACCA-3′TMEM173_F279L_R5′-GTTACAGGCTGAGGGAGTGG-3′MYO18A_A1729V_F5′-CTGTCTAGGGTGAAGGGAGC-3′MYO18A_A1729V_R5′-TCTTTCCTGTACAGCCCTCC-3′BBS1_R196W_F5′-AGAATGATGGAGGAGGGCAG-3′BBS1_R196W_R5′-TGGAAGTCACTGCAGCTTTA-3′MMP13_I165N_F5′-CCAGGAGTACTTAGCACAGGT-3′MMP13_I165N_R5′-GCCTTCAAAGTTTGGTCCGA-3′BRWD3_G1286Q_F5′-TTCTCCAGACTCTGCCTGTG-3′BRWD3_G1286Q_F5′-TTGTTCTACTTGCTGCTCCA-3′IFN-β_qPCR_F5′-AAACTCATGAGCAGTCTGCA-3′IFN-β_qPCR_R5′-AGGAGATCTTCAGTTTCGGAGG-3′ Open table in a new tab F, Female; M, male; NA, data not available. CorrectionJournal of Allergy and Clinical ImmunologyVol. 139Issue 6PreviewWith regard to the article in the April 2017 issue entitled ''Tofacitinib relieves symptoms of stimulator of interferon genes (STING)–associated vasculopathy with onset in infancy caused by 2 de novo variants in TMEM173" (J Allergy Clin Immunol 2017;139:1396-9), the authors wish to amend the funding support section to state "A portion of this study was supported by grants from the Korea Healthcare Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry for Health and Welfare, Republic of Korea (HI12C0066; to J.-H.C.), and the Brain Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (NRF-2014M3C7A1046049; to J.-H.C.). Full-Text PDF