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Pyogenic sterile [[arthritis]], [[pyoderma gangrenosum]], acne syndrome, PAPA syndrome, is one of the inherited [[Periodic fever syndrome|autoinflammatory disorders]]. PAPA syndrome presents with the triad of [[aseptic]] [[arthritis]], [[pyoderma gangrenosum]], and [[acne]]. However, not all the features may be present in all the [[patients]]. | Pyogenic sterile [[arthritis]], [[pyoderma gangrenosum]], acne syndrome, PAPA syndrome, is one of the inherited [[Periodic fever syndrome|autoinflammatory disorders]]. PAPA syndrome presents with the triad of [[aseptic]] [[arthritis]], [[pyoderma gangrenosum]], and [[acne]]. However, not all the features may be present in all the [[patients]]. | ||
==Historical Perspective== | ==Historical Perspective== | ||
* PAPA syndrome was first discovered by Dr. Noralane M. Lindor, in 1997 following visiting several patients from three generations of a family with similar presentations.<ref name="LindorArsenault1997">{{cite journal|last1=Lindor|first1=Noralane M.|last2=Arsenault|first2=Todd M.|last3=Solomon|first3=Herman|last4=Seidman|first4=Christine E.|last5=McEvoy|first5=Marian T.|title=A New Autosomal Dominant Disorder of Pyogenic Sterile Arthritis, Pyoderma Gangrenosum, and Acne: PAPA Syndrome|journal=Mayo Clinic Proceedings|volume=72|issue=7|year=1997|pages=611–615|issn=00256196|doi=10.4065/72.7.611}}</ref> | |||
* The [[Association (statistics)|association]] between [[PSTPIP1]] [[gene]] [[mutation]] and PAPA syndrome was made in the year 2000.<ref name="YeonLindor2000">{{cite journal|last1=Yeon|first1=Howard B.|last2=Lindor|first2=Noralane M.|last3=Seidman|first3=J.G.|last4=Seidman|first4=Christine E.|title=Pyogenic Arthritis, Pyoderma Gangrenosum, and Acne Syndrome Maps to Chromosome 15q|journal=The American Journal of Human Genetics|volume=66|issue=4|year=2000|pages=1443–1448|issn=00029297|doi=10.1086/302866}}</ref> | *PAPA syndrome was first discovered by Dr. Noralane M. Lindor, in 1997 following visiting several patients from three generations of a family with similar presentations.<ref name="LindorArsenault1997">{{cite journal|last1=Lindor|first1=Noralane M.|last2=Arsenault|first2=Todd M.|last3=Solomon|first3=Herman|last4=Seidman|first4=Christine E.|last5=McEvoy|first5=Marian T.|title=A New Autosomal Dominant Disorder of Pyogenic Sterile Arthritis, Pyoderma Gangrenosum, and Acne: PAPA Syndrome|journal=Mayo Clinic Proceedings|volume=72|issue=7|year=1997|pages=611–615|issn=00256196|doi=10.4065/72.7.611}}</ref> | ||
*The [[Association (statistics)|association]] between [[PSTPIP1]] [[gene]] [[mutation]] and PAPA syndrome was made in the year 2000.<ref name="YeonLindor2000">{{cite journal|last1=Yeon|first1=Howard B.|last2=Lindor|first2=Noralane M.|last3=Seidman|first3=J.G.|last4=Seidman|first4=Christine E.|title=Pyogenic Arthritis, Pyoderma Gangrenosum, and Acne Syndrome Maps to Chromosome 15q|journal=The American Journal of Human Genetics|volume=66|issue=4|year=2000|pages=1443–1448|issn=00029297|doi=10.1086/302866}}</ref> | |||
==Classification== | ==Classification== | ||
* There is no established system for the [[classification]] of PAPA syndrome. | |||
*There is no established system for the [[classification]] of PAPA syndrome. | |||
==Pathophysiology== | ==Pathophysiology== | ||
* The exact [[pathogenesis]] of PAPA syndrome is not fully understood. However, it develops as a result of a [[mutation]] in the [[PSTPIP1]] [[gene]].<ref name="J. SmithAllantaz2010">{{cite journal|last1=J. Smith|first1=Elisabeth|last2=Allantaz|first2=Florence|last3=Bennett|first3=Lynda|last4=Zhang|first4=Dongping|last5=Gao|first5=Xiaochong|last6=Wood|first6=Geryl|last7=L. Kastner|first7=Daniel|last8=Punaro|first8=Marilynn|last9=Aksentijevich|first9=Ivona|last10=Pascual|first10=Virginia|last11=A. Wise|first11=Carol|title=Clinical, Molecular, and Genetic Characteristics of PAPA Syndrome: A Review|journal=Current Genomics|volume=11|issue=7|year=2010|pages=519–527|issn=13892029|doi=10.2174/138920210793175921}}</ref><ref name="ShohamCentola2003">{{cite journal|last1=Shoham|first1=N. G.|last2=Centola|first2=M.|last3=Mansfield|first3=E.|last4=Hull|first4=K. M.|last5=Wood|first5=G.|last6=Wise|first6=C. A.|last7=Kastner|first7=D. L.|title=Pyrin binds the PSTPIP1/CD2BP1 protein, defining familial Mediterranean fever and PAPA syndrome as disorders in the same pathway|journal=Proceedings of the National Academy of Sciences|volume=100|issue=23|year=2003|pages=13501–13506|issn=0027-8424|doi=10.1073/pnas.2135380100}}</ref> | |||
* [[Mutation]] is inherited in an [[autosomal dominant]] mode. | *The exact [[pathogenesis]] of PAPA syndrome is not fully understood. However, it develops as a result of a [[mutation]] in the [[PSTPIP1]] [[gene]].<ref name="J. SmithAllantaz2010">{{cite journal|last1=J. Smith|first1=Elisabeth|last2=Allantaz|first2=Florence|last3=Bennett|first3=Lynda|last4=Zhang|first4=Dongping|last5=Gao|first5=Xiaochong|last6=Wood|first6=Geryl|last7=L. Kastner|first7=Daniel|last8=Punaro|first8=Marilynn|last9=Aksentijevich|first9=Ivona|last10=Pascual|first10=Virginia|last11=A. Wise|first11=Carol|title=Clinical, Molecular, and Genetic Characteristics of PAPA Syndrome: A Review|journal=Current Genomics|volume=11|issue=7|year=2010|pages=519–527|issn=13892029|doi=10.2174/138920210793175921}}</ref><ref name="ShohamCentola2003">{{cite journal|last1=Shoham|first1=N. G.|last2=Centola|first2=M.|last3=Mansfield|first3=E.|last4=Hull|first4=K. M.|last5=Wood|first5=G.|last6=Wise|first6=C. A.|last7=Kastner|first7=D. L.|title=Pyrin binds the PSTPIP1/CD2BP1 protein, defining familial Mediterranean fever and PAPA syndrome as disorders in the same pathway|journal=Proceedings of the National Academy of Sciences|volume=100|issue=23|year=2003|pages=13501–13506|issn=0027-8424|doi=10.1073/pnas.2135380100}}</ref> | ||
* The [[mutation]] leads to a hyper-phosphorylated [[PSTPIP1]] [[protein]] which changes its action in the inflammasome involved in [[interleukin-1]] ([[IL-1|IL-1β]]) production. | *[[Mutation]] is inherited in an [[autosomal dominant]] mode. | ||
* Overproduction of [[IL-1|IL-1β]] is a clear [[molecular]] feature of PAPA syndrome. | *The [[mutation]] leads to a hyper-phosphorylated [[PSTPIP1]] [[protein]] which changes its action in the inflammasome involved in [[interleukin-1]] ([[IL-1|IL-1β]]) production. | ||
*Overproduction of [[IL-1|IL-1β]] is a clear [[molecular]] feature of PAPA syndrome. | |||
==Causes== | ==Causes== | ||
* PAPA syndrome is [[Causes|caused]] by a [[mutation]] in the [[PSTPIP1]] [[gene]].<ref name="YeonLindor2000">{{cite journal|last1=Yeon|first1=Howard B.|last2=Lindor|first2=Noralane M.|last3=Seidman|first3=J.G.|last4=Seidman|first4=Christine E.|title=Pyogenic Arthritis, Pyoderma Gangrenosum, and Acne Syndrome Maps to Chromosome 15q|journal=The American Journal of Human Genetics|volume=66|issue=4|year=2000|pages=1443–1448|issn=00029297|doi=10.1086/302866}}</ref> | |||
*PAPA syndrome is [[Causes|caused]] by a [[mutation]] in the [[PSTPIP1]] [[gene]].<ref name="YeonLindor2000">{{cite journal|last1=Yeon|first1=Howard B.|last2=Lindor|first2=Noralane M.|last3=Seidman|first3=J.G.|last4=Seidman|first4=Christine E.|title=Pyogenic Arthritis, Pyoderma Gangrenosum, and Acne Syndrome Maps to Chromosome 15q|journal=The American Journal of Human Genetics|volume=66|issue=4|year=2000|pages=1443–1448|issn=00029297|doi=10.1086/302866}}</ref> | |||
==Differentiating PAPA syndrome from Other Diseases== | ==Differentiating PAPA syndrome from Other Diseases== | ||
* PAPA syndrome must be [[Differential diagnosis|differentiated]] from other [[diseases]] that cause [[arthritis]], [[skin rash]], and [[pyoderma gangrenosum]], such as [[Blau syndrome]], [[familial cold autoinflammatory syndrome]], [[chronic recurrent multifocal osteomyelitis]] ([[Chronic recurrent multifocal osteomyelitis|CRMO]]) , and [[juvenile idiopathic arthritis]] ([[Juvenile idiopathic arthritis|JIA]]). | |||
* For more information on the [[differential diagnosis]] of PAPA syndrome please [[Familial mediterranean fever differential diagnosis|click here]]. | *PAPA syndrome must be [[Differential diagnosis|differentiated]] from other [[diseases]] that cause [[arthritis]], [[skin rash]], and [[pyoderma gangrenosum]], such as [[Blau syndrome]], [[familial cold autoinflammatory syndrome]], [[chronic recurrent multifocal osteomyelitis]] ([[Chronic recurrent multifocal osteomyelitis|CRMO]]) , and [[juvenile idiopathic arthritis]] ([[Juvenile idiopathic arthritis|JIA]]). | ||
*For more information on the [[differential diagnosis]] of PAPA syndrome please [[Familial mediterranean fever differential diagnosis|click here]]. | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
* The [[prevalence]] of PAPA syndrome is approximately 0.01 case per 100,000 individuals worldwide.<ref name="SchellevisStoffels2011">{{cite journal|last1=Schellevis|first1=M. A.|last2=Stoffels|first2=M.|last3=Hoppenreijs|first3=E. P. A. H.|last4=Bodar|first4=E.|last5=Simon|first5=A.|last6=van der Meer|first6=J. W. M.|title=Variable expression and treatment of PAPA syndrome|journal=Annals of the Rheumatic Diseases|volume=70|issue=6|year=2011|pages=1168–1170|issn=0003-4967|doi=10.1136/ard.2009.126185}}</ref> | |||
* There are 53 cases of PAPA syndrome in the literature.<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref> | *The [[prevalence]] of PAPA syndrome is approximately 0.01 case per 100,000 individuals worldwide.<ref name="SchellevisStoffels2011">{{cite journal|last1=Schellevis|first1=M. A.|last2=Stoffels|first2=M.|last3=Hoppenreijs|first3=E. P. A. H.|last4=Bodar|first4=E.|last5=Simon|first5=A.|last6=van der Meer|first6=J. W. M.|title=Variable expression and treatment of PAPA syndrome|journal=Annals of the Rheumatic Diseases|volume=70|issue=6|year=2011|pages=1168–1170|issn=0003-4967|doi=10.1136/ard.2009.126185}}</ref> | ||
* PAPA syndrome commonly affects children. However, it may develop later in some individuals. | *There are 53 cases of PAPA syndrome in the literature.<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref> | ||
* There is no [[racial]] predilection to PAPA syndrome. | *PAPA syndrome commonly affects children. However, it may develop later in some individuals. | ||
* PAPA syndrome affects men and women equally. | *There is no [[racial]] predilection to PAPA syndrome. | ||
* The majority of PAPA syndrome cases are reported in Europe, New Zealand, and the USA. | *PAPA syndrome affects men and women equally. | ||
*The majority of PAPA syndrome cases are reported in Europe, New Zealand, and the USA. | |||
==Risk Factors== | ==Risk Factors== | ||
* There are no established [[risk factors]] for PAPA syndrome. | |||
*There are no established [[risk factors]] for PAPA syndrome. | |||
==Screening== | ==Screening== | ||
* There is insufficient evidence to recommend routine [[screening]] for PAPA syndrome. | |||
*There is insufficient evidence to recommend routine [[screening]] for PAPA syndrome. | |||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
* PAPA syndrome first manifests with [[signs]] and [[symptoms]] of [[arthritis]] by 1 to 10 years of age. [[Skin lesions]] usually develop later in adolescence and they tend to affect the skin of [[limbs]].<ref name="SchellevisStoffels2011">{{cite journal|last1=Schellevis|first1=M. A.|last2=Stoffels|first2=M.|last3=Hoppenreijs|first3=E. P. A. H.|last4=Bodar|first4=E.|last5=Simon|first5=A.|last6=van der Meer|first6=J. W. M.|title=Variable expression and treatment of PAPA syndrome|journal=Annals of the Rheumatic Diseases|volume=70|issue=6|year=2011|pages=1168–1170|issn=0003-4967|doi=10.1136/ard.2009.126185}}</ref><ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref> | |||
* The [[disease]] shows variable expressivity and [[incomplete penetrance]]. | *PAPA syndrome first manifests with [[signs]] and [[symptoms]] of [[arthritis]] by 1 to 10 years of age. [[Skin lesions]] usually develop later in adolescence and they tend to affect the skin of [[limbs]].<ref name="SchellevisStoffels2011">{{cite journal|last1=Schellevis|first1=M. A.|last2=Stoffels|first2=M.|last3=Hoppenreijs|first3=E. P. A. H.|last4=Bodar|first4=E.|last5=Simon|first5=A.|last6=van der Meer|first6=J. W. M.|title=Variable expression and treatment of PAPA syndrome|journal=Annals of the Rheumatic Diseases|volume=70|issue=6|year=2011|pages=1168–1170|issn=0003-4967|doi=10.1136/ard.2009.126185}}</ref><ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref> | ||
* Common [[complications]] of PAPA syndrome include erosive [[arthritis]]. | *The [[disease]] shows variable expressivity and [[incomplete penetrance]]. | ||
* The [[disease]] severity usually decreases by the age. However, there is no data available on the [[prognosis]] of PAPA syndrome. | *Common [[complications]] of PAPA syndrome include erosive [[arthritis]]. | ||
* The [[disease]] may lead to serious [[joint]] destruction. | *The [[disease]] severity usually decreases by the age. However, there is no data available on the [[prognosis]] of PAPA syndrome. | ||
*The [[disease]] may lead to serious [[joint]] destruction. | |||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Study of Choice=== | ===Diagnostic Study of Choice=== | ||
* There are no established criteria for the [[diagnosis]] of PAPA syndrome. The [[diagnosis]] may be made clinically.<ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref><ref name="HoriuchiFukatsu2016">{{cite journal|last1=Horiuchi|first1=Isao|last2=Fukatsu|first2=Yuko|last3=Ushijima|first3=Junko|last4=Nakamura|first4=Eishin|last5=Samajima|first5=Koki|last6=Kadowaki|first6=Kanako|last7=Takagi|first7=Kenjiro|title=A pregnancy-associated nonfamilial case of PAPA (pyogenic sterile arthritis, pyoderma gangrenosum, acne) syndrome|journal=Clinical Case Reports|volume=4|issue=10|year=2016|pages=989–991|issn=20500904|doi=10.1002/ccr3.662}}</ref><ref name="HongSu2009">{{cite journal|last1=Hong|first1=Jin-Bon|last2=Su|first2=Yi-Ning|last3=Chiu|first3=Hsien-Ching|title=Pyogenic arthritis, pyoderma gangrenosum, and acne syndrome (PAPA syndrome): Report of a sporadic case without an identifiable mutation in the CD2BP1 gene|journal=Journal of the American Academy of Dermatology|volume=61|issue=3|year=2009|pages=533–535|issn=01909622|doi=10.1016/j.jaad.2008.11.017}}</ref> | |||
* [[Genetic analysis]] and location of a [[mutation]] in the [[PSTPIP1]] [[gene]] may be done for the confirmation of the [[diagnosis]]. However, there are reported cases of PAPA syndrome with negative [[genetic]] results. | *There are no established criteria for the [[diagnosis]] of PAPA syndrome. The [[diagnosis]] may be made clinically.<ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref><ref name="HoriuchiFukatsu2016">{{cite journal|last1=Horiuchi|first1=Isao|last2=Fukatsu|first2=Yuko|last3=Ushijima|first3=Junko|last4=Nakamura|first4=Eishin|last5=Samajima|first5=Koki|last6=Kadowaki|first6=Kanako|last7=Takagi|first7=Kenjiro|title=A pregnancy-associated nonfamilial case of PAPA (pyogenic sterile arthritis, pyoderma gangrenosum, acne) syndrome|journal=Clinical Case Reports|volume=4|issue=10|year=2016|pages=989–991|issn=20500904|doi=10.1002/ccr3.662}}</ref><ref name="HongSu2009">{{cite journal|last1=Hong|first1=Jin-Bon|last2=Su|first2=Yi-Ning|last3=Chiu|first3=Hsien-Ching|title=Pyogenic arthritis, pyoderma gangrenosum, and acne syndrome (PAPA syndrome): Report of a sporadic case without an identifiable mutation in the CD2BP1 gene|journal=Journal of the American Academy of Dermatology|volume=61|issue=3|year=2009|pages=533–535|issn=01909622|doi=10.1016/j.jaad.2008.11.017}}</ref> | ||
*[[Genetic analysis]] and location of a [[mutation]] in the [[PSTPIP1]] [[gene]] may be done for the confirmation of the [[diagnosis]]. However, there are reported cases of PAPA syndrome with negative [[genetic]] results. | |||
===History and Symptoms=== | ===History and Symptoms=== | ||
* A positive history of recurrent [[arthritis]], skin ulceration, and [[acne]] is suggestive of PAPA syndrome.<ref name="SchellevisStoffels2011">{{cite journal|last1=Schellevis|first1=M. A.|last2=Stoffels|first2=M.|last3=Hoppenreijs|first3=E. P. A. H.|last4=Bodar|first4=E.|last5=Simon|first5=A.|last6=van der Meer|first6=J. W. M.|title=Variable expression and treatment of PAPA syndrome|journal=Annals of the Rheumatic Diseases|volume=70|issue=6|year=2011|pages=1168–1170|issn=0003-4967|doi=10.1136/ard.2009.126185}}</ref> | |||
* The presenting [[symptom]] of PAPA syndrome is usually culture-negative [[arthritis]]. | *A positive history of recurrent [[arthritis]], skin ulceration, and [[acne]] is suggestive of PAPA syndrome.<ref name="SchellevisStoffels2011">{{cite journal|last1=Schellevis|first1=M. A.|last2=Stoffels|first2=M.|last3=Hoppenreijs|first3=E. P. A. H.|last4=Bodar|first4=E.|last5=Simon|first5=A.|last6=van der Meer|first6=J. W. M.|title=Variable expression and treatment of PAPA syndrome|journal=Annals of the Rheumatic Diseases|volume=70|issue=6|year=2011|pages=1168–1170|issn=0003-4967|doi=10.1136/ard.2009.126185}}</ref> | ||
*The presenting [[symptom]] of PAPA syndrome is usually culture-negative [[arthritis]]. | |||
===Physical Examination=== | ===Physical Examination=== | ||
*[[Physical examination]] of [[patients]] with PAPA syndrome is usually remarkable for [[arthritis]], [[cystic acne]], [[pathergy]], and [[pyoderma gangreonosum]].<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref> | *[[Physical examination]] of [[patients]] with PAPA syndrome is usually remarkable for [[arthritis]], [[cystic acne]], [[pathergy]], and [[pyoderma gangreonosum]].<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref> | ||
* [[Fever]] may also accompany each flare of the [[disease]]. | *[[Fever]] may also accompany each flare of the [[disease]]. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
* Laboratory findings consistent with the [[diagnosis]] of PAPA syndrome include elevated [[serum]] levels of [[C-reactive protein]] ([[CRP]]), [[erythrocyte sedimentation rate]] ([[ESR]]), and [[WBC]].<ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref> | |||
* [[Skin lesions]] and [[joint]] fluid are [[sterile]]. However, [[synovial fluid]] shows [[Neutrophil|neutrophilic]] infiltrate. | *Laboratory findings consistent with the [[diagnosis]] of PAPA syndrome include elevated [[serum]] levels of [[C-reactive protein]] ([[CRP]]), [[erythrocyte sedimentation rate]] ([[ESR]]), and [[WBC]].<ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref> | ||
*[[Skin lesions]] and [[joint]] fluid are [[sterile]]. However, [[synovial fluid]] shows [[Neutrophil|neutrophilic]] infiltrate. | |||
*[[Tumor necrosis factor-alpha|Tumor necrosis factor-a]] and [[Interleukin 1|interleukin-1]] levels has been observed to be elevated in the [[blood]] of PAPA syndrome cases.<ref name="CortisDe Benedetti2004">{{cite journal|last1=Cortis|first1=Elisabetta|last2=De Benedetti|first2=Fabrizio|last3=Insalaco|first3=Antonella|last4=Cioschi|first4=Stefania|last5=Muratori|first5=Flaminia|last6=D'Urbano|first6=Leila E.|last7=Ugazio|first7=Alberto G.|title=Abnormal production of the tumor necrosis factor inhibitor etanercept and clinical efficacy of tumor in a patient with PAPA syndrome|journal=The Journal of Pediatrics|volume=145|issue=6|year=2004|pages=851–855|issn=00223476|doi=10.1016/j.jpeds.2004.08.001}}</ref> | *[[Tumor necrosis factor-alpha|Tumor necrosis factor-a]] and [[Interleukin 1|interleukin-1]] levels has been observed to be elevated in the [[blood]] of PAPA syndrome cases.<ref name="CortisDe Benedetti2004">{{cite journal|last1=Cortis|first1=Elisabetta|last2=De Benedetti|first2=Fabrizio|last3=Insalaco|first3=Antonella|last4=Cioschi|first4=Stefania|last5=Muratori|first5=Flaminia|last6=D'Urbano|first6=Leila E.|last7=Ugazio|first7=Alberto G.|title=Abnormal production of the tumor necrosis factor inhibitor etanercept and clinical efficacy of tumor in a patient with PAPA syndrome|journal=The Journal of Pediatrics|volume=145|issue=6|year=2004|pages=851–855|issn=00223476|doi=10.1016/j.jpeds.2004.08.001}}</ref> | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
* There are no [[ECG]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
*There are no [[ECG]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
===X-ray=== | ===X-ray=== | ||
* There are no specific [[x-ray]] findings [[Association (statistics)|associated]] with PAPA syndrome. However, an [[x-ray]] may be helpful in the [[diagnosis]] of [[complications]] of [[arthritis]], which include [[soft tissue]] [[swelling]], and large [[joint]] effusion.<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref><ref name="TallonCorkill2006">{{cite journal|last1=Tallon|first1=B.|last2=Corkill|first2=M.|title=Peculiarities of PAPA syndrome|journal=Rheumatology|volume=45|issue=9|year=2006|pages=1140–1143|issn=1462-0332|doi=10.1093/rheumatology/kei178}}</ref> | |||
* Other possible [[radiographic]] [[Features (pattern recognition)|features]] include pauciarticular, erosive arthritis, [[osteophytes|Osteophyte]] formation, diffuse [[joint]] narrowing, subchondral [[sclerosis]] and [[cyst]] formation, reactive new bone formation, and [[joint]] [[deformity]] or destruction with [[ankylosis]]. | *There are no specific [[x-ray]] findings [[Association (statistics)|associated]] with PAPA syndrome. However, an [[x-ray]] may be helpful in the [[diagnosis]] of [[complications]] of [[arthritis]], which include [[soft tissue]] [[swelling]], and large [[joint]] effusion.<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref><ref name="TallonCorkill2006">{{cite journal|last1=Tallon|first1=B.|last2=Corkill|first2=M.|title=Peculiarities of PAPA syndrome|journal=Rheumatology|volume=45|issue=9|year=2006|pages=1140–1143|issn=1462-0332|doi=10.1093/rheumatology/kei178}}</ref> | ||
*Other possible [[radiographic]] [[Features (pattern recognition)|features]] include pauciarticular, erosive arthritis, [[osteophytes|Osteophyte]] formation, diffuse [[joint]] narrowing, subchondral [[sclerosis]] and [[cyst]] formation, reactive new bone formation, and [[joint]] [[deformity]] or destruction with [[ankylosis]]. | |||
===Echocardiography or Ultrasound=== | ===Echocardiography or Ultrasound=== | ||
* There are no [[echocardiography]]/[[ultrasound]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
*There are no [[echocardiography]]/[[ultrasound]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
===CT scan=== | ===CT scan=== | ||
* There are no [[CT scan]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
*There are no [[CT scan]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
===MRI=== | ===MRI=== | ||
* There are no specific [[MRI]] findings [[Association (statistics)|associated]] with PAPA syndrome. However, a [[MRI]] may be helpful in the [[diagnosis]] of [[complications]] of [[arthritis]], which include [[synovitis]], [[synovial]] [[hypertrophy]], increased enhancement, [[bone marrow]] [[edema]]/enhancement and surrounding [[soft tissue]] [[edema]].<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref> | |||
*There are no specific [[MRI]] findings [[Association (statistics)|associated]] with PAPA syndrome. However, a [[MRI]] may be helpful in the [[diagnosis]] of [[complications]] of [[arthritis]], which include [[synovitis]], [[synovial]] [[hypertrophy]], increased enhancement, [[bone marrow]] [[edema]]/enhancement and surrounding [[soft tissue]] [[edema]].<ref name="Martinez-RiosJariwala2018">{{cite journal|last1=Martinez-Rios|first1=Claudia|last2=Jariwala|first2=Mehul P.|last3=Highmore|first3=Kerri|last4=Duffy|first4=Karen Watanabe|last5=Spiegel|first5=Lynn|last6=Laxer|first6=Ronald M.|last7=Stimec|first7=Jennifer|title=Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature|journal=Pediatric Radiology|volume=49|issue=1|year=2018|pages=23–36|issn=0301-0449|doi=10.1007/s00247-018-4246-1}}</ref> | |||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
* There are no other [[imaging]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
*There are no other [[imaging]] findings [[Association (statistics)|associated]] with PAPA syndrome. | |||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
* There are no other [[diagnostic]] studies [[Association (statistics)|associated]] with PAPA syndrome. | |||
*There are no other [[diagnostic]] studies [[Association (statistics)|associated]] with PAPA syndrome. | |||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
* There is no treatment for PAPA syndrome; the mainstay of therapy is supportive care.<ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref><ref name="DemidowichFreeman2012">{{cite journal|last1=Demidowich|first1=Andrew P.|last2=Freeman|first2=Alexandra F.|last3=Kuhns|first3=Douglas B.|last4=Aksentijevich|first4=Ivona|last5=Gallin|first5=John I.|last6=Turner|first6=Maria L.|last7=Kastner|first7=Daniel L.|last8=Holland|first8=Steven M.|title=Brief Report: Genotype, phenotype, and clinical course in five patients with PAPA syndrome (pyogenic sterile arthritis, pyoderma gangrenosum, and acne)|journal=Arthritis & Rheumatism|volume=64|issue=6|year=2012|pages=2022–2027|issn=00043591|doi=10.1002/art.34332}}</ref> | |||
* Treatment options for [[arthritis]] include [[intraarticular]] [[corticosteroid]] [[injections]]. | *There is no treatment for PAPA syndrome; the mainstay of therapy is supportive care.<ref name="Dierselhuis2005">{{cite journal|last1=Dierselhuis|first1=M. P.|title=Anakinra for flares of pyogenic arthritis in PAPA syndrome|journal=Rheumatology|volume=44|issue=3|year=2005|pages=406–408|issn=1460-2172|doi=10.1093/rheumatology/keh479}}</ref><ref name="DemidowichFreeman2012">{{cite journal|last1=Demidowich|first1=Andrew P.|last2=Freeman|first2=Alexandra F.|last3=Kuhns|first3=Douglas B.|last4=Aksentijevich|first4=Ivona|last5=Gallin|first5=John I.|last6=Turner|first6=Maria L.|last7=Kastner|first7=Daniel L.|last8=Holland|first8=Steven M.|title=Brief Report: Genotype, phenotype, and clinical course in five patients with PAPA syndrome (pyogenic sterile arthritis, pyoderma gangrenosum, and acne)|journal=Arthritis & Rheumatism|volume=64|issue=6|year=2012|pages=2022–2027|issn=00043591|doi=10.1002/art.34332}}</ref> | ||
* Oral [[corticosteroid]] may be useful for [[pyoderma gangrenosum]]. | *Treatment options for [[arthritis]] include [[intraarticular]] [[corticosteroid]] [[injections]]. | ||
*Oral [[corticosteroid]] may be useful for [[pyoderma gangrenosum]]. | |||
*[[Anakinra]] ([[Interleukin 1|interleukin-1]] [[antagonist]]) has also been observed to be effective in the management of [[disease]] flares especially [[Joint|arthicular]] [[symptoms]]. | *[[Anakinra]] ([[Interleukin 1|interleukin-1]] [[antagonist]]) has also been observed to be effective in the management of [[disease]] flares especially [[Joint|arthicular]] [[symptoms]]. | ||
*[[Adalimumab]] ([[tumor necrosis factor]] [[antagonist]]) may be effective against [[cutaneous]] manifestations of this [[disorder]]. | *[[Adalimumab]] ([[tumor necrosis factor]] [[antagonist]]) may be effective against [[cutaneous]] manifestations of this [[disorder]]. | ||
===Surgery=== | ===Surgery=== | ||
* [[Surgical]] [[intervention]] is not recommended for the management of PAPA syndrome. | |||
*[[Surgical]] [[intervention]] is not recommended for the management of PAPA syndrome. | |||
===Primary Prevention=== | ===Primary Prevention=== | ||
* There are no established measures for the [[primary prevention]] of PAPA syndrome. | |||
*There are no established measures for the [[primary prevention]] of PAPA syndrome. | |||
===Secondary Prevention=== | ===Secondary Prevention=== | ||
* There are no established measures for the [[secondary prevention]] of PAPA syndrome. | |||
*There are no established measures for the [[secondary prevention]] of PAPA syndrome. | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
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{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
Latest revision as of 18:17, 26 April 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]
Synonyms and keywords: PAPA syndrome
Overview
Pyogenic sterile arthritis, pyoderma gangrenosum, acne syndrome, PAPA syndrome, is one of the inherited autoinflammatory disorders. PAPA syndrome presents with the triad of aseptic arthritis, pyoderma gangrenosum, and acne. However, not all the features may be present in all the patients.
Historical Perspective
- PAPA syndrome was first discovered by Dr. Noralane M. Lindor, in 1997 following visiting several patients from three generations of a family with similar presentations.[1]
- The association between PSTPIP1 gene mutation and PAPA syndrome was made in the year 2000.[2]
Classification
- There is no established system for the classification of PAPA syndrome.
Pathophysiology
- The exact pathogenesis of PAPA syndrome is not fully understood. However, it develops as a result of a mutation in the PSTPIP1 gene.[3][4]
- Mutation is inherited in an autosomal dominant mode.
- The mutation leads to a hyper-phosphorylated PSTPIP1 protein which changes its action in the inflammasome involved in interleukin-1 (IL-1β) production.
- Overproduction of IL-1β is a clear molecular feature of PAPA syndrome.
Causes
Differentiating PAPA syndrome from Other Diseases
- PAPA syndrome must be differentiated from other diseases that cause arthritis, skin rash, and pyoderma gangrenosum, such as Blau syndrome, familial cold autoinflammatory syndrome, chronic recurrent multifocal osteomyelitis (CRMO) , and juvenile idiopathic arthritis (JIA).
- For more information on the differential diagnosis of PAPA syndrome please click here.
Epidemiology and Demographics
- The prevalence of PAPA syndrome is approximately 0.01 case per 100,000 individuals worldwide.[5]
- There are 53 cases of PAPA syndrome in the literature.[6]
- PAPA syndrome commonly affects children. However, it may develop later in some individuals.
- There is no racial predilection to PAPA syndrome.
- PAPA syndrome affects men and women equally.
- The majority of PAPA syndrome cases are reported in Europe, New Zealand, and the USA.
Risk Factors
- There are no established risk factors for PAPA syndrome.
Screening
- There is insufficient evidence to recommend routine screening for PAPA syndrome.
Natural History, Complications, and Prognosis
- PAPA syndrome first manifests with signs and symptoms of arthritis by 1 to 10 years of age. Skin lesions usually develop later in adolescence and they tend to affect the skin of limbs.[5][7]
- The disease shows variable expressivity and incomplete penetrance.
- Common complications of PAPA syndrome include erosive arthritis.
- The disease severity usually decreases by the age. However, there is no data available on the prognosis of PAPA syndrome.
- The disease may lead to serious joint destruction.
Diagnosis
Diagnostic Study of Choice
- There are no established criteria for the diagnosis of PAPA syndrome. The diagnosis may be made clinically.[7][8][9]
- Genetic analysis and location of a mutation in the PSTPIP1 gene may be done for the confirmation of the diagnosis. However, there are reported cases of PAPA syndrome with negative genetic results.
History and Symptoms
- A positive history of recurrent arthritis, skin ulceration, and acne is suggestive of PAPA syndrome.[5]
- The presenting symptom of PAPA syndrome is usually culture-negative arthritis.
Physical Examination
- Physical examination of patients with PAPA syndrome is usually remarkable for arthritis, cystic acne, pathergy, and pyoderma gangreonosum.[6]
- Fever may also accompany each flare of the disease.
Laboratory Findings
- Laboratory findings consistent with the diagnosis of PAPA syndrome include elevated serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and WBC.[7]
- Skin lesions and joint fluid are sterile. However, synovial fluid shows neutrophilic infiltrate.
- Tumor necrosis factor-a and interleukin-1 levels has been observed to be elevated in the blood of PAPA syndrome cases.[10]
Electrocardiogram
- There are no ECG findings associated with PAPA syndrome.
X-ray
- There are no specific x-ray findings associated with PAPA syndrome. However, an x-ray may be helpful in the diagnosis of complications of arthritis, which include soft tissue swelling, and large joint effusion.[6][11]
- Other possible radiographic features include pauciarticular, erosive arthritis, Osteophyte formation, diffuse joint narrowing, subchondral sclerosis and cyst formation, reactive new bone formation, and joint deformity or destruction with ankylosis.
Echocardiography or Ultrasound
- There are no echocardiography/ultrasound findings associated with PAPA syndrome.
CT scan
- There are no CT scan findings associated with PAPA syndrome.
MRI
- There are no specific MRI findings associated with PAPA syndrome. However, a MRI may be helpful in the diagnosis of complications of arthritis, which include synovitis, synovial hypertrophy, increased enhancement, bone marrow edema/enhancement and surrounding soft tissue edema.[6]
Other Imaging Findings
- There are no other imaging findings associated with PAPA syndrome.
Other Diagnostic Studies
- There are no other diagnostic studies associated with PAPA syndrome.
Treatment
Medical Therapy
- There is no treatment for PAPA syndrome; the mainstay of therapy is supportive care.[7][12]
- Treatment options for arthritis include intraarticular corticosteroid injections.
- Oral corticosteroid may be useful for pyoderma gangrenosum.
- Anakinra (interleukin-1 antagonist) has also been observed to be effective in the management of disease flares especially arthicular symptoms.
- Adalimumab (tumor necrosis factor antagonist) may be effective against cutaneous manifestations of this disorder.
Surgery
- Surgical intervention is not recommended for the management of PAPA syndrome.
Primary Prevention
- There are no established measures for the primary prevention of PAPA syndrome.
Secondary Prevention
- There are no established measures for the secondary prevention of PAPA syndrome.
References
- ↑ Lindor, Noralane M.; Arsenault, Todd M.; Solomon, Herman; Seidman, Christine E.; McEvoy, Marian T. (1997). "A New Autosomal Dominant Disorder of Pyogenic Sterile Arthritis, Pyoderma Gangrenosum, and Acne: PAPA Syndrome". Mayo Clinic Proceedings. 72 (7): 611–615. doi:10.4065/72.7.611. ISSN 0025-6196.
- ↑ 2.0 2.1 Yeon, Howard B.; Lindor, Noralane M.; Seidman, J.G.; Seidman, Christine E. (2000). "Pyogenic Arthritis, Pyoderma Gangrenosum, and Acne Syndrome Maps to Chromosome 15q". The American Journal of Human Genetics. 66 (4): 1443–1448. doi:10.1086/302866. ISSN 0002-9297.
- ↑ J. Smith, Elisabeth; Allantaz, Florence; Bennett, Lynda; Zhang, Dongping; Gao, Xiaochong; Wood, Geryl; L. Kastner, Daniel; Punaro, Marilynn; Aksentijevich, Ivona; Pascual, Virginia; A. Wise, Carol (2010). "Clinical, Molecular, and Genetic Characteristics of PAPA Syndrome: A Review". Current Genomics. 11 (7): 519–527. doi:10.2174/138920210793175921. ISSN 1389-2029.
- ↑ Shoham, N. G.; Centola, M.; Mansfield, E.; Hull, K. M.; Wood, G.; Wise, C. A.; Kastner, D. L. (2003). "Pyrin binds the PSTPIP1/CD2BP1 protein, defining familial Mediterranean fever and PAPA syndrome as disorders in the same pathway". Proceedings of the National Academy of Sciences. 100 (23): 13501–13506. doi:10.1073/pnas.2135380100. ISSN 0027-8424.
- ↑ 5.0 5.1 5.2 Schellevis, M. A.; Stoffels, M.; Hoppenreijs, E. P. A. H.; Bodar, E.; Simon, A.; van der Meer, J. W. M. (2011). "Variable expression and treatment of PAPA syndrome". Annals of the Rheumatic Diseases. 70 (6): 1168–1170. doi:10.1136/ard.2009.126185. ISSN 0003-4967.
- ↑ 6.0 6.1 6.2 6.3 Martinez-Rios, Claudia; Jariwala, Mehul P.; Highmore, Kerri; Duffy, Karen Watanabe; Spiegel, Lynn; Laxer, Ronald M.; Stimec, Jennifer (2018). "Imaging findings of sterile pyogenic arthritis, pyoderma gangrenosum and acne (PAPA) syndrome: differential diagnosis and review of the literature". Pediatric Radiology. 49 (1): 23–36. doi:10.1007/s00247-018-4246-1. ISSN 0301-0449.
- ↑ 7.0 7.1 7.2 7.3 Dierselhuis, M. P. (2005). "Anakinra for flares of pyogenic arthritis in PAPA syndrome". Rheumatology. 44 (3): 406–408. doi:10.1093/rheumatology/keh479. ISSN 1460-2172.
- ↑ Horiuchi, Isao; Fukatsu, Yuko; Ushijima, Junko; Nakamura, Eishin; Samajima, Koki; Kadowaki, Kanako; Takagi, Kenjiro (2016). "A pregnancy-associated nonfamilial case of PAPA (pyogenic sterile arthritis, pyoderma gangrenosum, acne) syndrome". Clinical Case Reports. 4 (10): 989–991. doi:10.1002/ccr3.662. ISSN 2050-0904.
- ↑ Hong, Jin-Bon; Su, Yi-Ning; Chiu, Hsien-Ching (2009). "Pyogenic arthritis, pyoderma gangrenosum, and acne syndrome (PAPA syndrome): Report of a sporadic case without an identifiable mutation in the CD2BP1 gene". Journal of the American Academy of Dermatology. 61 (3): 533–535. doi:10.1016/j.jaad.2008.11.017. ISSN 0190-9622.
- ↑ Cortis, Elisabetta; De Benedetti, Fabrizio; Insalaco, Antonella; Cioschi, Stefania; Muratori, Flaminia; D'Urbano, Leila E.; Ugazio, Alberto G. (2004). "Abnormal production of the tumor necrosis factor inhibitor etanercept and clinical efficacy of tumor in a patient with PAPA syndrome". The Journal of Pediatrics. 145 (6): 851–855. doi:10.1016/j.jpeds.2004.08.001. ISSN 0022-3476.
- ↑ Tallon, B.; Corkill, M. (2006). "Peculiarities of PAPA syndrome". Rheumatology. 45 (9): 1140–1143. doi:10.1093/rheumatology/kei178. ISSN 1462-0332.
- ↑ Demidowich, Andrew P.; Freeman, Alexandra F.; Kuhns, Douglas B.; Aksentijevich, Ivona; Gallin, John I.; Turner, Maria L.; Kastner, Daniel L.; Holland, Steven M. (2012). "Brief Report: Genotype, phenotype, and clinical course in five patients with PAPA syndrome (pyogenic sterile arthritis, pyoderma gangrenosum, and acne)". Arthritis & Rheumatism. 64 (6): 2022–2027. doi:10.1002/art.34332. ISSN 0004-3591.