title: Macrophage activation syndrome in patients with systemic juvenile idiopathic arthritis is associated with MUNC13-4 polymorphisms.
abstract: OBJECTIVE
  Systemic juvenile idiopathic arthritis (JIA) is associated with macrophage activation syndrome. Macrophage activation syndrome bears a close resemblance to familial hemophagocytic lymphohistiocytosis (HLH). The development of familial HLH has been recently associated with mutations in MUNC13-4. The purpose of this study was to assess for possible sequence alterations in MUNC13-4 in patients with systemic JIA/macrophage activation syndrome.
  
  
  METHODS
  The MUNC13-4 sequence was analyzed in 18 unrelated patients with systemic JIA/macrophage activation syndrome, using 32 primer pair sets designed to amplify the 32 exons and at least 100 basepairs of the adjacent intronic regions. DNA samples obtained from 73 unrelated patients with systemic JIA and no history of macrophage activation syndrome and 229 unrelated healthy individuals were used as controls.
  
  
  RESULTS
  The biallelic sequence variants in MUNC13-4 reported in familial HLH were present in 2 of the 18 patients with JIA/macrophage activation syndrome. Further analysis of the MUNC13-4 sequences revealed an identical combination of 12 single-nucleotide polymorphisms (SNPs) in 9 of the remaining 16 patients with systemic JIA/macrophage activation syndrome (56%). Additional analysis suggested that these 12 SNPs (154[-19] g>a, 261[+26] c>g, 388[+81] g>a, 388[+122] c>t, 570[-60] t>g, 888 G>C, 1389[+36] g>a, 1992[+5] g>a, 2447[+144] c>t, 2599 A>G, 2830[+37] c>g, 3198 A>G) were inherited as an extended haplotype. In several patients, in addition to the described haplotype, there were other SNPs in the second allele of MUNC13-4. Moreover, 1 patient had a complex mutation with 2 changes, 2542 A>C and 2943 G>C, in a cis configuration. The haplotype was present in only 27 (12%) of 229 healthy control subjects (chi(2) = 23.5) and in 6 (8.2%) of 73 patients with systemic JIA and no history of macrophage activation syndrome.
  
  
  CONCLUSIONS
  The data suggest an association between MUNC13-4 polymorphisms and macrophage activation syndrome in patients with systemic JIA.
authors.affiliation: Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
authors.forename: Kejian
authors.initials: K
authors.lastname: Zhang
authors.forename: Jennifer
authors.initials: J
authors.lastname: Biroschak
authors.forename: David N
authors.initials: DN
authors.lastname: Glass
authors.forename: Susan D
authors.initials: SD
authors.lastname: Thompson
authors.forename: Terri
authors.initials: T
authors.lastname: Finkel
authors.forename: Murray H
authors.initials: MH
authors.lastname: Passo
authors.forename: Bryce A
authors.initials: BA
authors.lastname: Binstadt
authors.forename: Alexandra
authors.initials: A
authors.lastname: Filipovich
authors.forename: Alexei A
authors.initials: AA
authors.lastname: Grom