Skip to content


Pediatric Rheumatology

Open Access

OR13-002 Recessive mutations in CECR1, encoding adenosine deaminase 2 (ADA2), cause systemic and cutaneous polyarteritis nodosa (PAN)

  • E Levy-Lahad1,
  • P Elkan-Navon1,
  • R Segel1,
  • SB Pierce2,
  • T Walsh2,
  • J Barash3,
  • S Padeh4,
  • A Zlotogorski5,
  • YY Berkun5,
  • JJ Press6,
  • M Mukamel6,
  • PJ Hashkes1,
  • LL Harel6,
  • M Tekin7, 8,
  • F Yalcinkaya7,
  • O Kasapcopur9,
  • EF Emirogullari8,
  • MK Lee2,
  • RE Klevit2,
  • PF Renbaum1,
  • A Weinberg-Shukron1,
  • S Zeligson1,
  • D Marek-Yagel4,
  • M Shohat10,
  • A Singer11,
  • E Pras4,
  • AA Rubinow5,
  • Y Anikster4 and
  • M-C King2
Contributed equally
Pediatric Rheumatology201311(Suppl 1):A264

Published: 8 November 2013


VasculitisAdenosine DeaminaseDamage VariantPolyarteritis NodosaPatient Seron


Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis of middle-sized arteries, found in both adults and children. Disease pathogenesis is poorly understood. We identified multiple cases of systemic PAN and cutaneous PAN in families and individuals of Georgian-Jewish ancestry, consistent with autosomal recessive inheritance. While most cases (17/20) had childhood onset, cutaneous PAN could also initiate in middle age.


To determine the genetic basis of monogenic PAN.


Exome sequencing of 4 affected individuals from 2 families was followed by targeted sequencing of 16 additional Georgian-Jewish cases and 6 Turkish pediatric cases of PAN. Mutations were assayed by protein structure analysis, expression in mammalian cells, biophysical analysis of purified protein, and enzymatic activity in patient sera.


Missense mutation CECR1 p.G47R (c.139G>A), in the gene encoding ADA2, was the only damaging variant homozygous in all 4 exomes. Of the 20 Georgian-Jewish patients, 19 were homozygous for this mutation and one was compound heterozygous for G47R and H391Y. One Turkish patient was compound heterozygous for G47V and W264S. In the Georgian-Jewish population, the frequency of G47R was 0.05, reflecting the high prevalence of PAN in this endogamous community. The other mutations were absent from ethnically matched controls.

ADA2 activity was significantly reduced in patient sera. Expression of mutant proteins in HEK293T cells yielded significantly reduced levels of secreted ADA2 and biophysical assays indicated reduced protein stability.


We report mutations in the gene encoding ADA2 as the first genetic cause of a systemic vasculitis. ADA2 is the major extra-cellular ADA, so blood vessels may be particularly vulnerable to loss of its catalytic and immune growth factor activity.

Disclosure of interest

None declared


Authors’ Affiliations

Shaare Zedek Medical Center, Jerusalem, Israel
University of Washington, Seattle, USA
Kaplan Medical Center, Rehovoth, Israel
Sheba Medical Center, Tel Hashomer, Israel
Hadassah Medical Center, Jerusalem, Israel
Schneider Children’s Medical Center, Petach Tikvah, Israel
Ankara University, Ankara, Turkey
University of Miami, Miami, USA
Istanbul University, Istanbul, Turkey
Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
Barzilai Medical Center, Ashkelon, Israel


© Levy-Lahad et al; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.