Review Article Open Access
Skeletal and Joint Manifestations of Primary Immunodeficiency Diseases
Asal Gharib* and Sudhir Gupta
Programs in Primary Immunodeficiency and Aging, Division of Basic and Clinical Immunology, University of California, Irvine, USA
*Corresponding author: Asal Gharib, Division of Basic and Clinical Immunology, University of California at Irvine, Medical Sci. I, C-240, Irvine,CA 92697, USA, Tel: +949-824-5818; Fax: +949-824-4362; E-mail: @
Received: May 23, 2016; Accepted: June 16, 2016; Published: June 24, 2016
Citation: Gharib A, Gupta S (2016) Skeletal and Joint Manifestations of Primary Immunodeficiency Diseases. SOJ Immunol 4(1): 1-13. DOI: http://dx.doi.org/10.15226/2372-0948/4/1/00145
Abstract Top
Primary Immunodeficiencies (PIDs) occur due to inherited disorders in the innate or adaptive immune systems, or combinations of disorders in both. The underlying disorder may be attributed to decreased levels, decreased function, or complete nonfiction of immune components. There are 200 different PIDs and more than 270 genes have been described that are associated with or cause PIDs. These PIDs have recently been re-classified into nine different categories using the International Union of Immunological Societies (IUIS) classification of Primary Immunodeficiencies. This review highlights the different manifestations, including infectious as well as noninfectious etiologies that may occur in the skeletal system of patients with primary Immunodeficiencies.

Keywords: Primary immunodeficiency; Arthritis; Osteopenia; Osteomyelitis; Bone findings; Skeletal findings; Bone anomalies; Joint findings
Introduction
Primary Immune deficiencies (PIDs) are inherited disorders that qualitatively or quantitatively affect components of the innate and adaptive immune systems. The pulmonary [1], dermatological [2], gastrointestinal [3], rheumatological [4], autoimmune [5], and hematological/oncological [6,7] manifestations of PIDs have been reviewed. However, skeletal manifestations of PIDs have not been reviewed. There are 200 different PIDs and more than 270 genes have been described that are associated with or cause PIDs. Registry data has been used in epidemiological studies to gauge PID prevalence: 5.38/100,000 in France, 5.6/100,000 in Australia, USA 86.3/100,000 inhabitants [8]. Bousfiha and colleagues [9] calculated the number of PID cases based on the prevalence estimates which ranges from 390,546 using the Australian model, 6 million using the USA model while PID registries and Jeffrey Modell Centers list 27,243-60,000 cases. These PIDs have recently been reclassified into nine different categories. PID treatment ranges from immunoglobulin replacement therapy to hematopoietic stem cell transplant [10]. We present a comprehensive review of skeletal and joint manifestations in PIDs according to the most recent classifications.
Methods
The information offered in this article is based upon PubMed (Medline) and Scopus search engines for the search terms of each individual disease state and one of the following: arthritis, skeletal, musculoskeletal, osteoporosis, osteopenia, or osteomyelitis. The inclusion criteria included Humans and English as the language.
Results
Skeletal and joint abnormalities in nine different categories are shown in the Tables 1-9. Skeletal abnormalities are discussed in detail.
Discussion
Patients with certain types of primary immunodeficiencies display a number of musculoskeletal changes. In patients with primary immunodeficiencies, septic arthritis due to pyogenic bacteria or mycoplasmal arthritis is the most common osteoarticular manifestation. In certain PIDs, chronic, noninfectious arthritis resembling rheumatoid arthritis may occur. In this paper we have extensively reviewed musculoskeletal and osteoarticular changes in PIDs and presented them under most recent IUIS primary immunodeficiency classification.

In SCID, a number of patients developing osteomyelitis following BCG vaccination have been reported [11]. A T-B+NK+ SCID patient developed Mycobacteria marinum arthritis and osteomyelitis [12]. Reticular dysgenesis is associated with bone anomalies of square shaped scapular tips and cupped costochondral junctions [13]. Characteristic skeletal changes of anterior rib junction, metaphyseal changes, and scapular squaring have been reported in SCID due to adenosine deaminase deficiency [14,15]. Chronic adenoviral arthritis and microcephaly have been reported in Cernunnos deficiency [16].

In Wiskott- Aldrich syndrome, 29% of patients have aseptic arthritis [17-20]. Ataxia Telangiectasia has been associated with rickets where all three members of a family had rickets [21]. Ataxia Telangiectasia-like syndrome has been associated with microcephaly in 40% of patients [22]. Nijmegen-Breakage syndrome (a rare DNA repair disorder characterized by microcephaly, immunodeficiency, and predisposition to
Table 1: Severe Combined Immunodeficiencies.

Diseases

Bone/Joint Findings

Reference #

T-B+ SCID

Osteomyelitis

[11]

T-B- SCID

 

 

a. RAG2 deficiency

Osteomyelitis

[159]

b. Reticular Dysgenesis  AK2 deficiency

Bone anomalies:

- scapular tip squaring

- costochondral junction cupping

[13]

c. Cernunnos Deficiency

Septic Arthritis

[16]

d. DNA Ligase IV deficiency

Bone anomalies:

- Microcephaly

- Severe growth failure

[160,161]

e. Adenosine Deaminase Deficiency

Bone anomalies:

- Chondro-osseus dysplasia

[14-15]

f. MHC Class I deficiency

Osteomyelitis

[162]

g. MHC Class II deficiency

Bone Anomalies:

- Dolichocephaly

- Low implanted thumb

[163]

Table 2: Well Defined Syndrome with Immunodeficiencies.

Diseases

Bone/Joint Findings

 Reference #

Congenital Thrombocytopenia

a. Wiskott-Aldrich Syndrome

Aseptic  Arthritis

Arthralgia

[17-20]

DNA Repair Defects

a. Ataxia-Telangiectasia

Aseptic Arthritis

Rickets

[21]

b. Ataxia- Telangiectasia Like   Disease

Microcephaly

[22]

c. Nijmegen Breakage Syndrome

Bone anomalies:

- hip dysplasia

- rib dysplasia

- sacral genesis

- clinodactyly

- polydactyly

- microcephaly

- scoliosis

- absent thumbs

- Juvenile Idiopathic Arthritis

[23-26]

d. Bloom Syndrome

Bone anomalies:

- dolichocephaly

- short stature

[27]

e. Immunodeficiency with centromeric Instability And Facial Anomalies (ICF)

Bone anomalies:

- syndactyly

- Juvenile Idiopathic Arthritis

[28-30]

f. MCM4 deficiency

Short Stature

[164]

Thymic Defects with additional congenital anomalies

a. DiGeorge Syndrome

Bone  Anomalies

Juvenile Idiopathic Arthritis

[31,32]

Immune-Osseus Dysplasias:

a. Cartilage Hair Hypoplasia

Aseptic Arthritis

Bone anomalies:

- Metaphyseal chondrodysplasia

- genu varum

- metaphyseal flaring

- brachydactyly

- macrocephaly

- lordosis

[33,34]

b. Schimke Syndrome

Aseptic Arthritis

Bone anomalies:

- epiphyseal dysplasia

- metaphyseal dysplasia

- platyspondyly

- vertebral anomalies

- lordosis

[35,36]

Hyper IgE Syndrome

a. AD-HIES (Job's Syndrome)

Bone anomalies:

- scoliosis

- recurrent fractures

- Septic Arthritis

- Osteomyelitis

[37,39,40-46]

b. DOCK8 deficiency

Lupus Arthritis

- Scoliosis

- Fractures

[47,48]

Dyskeratosis Congenital (DKC)

a. XL-DKC

Bone anomalies:

- phalangeal absorption

- fractures

- avascular necrosis

[49,158]

b. AR-DKC due to RTEL deficiency

Microcephaly

[50]

c. AD-DKC due to TERT deficiency

Bone anomaly

Scoliosis

Osteoporosis

[51]

Comel -  Netherton  Syndrome

Bone anomalies:

- epiphyseal  osteosclerosis

- rickets

[52,53]

ORA-I Deficiency

Bone anomaly: club foot

[54]

STAT 5b deficiency

Juvenile Idiopathic Arthritis

[87]

Hepatic Veno-Occlusive Disease with immunodeficiency (VODI)

Microcephaly

[55]

FILS Syndrome

Bone Anomaly: macrocephaly

[56]

Table 3: Predominantly Antibody Deficiency.

Diseases

Bone/Joint Findings

Reference #

BTK Deficiency

Aseptic  Arthritis

Septic Arthritis

Aseptic Osteomyelitis

Septic Osteomyelitis

[57-61]

µ heavy chain deficiency

Aseptic Arthritis

[62,165]

ʎ5 deficiency

Aseptic Arthritis

[63]

Thymoma with immunodeficiency (Good Syndrome)

Aseptic Arthritis

Septic Arthritis

[64,65]

Common Variable Immunodeficiency

Septic Arthritis

Rheumatoid Arthritis

Septic Osteomyelitis

[66-70,166]

ICOS deficiency

Rheumatoid Arthritis

[71,72]

TWEAK Deficiency

Osteomyelitis

[73]

Warts, Hypogammaglobulinemia, infection, Myelokathexis Syndrome (WHIM)

Osteomyelitis

[74]

CD40L deficiency

Osteomyelitis, Unspecified

[75]

AID Deficiency

Aseptic Arthritis

[76,77]

Isolated IgG Subclass deficiency

Septic Arthritis

Osteomyelitis

[78]

IgA with IgG subclass deficiency

Rheumatoid Arthritis

[79]

PRKC  δ

Bone Anomalies:

- microcephaly

- polysyndactyly

[80]

Selective IgA Deficiency

Juvenile Idiopathic Arthritis

Rheumatoid Arthritis

Osteomyelitis

[81-84]

Table 4: Diseases of Immune Dysregulation.

Diseases

Bone/Joint Findings

Reference #

UNC13D/MUNC 13-4 Deficiency

Juvenile Idiopathic Arthritis

[85]

IPEX (Immune dysregulation, polyendocrinopathy, enteropathy, X-linked  syndrome)

Arthritis

[86]

APCED (Autoimmune polyendocrinopathy candidiasis ectodermal  dysplasia)

Short Stature

Juvenile Rheumatoid Arthritis

Osteopenia/Osteoporosis

[88]

ITCH Deficiency (Human ITCH E3 ubiquitin ligase deficiency)

Arthritis

[89]

Autoimmune Lymphoproliferative Syndrome

a. ALPS-FAS

Osteopenia

[90]

b. ALPS-FASL (TNFR)

Arthritis/Arthralgia

[91]

Immune Dysregulation with Colitis

a. IL-10 Rα deficiency

Arthritis/Arthralgias

[92]

b. IL-10 Rβ deficiency

Aseptic  Arthritis

[92]

Type 1 Interferonopathies

a. TREX1 deficiency, Aicardi-Goutieres Syndrome

Bone Anomaly: hypoplastic digit(s)

[167]

b. SAMHD1 deficiency

Aseptic Arthritis

Microcephaly

[93,94]

c. Spondyloenchondrodysplasia with immune dysregulation

Bone Anomalies:

- metaphyseal changes

- vertebral changes

- platyspondyly

[95]

Table 5: Congenital Defects of Phagocytes number, Function or Both.

Diseases

 Bone/Joint Findings

Reference #

1. Defects of Neutrophil Differentiation

Short Stature

Osteopenia

 

a. Glycogen storage disease 1b

Osteomyelitis

[96]

b. Cyclic Neutropenia

Osteomyelitis

[97]

Defects of Motility

a. Leukocyte Adhesion Deficiency Type 1

Septic Osteomyelitis

[98,99]

b. Leukocyte Adhesion Deficiency Type 2

Bone Anomalies:

- short limbs

- overriding toes

- microcephaly

[100]

c. Leukocyte adhesion deficiency Type 3

Osteomyelitis

[157]

d. Shwachman-Diamond Syndrome

Bone anomalies:

- metaphyseal abnormalities

- growth plate thickening

- secondary ossification

- centers

- coxa valga

- stress fractures

- Osteopenia

[101-103]

Defects of Respiratory Burst

a. X-linked chronic granulomatous disease (CGD)

Septic Arthritis

Osteomyelitis

[104-110,168]

b. Autosomal recessive CGD-p22 phox deficiency

Septic Osteomyelitis

[111]

c. Autosomal Recessive CGD- p47 phox deficiency

Juvenile Idiopathic Arthritis

[114]

d. Autosomal Recessive CDG p-67 phox deficiency

Septic Osteomyelitis

[112,113]

Mendelian susceptibility to mycobacterial disease (MSMD)

 

 

a. IL12 and IL23 Receptor β1 chain deficiency

Septic Arthritis

Osteomyelitis

[115]

b. GATA2  deficiency

Arthritis

[169]

Table 6: Defects in Innate Immunity.

Diseases

Bone/Joint Findings

Reference  #

Anhidrotic Ectodermal Dysplasia with immunodeficiency

a. EDA-ID, X Linked

Septic Arthritis

Septic Osteomyelitis

[116,117]

b. EDA-ID, Autosomal Dominant

Septic Arthritis

Septic Osteomyelitis

[116]

TIR signaling pathway defect

a. IRAK4 deficiency

Septic Arthritis

Septic Osteomyelitis

[118]

b. Myd88 deficiency

Septic Arthritis

Septic Osteomyelitis

[119]

Predisposition to fungal diseases

a. CARD 9 Deficiency

Osteomyelitis

[119,120]

Table 7: Autoinflammatory Diseases.

Diseases

Bone/Joint Findings

Reference #

Defects  affecting the inflammasome

a. Familial Mediterranean Fever

Aseptic Arthritis

Rheumatoid Arthritis

Juvenile Idiopathic Arthritis

Aseptic Osteonecrosis

Osteoporosis

[121-125]

b. Hyper IgD Syndrome

Aseptic Arthritis

[126]

c. Muckle-Wells Syndrome

Aseptic Arthritis

[127,128]

d. Familial Cold Autoinflammatory Syndrome

Arthralgias

[129]

e. Neonatal Onset  Multisystem inflammatory disease (NOMID)

Aseptic Arthritis

Bone anomalies:

- Hyperostosis

- Contractures

[130]

Non-inflammasome related conditions

a. TNFR associated periodic fevers

Arthralgia/Arthritis

[131]

b. Pyogenic sterile arthritis Pyoderma gangrenosum Acne Syndrome

Aseptic Arthritis

Aseptic Osteomyelitis

Fractures

[132]

c. Blau Syndrome

Aseptic Arthritis

[133]

d. Chronic Recurrent Multifocal Osteomyelitis and congenital dyserythropoietic anemia

Aseptic Osteomyelitis

Septic Osteomyelitis

[134]

1. DIRA (deficiency of the Interleukin 1 antagonist)

Bone anomalies:

- widened bones

- bone ossification

[135,136]

2. Cherubism

Bone anomaly:

- jaw resorption

Aseptic Osteomyelitis

[137]

3. CANDLE (chronic atypical neutrophilic dermatitis with lipodystrophy)

Bone anomalies:

- microcephaly

- contractures

[138]

4. PLAID (PLCγ2 associated antibody deficiency and immune dysregulation)

Aseptic Arthritis

[170]

Table 8: Complement Deficiencies.

Diseases

Bone/Joint Findings

Reference#

C1q deficiency

Lupus Arthritis

[139,140]

C1s deficiency

Lupus Arthritis

[141]

C4 deficiency

Lupus Arthritis

[141]

C2 deficiency

Juvenile Idiopathic Arthritis

Lupus Arthritis

Osteoporosis

Septic Arthritis

Septic Osteomyelitis

 

[142-145]

C3 deficiency

Lupus Arthritis

Osteomyelitis

[140,142]

C5 deficiency

Lupus Arthritis

Septic Arthritis

[146,147]

C6 deficiency

Aseptic Arthritis

Septic Arthritis

[148,149]

C7 deficiency

Rheumatoid Arthritis

Ankylosing Spondylitis

Septic Arthritis

[150,151]

C9 deficiency

Ankylosing Spondylitis

[152]

C1 inhibitor deficiency

Aseptic Arthritis

Lupus Arthritis

Rheumatoid Arthritis

[153]

Properdin deficiency

Septic Arthritis

Septic Osteomyelitis

[154]

Factor I deficiency

Juvenile Idiopathic Arthritis

Septic Arthritis

[171]

Table 9: Phenocopies of PID Associated with Somatic Mutations.

Diseases

Bone/Joint Findings

Reference #

a. Autoimmune lymphoproliferative Syndrome (ALPS-FAS_

Aseptic Arthritis

[155,156]

malignant lymphomas) is associated with Juvenile Idiopathic Arthritis (JIA)-like clinodactyly, syndactyly, and hip dysplasia [23-26]. In Bloom Syndrome, two patients with dolichocephaly have been reported [27]. In Immunodeficiency with centromeric instability and facial anomalies syndrome, 20% of patients present with juvenile idiopathic arthritis, 12% with dolichocephaly, 6% each had microcephaly or macrocephaly, 7% had cleft palate, and 5% had syndactyly [28-30]. DiGeorge syndrome is associated with juvenile idiopathic arthritis, and 20% with cleft palate and vertebral anomalies [31,32]. A cartilage hair hypoplasia patient was found to have aseptic arthritis [33], while another patient was found to have brachydactyly and femoral bone widening [34]. Aseptic arthritis, platyspondyly, phalangeal anomaly, and clinodactyly have been observed in Schimke syndrome [35,36]. Autosomal dominant Hyper IgE Syndrome, which is caused by mutation of STAT-3, is associated with increased frequency of fractures, 66% hyperextensibility (66%), scoliosis (63%), osteopenia (40%), osteoporosis (20%), aseptic arthritis (8%), and septic arthritis (17%) [37-43]. Osteogenesis imperfecta as well as craniosynostosis has also been reported [44-46]. Autosomal recessive Hyper-IgE Syndrome, which is caused by DOCK8 mutations, presented with

Systemic Lupus Erythematosus (SLE) with purpuric and necrotic skin lesions diffuse arthritis, and glomerulonephritis [47]. Scoliosis and fractures have been reported in some cases [48]. In autosomal recessive Dyskeratosis Congenita (DKC) due to RTEL (regulation of telomere elongation helicase 1) deficiency, one patient had avascular necrosis [49]. In autosomal recessive DKC, a syndrome characterized by immunodeficiency, bone marrow failure, somatic abnormalities, and cancer predisposition resulting from defective telomere, 80% have microcephaly [50]. In autosomal dominant DKC due to Telomerase Reverse Transcriptase (TERT) deficiency, 26% have osteoporosis/ osteopenia and 3% scoliosis [51]. In Comel-Netherton syndrome, two out of three patients were found to have rickets in addition to the ichthyoses, hair shaft defect, and atopy found in patients that have the disease [52,53]. Oral calcium release activated calcium modulator (ORAI-I) deficiency known for autoimmunity, ectodermic dysplasia, and myopathy also had a case report of skeletal findings of clubfoot and defect of posterior arch closing in a patient [54]. Hepatic veno-occlusive disease with immunodeficiency, 33% of patients had microcephaly [55]. In facial dysmorphism, immunodeficiency, live do and short stature (FILS) syndrome, patients have facial dysmorphisms, immunodeficiency, live do and short stature with 9% of patients having macrocephaly [56]. Table 2 has highlighted the specific disease manifestations with the bone findings specific to each disease.

In X-linked Agammaglobulinemia (XLA), a primary immunodeficiency disease caused by mutations in the Bruton's Tyrosine Kinase (BTK) gene, arthritis and osteomyelitis occurs with different frequency; aseptic arthritis (11%), juvenile idiopathic arthritis (17%), septic arthritis (8%), and nonspecific osteomyelitis (3%) [57-60]. Zhu and associates described a patient with XLA and Juvenile Idiopathic Arthritis (JIA) who later developed invasive Klebsiella pneumonia polyarticular septic arthritis [61]. Authors suggested that XLA combined with JIA may contribute to invasive K. pneumoniae infection. A single case of aseptic arthritis has been reported with μ heavy chain deficiency and λ5 deficiency [62,63]. Thymoma with immunodeficiency (Good syndrome) has a 2% risk of septic arthritis (Mycoplasma as implicated species) and one case report of rheumatoid-like arthritis has been reported [64,65]. In a cohort of 243 patients with Common Variable Immunodeficiency (CVID), 2% had rheumatoid arthritis, 1.6% juvenile idiopathic arthritis, 0.8% septic arthritis (Mycoplasma pneumoniae, Chlamydia pneumoniae), 0.8% septic osteomyelitis [66-70]. Rheumatoid arthritis has been reported in patients with ICOS (inducible costimulator) deficiency [70- 72]. TWEAK (TNF-like weak inducer of apoptosis) deficiency has 33% osteomyelitis (unknown if septic or chronic) [73]. In Warts, Hypogammaglobulinemia, Infections and Myelokathexis Syndrome (WHIM), 10% of patients had osteomyelitis [74]. In CD40 ligand deficiency, 1% had osteomyelitis while 11% had aseptic arthritis [75]. Activation-Induced Cytidine Deaminase (AID) deficiency had 7% aseptic arthritis [76,77]. In Isolated IgG subclass deficiency, 27% had septic osteomyelitis with or without septic arthritis with the organisms being staphylococcal species or streptococcal species [78]. In IgA with IgG subclass deficiency, 6% had rheumatoid arthritis [79]. In PRKC δ (protein kinase c delta) deficiency, there exists a case report with a patient that had microcephaly and polysyndactyly [80]. In Selective IgA deficiency, 2% had rheumatoid arthritis, 0.7% had juvenile idiopathic arthritis, with case reports of ankylosing spondylitis, another of aseptic arthritis, and finally one other with osteomyelitis due to Mycoplasma species [81-84]. Table 3 includes predominantly antibody deficiency syndromes with their respective bone/ joint findings.

In familial hemophagocytic lymphohistiocytosis type 3 due to mutations in UNC13D deficiency; one patient had juvenile idiopathic arthritis [85]. In Immune Dysregulation, Polyendocrinopathy, Enteropathy X linked (IPEX), 33% of patients had aseptic arthritis [86]. In STAT5b deficiency, patients present with dwarfism, eczema, lymphocytic pneumonitis with 10% of patients having juvenile idiopathic arthritis [87]. In Autoimmune Polyendocrinopathy with Candidiasis and Ectodermal Dystrophy (APCED), there exists a case report of a patient that had juvenile idiopathic arthritis [88]. In ITCH deficiency, mutations in an E3 ubiquitin ligase called ITCH, patients may have chronic lung disease, autoimmune disease as well as dysmorphic facial features; 90% of patients had macrocephaly while all patients in the case report of 10 had dolichocephaly [89]. In Autoimmune Lymphoproliferative Syndrome (ALPS) due to FAS mutation, 33% of patients developed aseptic arthritis, whereas in ALPS due to FASL mutation rarely osteopenia has been reported [90,91]. IL- 10Rα and IL-10Rβ deficiency are associated with aseptic arthritis [92]. In Aicardi-Goutieres Syndrome Type 5 due to SAMHD1 mutations, patients present with encephalopathy, cerebral atrophy, vasculitis as well as aseptic arthritis, microcephaly, osteopenia, and sporadic reports of aseptic arthritis and scoliosis [93,94]. In case reports of Spondyloenchondrodysplasia with Immune Dysregulation (SPENCD), two patients had vertebral changes and platyspondyly [95]. The bone and joint findings above have also been listed for each disease in Table 4 or Table 9.

In Glycogen storage disease 1b, 32% had osteopenia, and 12% had short stature [96]. In cyclic neutropenia, there is a report of a patient with unspecified osteomyelitis [97]. Osseous and joint changes are rare in leukocyte adhesion defect 1 (LAD-1) and LAD-2, while osteomyelitis is frequently (33%) observed in LAD-3 [98-100]. In Shwachman-Diamond Syndrome, 64% of patients had osteoporosis, 55% fractures, and 36% with osteopenia [101-103]. X-linked Chronic Granulomatous Disease (CGD) is associated with osteomyelitis with a variety of organisms, including Cladophialophora arxii, Aspergillus nidulans, Edwardsiella tarda, Serratia marcescens, Burkholderia gladioli, Chrysosporium zonatum, Paecilomyces Variotii, Pseudoallescheria boydii, Inonotus tropicalis, Penicillium piceum [104-110]. In autosomal recessive CGD-p22 phox and CGD-p67 phox deficiency, patients with osteomyelitis due to Aspergillus fumigatus have been reported [111-113]. In autosomal recessive CGD-p47 phox deficiency, juvenile idiopathic arthritis has been reported [114]. In IL12 and IL23 receptor β1 chain deficiency, there is a case report of one patient with cryptococcal arthritis as well as osteomyelitis [115]. The defects found in phagocytes with their respective bone findings have been listed in Table 5. In Ectodermal Dysplasia Agammaglobulinemia (EDA) due to mutation in NEMO, 16% of patients had arthritis and osteomyelitis [116,117], while in series of EDA due to IKKβ 20% of patients had septic osteomyelitis and arthritis [116]. In IRAK4 deficiency, 29% of patients had septic arthritis while 14% had septic osteomyelitis [118]. In MyD88 deficiency, 6% had septic arthritis and 9% had osteomyelitis [119]. In CARD9 deficiency, one of five patients was found to have osteomyelitis due to Candidal species [119-120]. The bone and joint findings with the diseases have been listed in Table 6.

In familial Mediterranean fever syndrome, aseptic arthritis (2/2 patients), rheumatoid arthritis (2/2), 0.8% juvenile idiopathic arthritis, and ankylosing spondylitis (1/1) have been reported [121-125]. In Hyper IgD Syndrome, 50% have aseptic arthritis while 4% have contractures [126]. Muckle- Wells patients may have arthritis [127,128]. In familial cold autoinflammatory syndrome, 96% of patients have arthralgias [129]. A Neonatal Onset Multisystem Inflammatory Disease (NOMID) patient presented with arthritis while the majority of patients have hyperostosis (92%), patellar overgrowth (92%) and contractures (85%) [130]. TNF-Receptor Associated Periodic Syndrome (TRAPS) is associated with aseptic arthritis and arthralgias [131]. In Pyogenic Sterile Arthritis Pyoderma Gangrenosum Acne (PAPA) syndrome, all patients had aseptic arthritis while 20% had chronic osteomyelitis [132]. In Blau syndrome, 50% had aseptic arthritis while the other 50% of patients in the study had boutonniere's deformity [133]. In chronic recurrent multifocal osteomyelitis and congenital dyserythropoietic anemia, all patients had aseptic osteomyelitis while 12% had concomitant septic osteomyelitis [134]. In Deficiency of the Interleukin 1 Receptor Antagonist (DIRA), the skeletal anomalies include widened ribs, periosteal reaction, vertebral fusion, and proximal interphalangeal joint swelling [135,136]. In addition to the main pathophysiologic finding of fibro-osseous bone formation, craniosynostosis has been reported in Cherubism syndrome, where a mutation in SH3BP2 causes bone degeneration in the jaws [137]. Microcephaly and contractures have been described in Chronic Atypical Neutrophilic Dermatitis with Lipodystrophy (CANDLE) syndrome [138]. The bone findings with autoinflammatory diseases have been summarized in table 7.

Complement deficiencies have many skeletal manifestations. C1q deficiency has been associated with lupus arthritis in 50% of cases [139,140]. There is a case report of a C1s deficiency also having lupus arthritis [141]. In C4 deficiency, 4% had lupus arthritis [141]. In C2 deficiency, septic arthritis (Haemophilus influenzae, Streptococcal pneumoniae), septic osteomyelitis (Streptococcal pneumoniae), osteoporosis, fractures, and lupus arthritis have been reported [142-145]. Osteomyelitis has been observed in C3 deficiency [140,142]. There are case reports of gonococcal arthritis in a patient with C5 deficiency [146,147], and septic as well as aseptic arthritis in C6 deficiency [148,149]. C7 deficiency is associated with ankylosing spondylitis and rheumatoid arthritis [150,151]. C9 deficiency has reports of ankylosing spondylitis [152]. In C1 inhibitor deficiency, 0.6% had lupus arthritis, 0.6% had rheumatoid arthritis and 0.6% had polyarthritis [153]. In Properdin deficiency, septic arthritis and osteomyelitis due to Neisseria meningitidis have been reported [154]. Factor I deficiency may present with juvenile idiopathic arthritis or septic arthritis [155-156]. Lastly, the bone findings in complement deficiencies have been summarized in table 8.

In summary, osteomyelitis and septic and aseptic (rheumatoid arthritis and lupus arthritis, respectively) are the most common osseous and joint manifestations in PID; however frequency of certain other osseous abnormalities may be observed with specific PID syndrome.
Acknowledgement
This study was supported by funds from the Division of Basic and Clinical Immunology. We would also like to thank Arash Gharib for assisting in editing the paper.
Declarations
Dr. Gupta is on the advisory board for Baxter and Kedrion, is on the speakers bureau for Baxter, participated in clinical trials with Baxter and Octapharma, received a publication grant from CSL Behring and received a research grant from Baxter, and he is an Ad Hoc Advisor for Baxalta. Dr. Gharib has no disclosures to report. The authors report no conflicts of interest.
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