 And thank you for the invitation to speak today. It's really terrific. This is a very, very exciting program and it's a privilege to be speaking here. So in any case, I will be talking for the next few minutes about some work that has been a passion of my professional life for the last over 20 years. And that has been understanding some of the disorders that present as undiagnosed hereditary fevers in patients. And over the course of time, has had really unexpectedly, I think, large implications for our understanding of the regulation of inflammation in man. So in any case, let's get into it. And certainly in terms of our thinking about charting a course for genomic medicine, at least for us, it's been very much a matter of starting with particular patients, with particular phenotypes. And so I will just regale you with a few of them over the course of the next minute or two. First of all, here is a, at the time this image was taken, seven-year-old girl from California who had months-long episodes of fever with severe abdominal pain, a migratory rash, and sometimes arthritis. And you can see here this is actually a laparoscopic view of her abdominal cavity showing adhesions that it formed as the result of recurrent episodes of inflammation. Here's a toddler from Baltimore who had a different type of recurrent fever syndrome, also hereditary. And in this case, this patient had week-long episodes of fever with diarrhea, the skin rash, and cervical lymphadenopathy. This is a kidney biopsy looked at under polarizing light showing amyloid deposition in a young man from Turkey who came to the United States as a graduate student at Georgetown and actually was seen in a screening physical examination with proteinuria and turned out to have amyloid deposits in his kidneys and incidentally had a history of a few-day episodes of fever intermittently over the course of the first 20 years of his life. And then here is an audiogram taken from a young woman in her early 20s from Texas with high-frequency hearing loss associated with a syndrome of single-day fevers. Just a little bit more, we have here an MRI of the brain of a young child with chronic aseptic meningitis. This is a flare image and shows basically the white inflammation on the meninges. This patient has a condition called NOMID, neonatal onset multi-system inflammatory disease. This is a young man from Kansas City whom we take care of at the clinical center who has a syndrome in which he develops pyoderma gangranosum. That's shown here. It's basically a breakdown of the skin. These patients develop a purulent area on the skin and bleeding. This particular lesion lasted for about a year and was refractory to high doses of corticosteroids and required high doses of narcotics to control the pain. This is a child from Puerto Rico, a seven-year-old who has a new disorder that I'll tell you about in a few minutes, something called DERA, Deficiency of IEL1 Receptor Antagonist. And then finally, the last image I'll show you is of an autopsy specimen of the father of one of the patients that we follow at the NIH with a different recurrent fever syndrome, a fever syndrome that presents with prolonged fever's periorabiladema, migratory rash, and abdominal pain. Unfortunately, he lived a little bit too early for the genome project and passed away before we started seeing his daughter. All of these patients have diseases that have basically been susceptible to the analysis of the genome project. And basically, we have an explanation for the illness in all eight of these cases that I'm telling you about right now. And luckily, both for us and for the patients, we actually have treatments, targeted treatments for each of these patients, except for the last, of course. And essentially, these targeted treatments are based on our understanding of the pathophysiology that came out of the genetic studies and the fortuitous parallel universe of immunology and biotechnology that developed cytokine antagonists that are effective in treating these patients. So anyway, let's just talk a little bit about some of these diseases in more detail. So first, we'll start with this patient here, a young man, a young Armenian man that I saw at the beginning of my rheumatology fellowship here some 25 years ago. There was only five at the time. And in any case, he had recurrent episodes of fever and arthritis that would last a few days at the time. He turned out to have familial Mediterranean fever, at least by clinical diagnosis, which led us to get interested in the positional cloning of the gene for this disease. And of course, this was back at the time in the first phase, if you will, of the genome project that Rick was referring to. And certainly, the paradigm of cystic fibrosis was a siren song for us. And so we mapped the gene for this disease to chromosome 16, having looked actually at every other chromosome before finally localizing the causative locus to chromosome 16 and then became the genome project for this area of the human genome and eventually narrowed the interval to 200,000 base pair interval. There were 10 genes that we sifted out of this region. And of course, it was the 10th of the 10 that turned out to have mutations associated with disease. It encodes what was then a novel protein that we called pyrin after pyrrexia for fever and a competing French group denoted marinostrin, they being a little bit more erudite than we after marinostrum for the Latin for the Mediterranean sea. In any case, we'll talk a little bit more about this protein in a bit, but just to turn to another of these diseases. This is the back actually of the man whose forearm I showed you a few minutes ago. You can see severe cystic acne in his case. And we were interested in this phenotype and we were also interested at the same time in proteins that interact with pyrin, the FMF protein. And by basically a comprehensive approach using yeast to hybrid studies, we found that one of the proteins that interacts with pyrin is this one here, PSTPIP1, choline serine 3-anine phosphatase interacting protein. Basically, it's a pyrin binding protein and mutations in it have an effect on the avidity of binding of this protein to pyrin and actually lead to increased IL-1 secretion in peripheral blood leukocytes from these patients. So we have both pyrin and a pyrin binding protein. Here is another patient, a young man named Jonathan who was referred to us from North Carolina who had a different syndrome. He actually had fevers, a hives like rash and evidence of central nervous system inflammation and overgrowth of the epithesis of his long bones leading to this knobby knee appearance. In any case, he has mutations in not a pyrin binding protein but a pyrin homolog. So there is actually a family of proteins that we'll talk about in a bit that have an N-terminal domain that's known as the pyrin domain, not the Maranostrin domain but the pyrin domain. And actually these proteins are involved in the regulation of inflammation. In patients who have the disease that he has, NOMID, neonatal onset multisystem inflammatory disease have mutations not in the pyrin domain but in an aggregation domain in the middle of the protein. And actually there are other phenotypes that are also associated with this as well. So we have pyrin, a pyrin binding protein, a pyrin homolog. And now we'll turn to another patient who was referred to us from Newfoundland, Canada, who has this pustular rash all over his body. This was an image taken when he was nine months old. This is actually the fold of the neck. So these are just pustules all over the back. And this patient has mutations in the IL-1 receptor antagonist gene. So this is a gene that's actually in that same pathway. And actually there are several other patients that we have identified with other mutations in this gene but the same phenotype leading to the new disease, deficiency in IL-1 receptor antagonist. Here is a photo of a family that have yet another phenotype. This is the phenotype actually. This girl's father is the one whose autopsy slides are featured on that issue of cell, but I showed you a while back. She has long episodes of fever with serosal and joint inflammation. And patients who have this actually have mutations in another inflammatory molecule, another molecule that's important in the regulation of fever in humans. And that is the P55 TNF receptor or TNF RSF1A. Patients who have this disease, many of them have mutations at cysteine residues that are involved in holding the folding structure of the cysteine-rich domains in place in the extracellular part of this protein. This is yet another patient who has a disorder. She's from Chicago, has a disorder in which the episodes of fever are shorter and they are caused. This is a work of a group from the Netherlands in mutations in mevalonic kinase, which is an enzyme that's involved in cholesterol biosynthesis. And then finally, the last disease that I will at least mention is Bichette's disease, which in contradistinction to the other disorders that I told you about is a disease with complex inheritance. And Bichette's disease is characterized by the triad that's illustrated here, oral ulceration, ocular inflammation. This is hypopian uveitis. This is the accumulation of pus in the anterior chamber of the eye and genital ulcerations. And so we've been involved in a genome-wide association study in this disorder and basically looking at about 1,200 individuals with Bichette's disease from Turkey and 1,200 Turkish controls and then confirming it with cohorts from Japan, Korea, and a number of other areas. We found that actually there is a variant of the IL-10 locus that's highly associated with Bichette's disease in all of these populations with a modest risk, but a biological story that goes along with it. And so individuals who actually have two copies of the risk allele produce less IL-10 than individuals who have either one copy or who are homozygous for the non-risk allele. That's interesting because IL-10 is an anti-inflammatory cytokine and so it actually does give some account of how it is that people with Bichette's disease might develop that phenotype. So in any case, that's just a little overview of the genetics, what we've learned in terms of diagnosis. What have we learned in terms of biology? Well, there's a lot more biology than what I can probably talk to you about in the next two hours that I have for the talk. So I'll try to make it brief. But in any case, it turns out that pyrin itself, the first protein that I told you about, which is mutated in FMF, is the prototype for a domain that's found at its end terminus, which is a six-alpha helix domain that at least oftentimes can form a dipole that's involved in homotypic interactions. So pyrin domains can interact with other pyrin domains. In the case of pyrin itself, it interacts with an adapter protein called ASC, which in turn can interact with Caspace-1, the enzyme that's involved in the activation of pro-iol-1-beta to iol-1-beta itself. And actually, the pyrin domain is now known to be a motif that's found in a whole large category of proteins that are involved in the regulation of inflammation and cell death. And this is just a phylogenetic diagram that indicates some of the proteins that have pyrin domains in them. Many of them are the NLRP family of proteins which are shown here with the N-terminal pyrin domain shown in green. So in any case, if one then thinks about the biology of a disease like FMF, we've actually knocked in the mutations in the FMF gene, or at least some of them, into mice. This is the work of J. Chae in our lab. And you can see that in mice that are knock-ins for the V726A mutation, you may not be able to see this, but these mice actually spontaneously develop arthritis. And if one sections the joint, one sees the characteristic influx of polymorphonuclear leukocytes into the joint as one would see in human FMF. And if one breeds these mice onto IL-1 receptor knock-out background, one can see that actually there's a marked reduction in the inflammatory phenotype that these animals have. The pyrin domain proteins, actually at least one of them, NLRP3, is actually an important mediator in a macromolecular complex that's called the inflamosome that's involved in IL-1 beta activation. And this slide just illustrates the IL-1 activation pathway and the various phenotypes that we and others have seen that are associated with molecular lesions in this pathway so that individuals who have NLRP3 mutations develop hives like rash and a spectrum of other inflammatory phenotypes, including CNS inflammation. Patients with FMF who have mutations at another point in that pathway get a different type of rash and a different duration of episodes. Patients with the Hyper-IGD syndrome have mutations in a regulator of that pathway. Patients with the deficiency of IL-1 receptor antagonists get yet a different phenotype illustrated here with the diffuse postulosis. Patients with mutations in PST-PIP-1 have the pyoderma gangrenosum phenotype and then, hearkening back to the first talk of the second part of the session here, this is actually hideout to deform mole and recurrent hideout to deform mole is actually an inflammatory condition which can be associated with variants of NLRP7, one of the regulators of this pathway. We've also learned a lot about other inflammatory disorders so that in the case of the TNF receptor, actually we know now that misfolded protein actually can form aggregates in the cell which are involved in assembling a signaling cascade which then lead to excessive cytokine production by leukocytes from these patients. Moreover, we've gotten a much better understanding of various disorders of inflammation. And a few years ago, we had proposed a categorization of inflammatory or immunologically mediated diseases in which disorders with auto-antibody formation and antigen-specific T cells, we think of as autoimmune diseases, disorders in which these antigen-specific variants are not present, auto-antibodies or antigen-specific T cells are not present. We think of as auto-inflammatory diseases. And this image just reminds us of the dichotomy between the adaptive immune system in which lymphocytes play a major role and in which the receptors somatically rearrange or mutate and the innate immune system in which the cell types are for the most part myeloid in nature and in which the receptors do not somatically rearrange or mutate. And so basically the auto-inflammatory diseases are diseases of innate immunity. And this table here just simply illustrates that there are now lots of diseases besides the periodic fever syndromes that in fact fall under this auto-inflammatory rubric and a couple of them that are much more common diseases are gout in which uric acid crystals actually activate the inflammasome. And this then does suggest and in fact has led to therapeutic trials of IL-1 inhibitors in gout. And atherosclerosis. This is a paper by Ike Lotz's group from a year ago basically demonstrating in mouse models of atherosclerosis that if one looks at knockouts for the IL-1 pathway we don't see atherosclerosis in those animal models. And so atherosclerosis is probably at least to some extent auto-inflammatory as well. We've also learned a lot about human history by tracing spread of these mutations across different populations. And so here is just shown the spread of various FMF mutations in the Mediterranean basin. And in fact there's an extraordinarily high frequency of these mutations in these different populations different mutations in different populations. The mutations cluster around what looks to be a binding pocket in the C-terminal domain of this protein suggesting that there probably is some sort of a selective pressure although we don't know yet what it is. In the case of the deficiency of IL-1 receptor antagonist we know that there are certain areas in Newfoundland, the Bible belt of the Netherlands and Northwestern Puerto Rico where we sometimes see founder effects and particularly in Northwestern Puerto Rico there actually have been additional patients identified from the original prepositives patients. And then finally for Bichette's disease many of you know Bichette's disease is distributed along the silk route of Marco Polo going from Venice through the Middle East to Korea and Japan and in point of fact the variants that we've seen at both IL-10 and the IL-23 receptor which I didn't talk about. They are seen both in the Turkish population and in the Far Eastern population suggesting that more than silk was traded along the silk route of Marco Polo. So in any case then to get to I'm sure what many are interested in as sort of the final indication of this kind of work we have been, we and our patients have been extraordinarily lucky in terms of treatment possibilities and as I said at the outset this is at least in part due to the fact that there has been this parallel universe of immunology and biotechnology research that has been going on at the same time. So in the case of patients with NOMID the disease that's caused by mutations is an NLRP-3, the inflammasome protein. About four years ago Raphaela Goldbach-Mansky in NIMES set up a protocol to look at 18 patients with this disease with Anna Kinra, the IL-1 receptor antagonist which is basically an agent that binds to the type 1 IL-1 receptor but not to the accessory protein and thereby blocks IL-1 signaling. And one can see that there is just an absolutely, oops, dramatic response to Anna Kinra treatment. This is within three days of treatment. These patients' skin rash goes away. Their ocular inflammation goes away within about three months. The CNS inflammation, the chronic aseptic meningitis is largely gone. The aero points the cochlea. This is cochlear inflammation which dissipates as well with specific cytokine therapy. Here's a patient with GERA, the deficiency of IL-1 receptor antagonist with pustular lesions all over the body at age nine months. Within three days of beginning treatment with IL-1 inhibitor, you see that the skin is beginning to slough and the child is beginning to smile rather than cry. And by seven days after the initiation of treatment, you can see that nearly all of the skin has sloughed and basically this patient is well as long as he continues on the Anna Kinra injections. Here's a patient, a young man from Baghdad, Iraq who has familial Mediterranean fever. The usual treatment for that is colchicine but he has severe amyloidosis including in his gastrointestinal tract which leads to chronic diarrhea so he was not able to tolerate colchicine and so instead we have put him on Anna Kinra as well. At the time that we first saw him, his ejection fraction was about 37% and he had chronic malabsorption and we really didn't think that he was going to survive for very long at all. But actually on Anna Kinra, he has done extremely well. His amyloid deposits have at least to some extent regressed and five years later, here's his picture after having just eaten pizza for lunch. And then finally thinking about some of the more common diseases that now have what appears to be an auto-inflammatory component, type 2 diabetes. So you might not think of diabetes, especially type 2 diabetes as having an inflammatory component but in fact hyperglycemia induces islet cells to produce isle 1. Isle 1 in turn is toxic to islet cells so that in fact they end up producing something that causes them to commit suicide which of course then leads to more hyperglycemia and more isle 1 production. And one can see that if one treats these patients with an isle 1 inhibitor then in fact isle 1 control improves and isle 1 inhibitors are actually now in clinical trials for type 2 diabetes. Finally I would just end with yet another disease that I haven't talked about yet. PFAPA, the syndrome of periodic fever with apistomatitis, pharyngitis and cervical adenopathy. It's actually the most common recurrent fever syndrome in kids and we see it quite frequently in our clinic. It is caused by a complex set of genes that we don't yet understand but taking a genomic approach to it and just looking at gene expression profiling we found that in fact patients with PFAPA during their attacks have activation of the inflammasome pathway, the isle 1 pathway. So we have started treating a few of these patients with anikinra and we do see a diminution in fevers and other episodes. Just earlier this week on Tuesday I saw one of the patients that's in this study from Tennessee who actually has taken now 20 courses of anikinra and has aborted all of his attacks that basically within hours. A little bit later that morning we saw a three-year-old from Seattle whose mother had lost her job because she was having to stay home with her daughter with her attacks of fevers and of course we've now started the daughter on anikinra as well. There's a lot left to be done. This is a pie chart of some 1,300 patients that we've seen at the NIH with various recurrent fever syndromes and you can see that actually we only have genetic diagnosis and about 38% of them and so there's lots left to do. So in any case, I'll just close with some acknowledgments to people that made a big difference in terms of this work. Yvonne Akcentyevich who's been the person who's done a lot of the gene discovery work in terms of sequencing in our lab. Raphaela Goldbach-Mansky, now a tenure track investigator in NIAMS who's done a lot of the clinical studies. Jay Chae who's developed the animal models. Seth Masters who's done a lot of the work on functional studies. Richard Siegel, collaborator who does a lot of work on the cell biology of traps. Elaine Remmers who's headed up our GWAS studies and then our larger group of the lab and clinical people shown at a recent NHGRI retreat and then finally of course acknowledgment to the NIH Clinical Center where all this work took place. So anyway, thanks a lot.