Proteasome-associated autoinflammatory syndrome (PRAAS) is a genetically heterogeneous Mendelian type I interferonopathy caused by loss-of-function defects in proteasome or immunoproteasome subunits and proteasome assembly factors. The disease spectrum encompasses the historically named CANDLE, Nakajo-Nishimura, and JMP syndromes and is characterized by proteotoxic stress, chronic interferon activation, inflammatory skin disease, progressive lipodystrophy, joint contractures, and systemic inflammatory complications.
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name: Proteasome-Associated Autoinflammatory Syndrome
creation_date: "2026-04-14T05:24:49Z"
updated_date: "2026-04-22T20:53:03Z"
category: Mendelian
synonyms:
- PRAAS
- proteasome disability syndrome
- CANDLE syndrome
- Nakajo-Nishimura syndrome
- JMP syndrome
- autoinflammation-lipodystrophy-dermatosis syndrome
description: >
Proteasome-associated autoinflammatory syndrome (PRAAS) is a genetically
heterogeneous Mendelian type I interferonopathy caused by loss-of-function
defects in proteasome or immunoproteasome subunits and proteasome assembly
factors. The disease spectrum encompasses the historically named CANDLE,
Nakajo-Nishimura, and JMP syndromes and is characterized by proteotoxic
stress, chronic interferon activation, inflammatory skin disease,
progressive lipodystrophy, joint contractures, and systemic inflammatory
complications.
disease_term:
preferred_term: proteasome-associated autoinflammatory syndrome
term:
id: MONDO:0009726
label: proteosome-associated autoinflammatory syndrome
parents:
- Autoinflammatory diseases
- Interferonopathies
- Inborn errors of immunity
notes: >
This disease-level entry uses the umbrella name PRAAS for the shared
proteasome/immunoproteasome interferonopathy spectrum. The literature also
uses CANDLE syndrome, Nakajo-Nishimura syndrome, and JMP syndrome for
partially overlapping presentations within that spectrum, so those labels
are retained as synonyms rather than treated as separate umbrella disorders
here. MONDO:0009726 is the ontology anchor for the umbrella disease, but its
canonical label is misspelled as "proteosome-associated autoinflammatory
syndrome"; the entry name and preferred_term use the standard "proteasome"
spelling while term.label follows MONDO exactly for validation.
review_notes: >
Initial disease-level curation for issue 1276. Emphasis was placed on
spectrum-aware naming, chaining proteasome dysfunction to UPR and PKR-driven
interferonopathy, and capturing mechanism-grounded treatment evidence for
baricitinib and anifrolumab.
genetic:
- name: Proteasome subunit and assembly-factor loss-of-function variants
association: Causative
notes: >
PRAAS is genetically heterogeneous and includes recessive, digenic, and de
novo dominant-negative defects affecting proteasome catalytic subunits and
proteasome assembly factors. Reported genes across the spectrum include
PSMB8, PSMB9, PSMB7, PSMA3, POMP, PSMG2, PSMB10, PSMA5, and PSMC5.
evidence:
- reference: PMID:31827472
reference_title: "Contribution of the Unfolded Protein Response (UPR) to the Pathogenesis of Proteasome-Associated Autoinflammatory Syndromes (PRAAS)."
supports: SUPPORT
evidence_source: OTHER
snippet: "By definition, PRAAS are caused by inherited and/or de novo loss-of-function mutations in genes encoding proteasome subunits such as PSMB8, PSMB9, PSMB7, PSMA3, or proteasome assembly factors including POMP and PSMG2, respectively."
explanation: Review abstract defines the umbrella disease genetically and anchors the core subunit and assembly-factor gene set.
- reference: PMID:37600812
reference_title: "Identification of eight novel proteasome variants in five unrelated cases of proteasome-associated autoinflammatory syndromes (PRAAS)."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Variants in two previously not associated proteasome genes, PSMA5 and PSMC5, were found in a patient who also carried the PSMB8 founder mutation, p.T75M."
explanation: Recent case-series evidence expands the PRAAS gene spectrum beyond the earlier canonical set.
- name: PSMB8
association: Recurrent causative gene
gene_term:
preferred_term: PSMB8
term:
id: hgnc:9545
label: PSMB8
notes: >
PSMB8 encodes the inducible immunoproteasome beta-5i catalytic subunit and
remains the best-established recurrent PRAAS gene across CANDLE,
Nakajo-Nishimura, and JMP presentations.
evidence:
- reference: PMID:21129723
reference_title: "PSMB8 encoding the β5i proteasome subunit is mutated in joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "We conclude that mutations in PSMB8 cause JMP syndrome, most probably by affecting MHC class I antigen processing."
explanation: Discovery study establishes PSMB8 as a causative gene for one of the canonical PRAAS presentations.
- reference: PMID:31046790
reference_title: "Disease course and treatment effects of a JAK inhibitor in a patient with CANDLE syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Most patients have biallelic mutations in the PSMB8 gene that encodes the β5i catalytic subunit of the immunoproteasome."
explanation: Case-report abstract confirms PSMB8 as the recurrent disease gene in CANDLE, another historically named PRAAS phenotype.
pathophysiology:
- name: Proteasome Subunit and Assembly-Factor Loss of Function
description: >
Inherited or de novo loss-of-function defects in proteasome catalytic
subunits or assembly factors initiate the PRAAS disease cascade.
downstream:
- target: Impaired Proteasome Biogenesis and Activity
evidence:
- reference: PMID:31827472
reference_title: "Contribution of the Unfolded Protein Response (UPR) to the Pathogenesis of Proteasome-Associated Autoinflammatory Syndromes (PRAAS)."
supports: SUPPORT
evidence_source: OTHER
snippet: "By definition, PRAAS are caused by inherited and/or de novo loss-of-function mutations in genes encoding proteasome subunits such as PSMB8, PSMB9, PSMB7, PSMA3, or proteasome assembly factors including POMP and PSMG2, respectively."
explanation: Establishes the initiating lesion in PRAAS as loss of proteasome or proteasome-assembly function.
- name: Impaired Proteasome Biogenesis and Activity
description: >
PRAAS variants disrupt proteasome subunit expression, assembly, and mature
proteasome function, reducing proteolytic capacity.
biological_processes:
- preferred_term: proteasome-mediated protein degradation
term:
id: GO:0043161
label: proteasome-mediated ubiquitin-dependent protein catabolic process
modifier: DECREASED
downstream:
- target: Proteotoxic and Endoplasmic Reticulum Stress
evidence:
- reference: PMID:26524591
reference_title: "Additive loss-of-function proteasome subunit mutations in CANDLE/PRAAS patients promote type I IFN production."
supports: SUPPORT
evidence_source: IN_VITRO
snippet: "Function evaluation revealed that these mutations variably affect transcription, protein expression, protein folding, proteasome assembly, and, ultimately, proteasome activity."
explanation: Functional studies show that PRAAS-associated variants impair proteasome assembly and catalytic output.
- reference: PMID:37600812
reference_title: "Identification of eight novel proteasome variants in five unrelated cases of proteasome-associated autoinflammatory syndromes (PRAAS)."
supports: SUPPORT
evidence_source: IN_VITRO
snippet: "All newly identified mutations substantially impact the steady-state expression of the affected proteasome subunits and/or their incorporation into mature 26S proteasomes."
explanation: Additional contemporary functional evidence links newly reported PRAAS variants to defective mature proteasome formation.
- name: Proteotoxic and Endoplasmic Reticulum Stress
description: >
Impaired proteasome function causes accumulation of ubiquitinated or
misfolded proteins, engaging stress pathways including the unfolded
protein response.
biological_processes:
- preferred_term: response to endoplasmic reticulum stress
term:
id: GO:0034976
label: response to endoplasmic reticulum stress
modifier: INCREASED
downstream:
- target: PKR-Mediated Type I Interferon Signaling
evidence:
- reference: PMID:31827472
reference_title: "Contribution of the Unfolded Protein Response (UPR) to the Pathogenesis of Proteasome-Associated Autoinflammatory Syndromes (PRAAS)."
supports: SUPPORT
evidence_source: OTHER
snippet: "Disruption of any of these subunits results in perturbed intracellular protein homeostasis including accumulation of ubiquitinated proteins which is accompanied by a type I interferon (IFN) signature."
explanation: Review abstract directly links proteasome defects to ubiquitinated-protein accumulation and the interferon signature.
- reference: PMID:31827472
reference_title: "Contribution of the Unfolded Protein Response (UPR) to the Pathogenesis of Proteasome-Associated Autoinflammatory Syndromes (PRAAS)."
supports: SUPPORT
evidence_source: OTHER
snippet: "One promising candidate for triggering type I IFN under sterile conditions is the unfolded protein response (UPR) which is typically initiated in response to an accumulation of unfolded and/or misfolded proteins in the endoplasmic reticulum (ER) (also referred to as ER stress)."
explanation: Supports ER stress and UPR engagement as a mechanistic bridge between proteasome dysfunction and interferon activation.
- name: PKR-Mediated Type I Interferon Signaling
description: >
Protein kinase R senses proteotoxic stress in PRAAS and amplifies type I
interferon and inflammatory signaling.
biological_processes:
- preferred_term: type I interferon-mediated signaling pathway
term:
id: GO:0060337
label: type I interferon-mediated signaling pathway
modifier: INCREASED
downstream:
- target: Persistent Interferon Signature
evidence:
- reference: PMID:35148201
reference_title: "Protein kinase R is an innate immune sensor of proteotoxic stress via accumulation of cytoplasmic IL-24."
supports: SUPPORT
evidence_source: IN_VITRO
snippet: "Here, we identified protein kinase R (PKR) as an innate immune sensor for proteotoxic stress."
explanation: Mechanistic study identifies PKR as the sensor that connects proteasome dysfunction to inflammatory signaling.
- reference: PMID:35148201
reference_title: "Protein kinase R is an innate immune sensor of proteotoxic stress via accumulation of cytoplasmic IL-24."
supports: SUPPORT
evidence_source: IN_VITRO
snippet: "under conditions of proteasome dysfunction, PKR sensed the cytoplasmic accumulation of a known interactor, interleukin-24 (IL-24)."
explanation: Abstract-level evidence specifies the proximate signal sensed by PKR during proteasome dysfunction.
- name: Persistent Interferon Signature
description: >
Patient immune and stromal cells show a sustained interferon-response
program that remains a central molecular hallmark across PRAAS genotypes.
cell_types:
- preferred_term: monocyte
term:
id: CL:0000576
label: monocyte
evidence:
- reference: PMID:26524591
reference_title: "Additive loss-of-function proteasome subunit mutations in CANDLE/PRAAS patients promote type I IFN production."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Patient-isolated hematopoietic and nonhematopoietic cells exhibited a strong IFN gene-expression signature, irrespective of genotype."
explanation: Demonstrates that the interferon program is a shared downstream phenotype across genetically diverse PRAAS cases.
- reference: PMID:21953331
reference_title: "Mutations in proteasome subunit β type 8 cause chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature with evidence of genetic and phenotypic heterogeneity."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Microarray profiles and monocyte STAT-1 activation suggested a unique IFN signaling signature, unlike in other autoinflammatory disorders."
explanation: Early CANDLE cohort data confirm monocyte interferon-pathway activation as a core disease feature.
phenotypes:
- name: Periodic fever
category: Systemic
description: >
Recurrent febrile inflammatory episodes are a core systemic manifestation
across the PRAAS spectrum.
phenotype_term:
preferred_term: periodic fever
term:
id: HP:0032323
label: Periodic fever
evidence:
- reference: PMID:31576159
reference_title: "Nakajo-Nishimura syndrome and related proteasome-associated autoinflammatory syndromes."
supports: SUPPORT
evidence_source: OTHER
snippet: "Phenotypes of NNS patients are periodic fever, pernio-like rash, nodular erythema-like eruptions, and lipomuscular dystrophy, especially in the upper body, leading to the characteristic long, clubbed fingers."
explanation: Review abstract identifies periodic fever as a canonical feature of Nakajo-Nishimura syndrome within the PRAAS spectrum.
- name: Chilblains
category: Dermatologic
description: >
Pernio-like acral inflammatory lesions are a characteristic skin finding in
the PRAAS/Nakajo-Nishimura end of the spectrum.
phenotype_term:
preferred_term: pernio-like rash
term:
id: HP:0009710
label: Chilblains
evidence:
- reference: PMID:31576159
reference_title: "Nakajo-Nishimura syndrome and related proteasome-associated autoinflammatory syndromes."
supports: SUPPORT
evidence_source: OTHER
snippet: "Phenotypes of NNS patients are periodic fever, pernio-like rash, nodular erythema-like eruptions, and lipomuscular dystrophy, especially in the upper body, leading to the characteristic long, clubbed fingers."
explanation: The same review abstract supports pernio-like acral skin inflammation as part of the PRAAS phenotype spectrum.
- name: Lipodystrophy
category: Metabolic
description: >
Progressive lipodystrophy is one of the most distinctive shared features
across CANDLE, NNS, and JMP presentations.
phenotype_term:
preferred_term: lipodystrophy
term:
id: HP:0009125
label: Lipodystrophy
evidence:
- reference: PMID:31046790
reference_title: "Disease course and treatment effects of a JAK inhibitor in a patient with CANDLE syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Clinical manifestations include presentation in the first year of life, episodes of fever accompanied by erythematous skin lesions, progressive lipodystrophy, violaceous periorbital swelling and failure to thrive."
explanation: Case-report abstract confirms progressive lipodystrophy as a key CANDLE manifestation within PRAAS.
- reference: PMID:21129723
reference_title: "PSMB8 encoding the β5i proteasome subunit is mutated in joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "We performed homozygosity mapping in two recently reported pedigrees from Portugal and Mexico with an autosomal-recessive autoinflammatory syndrome characterized by joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy (JMP)."
explanation: Discovery study supports lipodystrophy as a defining feature in the JMP presentation of the PRAAS spectrum.
- name: Panniculitis
category: Dermatologic
description: >
Lobular panniculitis is part of the inflammatory skin and adipose-tissue
phenotype in PRAAS, especially in JMP/CANDLE presentations.
phenotype_term:
preferred_term: panniculitis
term:
id: HP:0012490
label: Panniculitis
evidence:
- reference: PMID:21129723
reference_title: "PSMB8 encoding the β5i proteasome subunit is mutated in joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "We performed homozygosity mapping in two recently reported pedigrees from Portugal and Mexico with an autosomal-recessive autoinflammatory syndrome characterized by joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy (JMP)."
explanation: JMP discovery abstract directly supports panniculitis-associated adipose inflammation in PSMB8-related PRAAS.
- name: Joint contracture
category: Musculoskeletal
description: >
Progressive fixed joint limitation is a recurrent disabling musculoskeletal
manifestation across the PRAAS spectrum.
phenotype_term:
preferred_term: joint contracture
term:
id: HP:0034392
label: Joint contracture
evidence:
- reference: PMID:21129723
reference_title: "PSMB8 encoding the β5i proteasome subunit is mutated in joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "We performed homozygosity mapping in two recently reported pedigrees from Portugal and Mexico with an autosomal-recessive autoinflammatory syndrome characterized by joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy (JMP)."
explanation: The JMP discovery abstract directly anchors joint contracture as a core spectrum phenotype.
- name: Skeletal muscle atrophy
category: Musculoskeletal
description: >
Progressive muscular wasting is a recognized phenotype at the
Nakajo-Nishimura/JMP end of the PRAAS spectrum.
phenotype_term:
preferred_term: skeletal muscle atrophy
term:
id: HP:0003202
label: Skeletal muscle atrophy
evidence:
- reference: PMID:21129723
reference_title: "PSMB8 encoding the β5i proteasome subunit is mutated in joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "We performed homozygosity mapping in two recently reported pedigrees from Portugal and Mexico with an autosomal-recessive autoinflammatory syndrome characterized by joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy (JMP)."
explanation: Supports muscle atrophy as a defining feature of a canonical PSMB8-related PRAAS presentation.
- name: Microcytic anemia
category: Hematologic
description: >
Chronic microcytic anemia is part of the systemic inflammatory phenotype in
the JMP/PRAAS presentation.
phenotype_term:
preferred_term: microcytic anemia
term:
id: HP:0001935
label: Microcytic anemia
evidence:
- reference: PMID:21129723
reference_title: "PSMB8 encoding the β5i proteasome subunit is mutated in joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "We performed homozygosity mapping in two recently reported pedigrees from Portugal and Mexico with an autosomal-recessive autoinflammatory syndrome characterized by joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced lipodystrophy (JMP)."
explanation: Discovery study supports chronic microcytic anemia as a characteristic hematologic feature within PRAAS.
treatments:
- name: Baricitinib therapy
description: >
JAK1/2 inhibition with baricitinib can suppress interferon-driven disease
activity in PRAAS, but dose reductions may precipitate rebound flares.
treatment_term:
preferred_term: targeted therapy
term:
id: NCIT:C93352
label: Targeted Therapy
therapeutic_agent:
- preferred_term: baricitinib
term:
id: CHEBI:95341
label: baricitinib
evidence:
- reference: PMID:38653530
reference_title: "Disease flares with baricitinib dose reductions and development of flare criteria in patients with CANDLE/PRAAS."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Patients with chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature/proteasome-associated autoinflammatory syndrome (CANDLE/PRAAS) respond to the janus kinase inhibitor 1/2 inhibition with baricitinib at exposures higher than in rheumatoid arthritis."
explanation: PRAAS-specific cohort data support baricitinib as an effective mechanism-based therapy and show its exposure-response dependence.
- reference: PMID:31046790
reference_title: "Disease course and treatment effects of a JAK inhibitor in a patient with CANDLE syndrome."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "We have treated the patient with the JAK inhibitor baricitinib for the past year and we observed a significant amelioration of his inflammatory episodes, skin and joint manifestations, and improvements in physical activities and growth."
explanation: Independent case evidence supports clinically meaningful baricitinib benefit in CANDLE/PRAAS.
- name: Anifrolumab therapy
description: >
IFNAR1 blockade with anifrolumab is an emerging treatment option for type I
interferonopathies and has early supportive evidence in CANDLE/PRAAS.
treatment_term:
preferred_term: Pharmacotherapy
term:
id: NCIT:C15986
label: Pharmacotherapy
therapeutic_agent:
- preferred_term: anifrolumab
term:
id: NCIT:C166658
label: Anifrolumab
evidence:
- reference: PMID:39441221
reference_title: "Normalized Interferon Signatures and Clinical Improvements by IFNAR1 Blocking Antibody (Anifrolumab) in Patients with Type I Interferonopathies."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Here we show in four patients with SAVI and one patient with CANDLE syndrome that blockade of the IFNAR1 receptor (Anifrolumab) exerts an additive effect over JAK-inhibitor alone."
explanation: The case-series abstract directly includes one CANDLE patient and supports IFNAR1 blockade as a rational add-on strategy.
- reference: PMID:39441221
reference_title: "Normalized Interferon Signatures and Clinical Improvements by IFNAR1 Blocking Antibody (Anifrolumab) in Patients with Type I Interferonopathies."
supports: SUPPORT
evidence_source: HUMAN_CLINICAL
snippet: "Anifrolumab normalizes IFN-I signature genes and relieves symptoms beyond what is typically achieved by a JAK-inhibitor (Baricitinib) alone in patients with type-I interferonopathies."
explanation: Supports the specific therapeutic rationale of directly suppressing IFN-I signaling in interferonopathy-spectrum disease.
This report is retrieval-only and is generated directly from Asta results.
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