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Assigning pathogenicity to novel variants in <jats:italic>FOXP3<\/jats:italic> is challenging due to the heterogeneous phenotype and variable immunological abnormalities. The number of cells with demethylation at the Treg cell-specific demethylated region (TSDR) is an independent biomarker of IPEX. We aimed to investigate if diagnosing IPEX at presentation with isolated diabetes could allow for effective monitoring of disease progression and assess whether TSDR analysis can aid <jats:italic>FOXP3<\/jats:italic> variant classification and predict disease course. We describe a large genetically diagnosed IPEX cohort (<jats:italic>n<\/jats:italic>\u2009=\u200965) and 13 individuals with other monogenic autoimmunity subtypes in whom we quantified the proportion of cells with FOXP3 TSDR demethylation, normalized to the number with CD4 demethylation (%TSDR\/CD4) and compare them to 29 unaffected controls. IPEX patients presenting with isolated diabetes (50\/65, 77%) often later developed enteropathy (20\/50, 40%) with a median interval of 23.5\u00a0weeks. %TSDR\/CD4 was a good discriminator of IPEX vs. unaffected controls (ROC-AUC 0.81, median 13.6% vs. 8.5%, <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.0001) with higher levels of demethylation associated with more severe disease. Patients with other monogenic autoimmunity had a similar %TSDR\/CD4 to controls (median 8.7%, <jats:italic>p<\/jats:italic>\u2009=\u20091.0). Identifying increased %TSDR\/CD4 in patients with novel <jats:italic>FOXP3<\/jats:italic> mutations presenting with isolated diabetes facilitates diagnosis and could offer an opportunity to monitor patients and begin immune modulatory treatment before onset of severe enteropathy.<\/jats:p>","DOI":"10.1007\/s10875-022-01428-w","type":"journal-article","created":{"date-parts":[[2023,1,5]],"date-time":"2023-01-05T02:02:33Z","timestamp":1672884153000},"page":"662-669","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["FOXP3 TSDR Measurement Could Assist Variant Classification and Diagnosis of IPEX Syndrome"],"prefix":"10.1007","volume":"43","author":[{"given":"Rebecca C.","family":"Wyatt","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sven","family":"Olek","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elisa","family":"De Franco","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bjoern","family":"Samans","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kashyap","family":"Patel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jayne","family":"Houghton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steffi","family":"Walter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janika","family":"Schulze","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosa","family":"Bacchetta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew T.","family":"Hattersley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah E.","family":"Flanagan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6519-6687","authenticated-orcid":false,"given":"Matthew B.","family":"Johnson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,1,5]]},"reference":[{"key":"1428_CR1","doi-asserted-by":"publisher","unstructured":"Barzaghi F, Passerini L, Bacchetta R (2012) Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome: a paradigm of immunodeficiency with autoimmunity. 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Ethical approval was provided by the North Wales Research Ethics Committee, UK (IRAS project ID 231760).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics Approval"}},{"value":"All study participants gave informed consent, or assent was obtained where children were too young, and parental consent was provided, in accordance with the declaration of Helsinki.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to Participate"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for Publication"}},{"value":"Sven Olek has equity interest in Precision for Medicine, the owner of the epigenetic markers used in this study. No other authors have any competing interest.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of Interest"}}]}}