ISG15 gene. It is inherited with an autosomal recessive pattern and is classified as a primary immunodeficiency or inborn error of immunity. Patients present in childhood with infectious, neurologic or dermatologic features. Basal ganglia calcification is observed in all patients reported to date and represents the underlying autoinflammatory disease of excessive IFN-I activity, known as type I interferonopathy. The basal ganglia calcifications may cause epileptic seizures but often are asymptomatic. The IFN-I inflammation may also manifest early in life as ulcerative skin lesions in the armpit, groin and neck regions. Finally, ISG15-deficiency leads to mendelian susceptibility to mycobacterial disease, although with incomplete penetrance. These infections present as fistulizing lymphadenopathies and respiratory symptoms following BCG vaccination. In pancreatic ductal adenocarcinoma, tumor-associated macrophages secrete ISG15 enhancing the phenotype of cancer stem cells in the tumor. History ISG15 was originally identified in the late 1970s as a 15-kDa protein produced in response to type I interferon, a potent class of antiviral cytokines. Given the molecular weight, it was originally termed ‘a 15-kDa protein’, but later renamed interferon-stimulated-gene-15 when the cassette of interferon-stimulated genes were recognized. In 1987 it was identified that ISG15 cross-reacts with anti-ubiquitin antibodies, and subsequent experiments uncovered the ubiquitin-like conjugation of ISG15 to other cellular proteins, coined ‘ISGylation’. Given its inducibility by IFN-I, studies in the following decades focused on the antiviral activity of ISG15. These studies were carried out predominantly with in vitro systems and mouse models, and ascribed several antiviral functions to ISGylation. During this time, it was also discovered that ISG15 could be detected outside of cells. and in human serum samples. This free form of ISG15 could stimulate IFN-II production in lymphocytes. Finally, ISG15 could also be detected as an un-conjugated intracellular molecule with functions independent of ISGylation. The discovery of humans deficient in ISG15 elucidated the importance of these functions in human biology. ISG15-deficient patients were first identified by their susceptibly to BCG-strain mycobacteria, owing to the essential function of free ISG15 to potentiate the IFN-gamma / Interleukin-12 axis Surprisingly, despite the IFN-inducible nature of ISG15 and the previously-ascribed antiviral functions in mice, ISG15-deficient patients showed no susceptibility to viral infections. In fact, follow-up studies uncovered enhanced type I IFN signatures, manifesting as basal ganglia calcifications akin to TORCH infection but without an infectious etiology. This persistent, low-level inflammation was later shown to confer enhanced resistance to a wide array of viruses. This phenotype results