Chronic Granulomatous Disease (CGD) is a well – known form of Primary Immune Deficiency Disorders (PIDD) where the neutrophils fails to perform intracellular killing of the organisms. These patients are highly susceptible to infections due to catalase +ve bacteria, Mycobacteria and fungal infection and Autoimmunity. They develop cutaneous as well as deep seated infections. CGD usually diagnosed by performing NBT test or more accurate OXIDATIVE BURST and we need genetic testing rarely. CGD is due to mutation in the different components:
Although Rare types of CGD might be associated with Normal Oxidative burst. In this case high clinical suspension should be confirmed by molecular genetic testing.
This is a case series report, the Index case was a 12 years old brother who has recurrent infections and Autoimmunity diagnosed by PID panel requested after the diagnosis of CGD
PID panel sent for the rest of the family members found in another 2 siblings a boy and a girl.
Oxidative burst was either normal or near normal in this family.
The PID panel showed the following mutation:
Variant: NCF4:NM_000631:exon5:c.407C>A:p.S136X -- (HOMOZYGOUS)
Strikingly that this family with CGD due to mutation in the P40 component of NADPH.
High clinical suspicion of Primary immune deficiency should warrant molecular genetic testing especially when routine immunological workup fail short to help in the diagnosis and thus treatment. Here we report a rare form of CGD were the gold standard test for diagnosis is oxidative burst was Normal or near normal.
The emerging of Next-Generation Sequencing (NGS) technologies has facilitated genetic diagnosis of PID patients. Nevertheless the underlying genetic cause is only identified in 5-15% of PID patients. Currently genetic workup consists of targeted sequencing and/or whole exome sequencing (WES) at the gDNA level, which fails to detect large deletions, deep-intronic mutations, or changes in gene expression. Therefore, the aim of this project is to reveal genetic alterations missed at the gDNA level.
cDNA and targeted RNA sequencing will be performed in patients with only one-disease related variant identified by WES or targeted analysis of known PID genes with recessive inheritance. For this study we selected patients with a clear PID phenotype based on symptoms and immunologic work-up in whom only 1 defect allele was detected in a relevant candidate gene based on pathway analysis.
In first instance we have optimised long-range PCRs to analyse the complete coding region of the relevant genes at the cDNA level. cDNA sequencing evaluating biallelic expression levels and/or aberrant transcripts in the patients has now been started. In parallel we will evaluate an NGS-based approach capturing all genes of interest to evaluate their expression.
NGS technologies enhanced the number of disease-related PID genes but final genetic confirmation of a PID diagnosis remains challenging. Identification of the underlying genetic defect is of utmost importance for risk stratification, improved therapeutic management strategies and genetic counselling. We believe that the implementation of RNA sequencing technologies in the workup of PID patients will improve diagnosis and management.
Late onset combined immune deficiency (LOCID) is recently described in patients with previous infection indicative of a severe defect in cell-mediated immunity and/or low CD4+ cell counts. This disease can occur at any age and it is extremely heterogeneous. Authors present here two new observations.
We describe the diagnosis of LOCID in two patients followed in the pediatric immune-hematology unit.
Case1: A 59-year-old woman with a history of B lymphoma diagnosed after two episodes of deep vein thrombosis and lower respiratory tract infections leading to bronchiectasis and postinfectious obliterating bronchopathy. The diagnosis of LOCID was retained in front of hypogammaglobulinemia (IgG=0.17g/L, IgA=0.02g/L , IgM=0.1g/L), B-lymphocytes at 1% and criteria of profound T cell deficiency (Lymphocytes=1000/mm3, CD4+ at 15.5% and CD4 naive at 4%).
Case2: A 22-year-old girl, from non-consanguineous parents, with family history of early death. In her past medical history, the patient had celiac disease with Evans syndrome at 12 years old. LOCID was suspected in front of the association of infectious episodes: oral candidiasis, recurrent upper and lower respiratory tract infections with bronchiectasis, hemi-corporal zona with severe retinal zoster and splenomegaly. Immunity exploration found hypogammaglobulinemia (IgG=3.4g/L, IgA=0.15g/L, IgM=0.2g/L) and 1%B lymphocyte count, decreased switched memory B cells , CD4+ at 25% (440/mm3).
Both patients responded to polyvalent immunoglobulin and anti-infectious prophylaxis (1 and 6 years follow-up, respectively) without evidence of immune reconstitution.
LOCID is still underdiagnosed. The main differential diagnosis is common variable immunodeficiency(CIVD). Systematic T cell phenotype may help to discriminate such patients from those with CVID.
Netherton syndrome is an inherited, autosomal recessive skin disease characterized by ichthyotic erythroderma, characteristic hair anomaly (trichorrhexia invaginata), growth retardation and atopic manifestations. Authors will describe the clinical characteristics and diagnosis of Netherton syndrome.
In this report, we present 4 cases of Netherton syndrome (2 girls and 2 boys) who were consulted at an average age of 22 months for the extent of erythroderma and infectious events. The diagnosis of Netherton Syndrome was established by immunohistochemistry.
Consanguinity was found in one case. The average beginning age of symptoms was 14 months with non-blistered pruritic erythroderma (n=4), itchy skin (n=4), growth retardation (n=2), recurrent ear infection (n=1), bamboo hair (n=1), signs of atopy (n=2) and sepsis (n=1). The IgE level is high in two cases (sex ratio=0.5). The clinical differential diagnosis essentially included Ommen syndrome and Netherton syndrome. Immunohistochemistry showed a LEKTI deficiency that confirmed the diagnosis of Netherton syndrome.
In all cases, therapeutic support was based on the treatment of infectious events and symptomatic skin treatment with emollients and antihistamines. Three children died and the other was lost sight of.
Netherton syndrome is a very rare severe immune deficiency with erythroderma and recurrent infections. Immunohistochemistry of LEKTI protein allows a fast diagnosis.
Selective IgM deficiency (IGMD) is defined as serum IgM levels below 2 SD of mean with normal serum IgG and IgA. IGMD can be associated with severe and/or recurrent infections, atopy and autoimmunity.
Objective: to describe the clinical and biological aspects of IGMD.
This is a retrospective study over a 14-year period (2005 to 2019) including patients with selective IGMD followed within the National Center of Bone-Marrow Transplant of Tunisia.
Eight patients were enrolled ( 4 males and 4 females). Consanguinity was found in five cases. Median age at diagnosis was 66 months (3 months, 14 years). Revealing signs were mostly infectious in six cases: bronchopulmonary infectious (n=6), upper and lower respiratory tract infections (n=4), skin infection with pseudomonas aeroginosa affecting the vulva and inguinal region (echthyma gangrenosum) (n=1). Tow patients had both infections and atopy. Other symptoms infections were hypotrophy (n=3) and hepatosplenomenomegaly (n=1). The two other cases presented isolated autoimmune manifestations: the first developed autoimmune haemolytic anemia and the second had an Evans syndrome.
The mean serum IgM level was 0,33 g/l (range 0,23-0,47). Mean serum levels of other immunoglobulins and IgG subclasses were normal. Lymphocytes immunophenotyping and lymphoblastic proliferation assays were normal.
Selective IgM deficiency is a rare type of Predominantly antibody deficiencies. It was characterized by isolated low levels of serum IgM. The clinical spectrum is broad, essentially associating infectious and autoimmune manifestations
Griscelli syndrome (GS) is a rare autosomal recessive disorder resulting in pigmentary dilution of the skin and hair with variable phenotypes depending upon genetic types. GS subtype 2 commonly develops hemophagocytic lymphohistiocytosis besides immunodeficiency.
A 14-year-old patient has been followed at the outpatient clinic of infectious diseases by recurrent visceral leishmaniasis and he was evaluated by the primary immunodeficiency outpatient service for suspicion of Griscelli syndrome due to silvery brows and hemophagocytosis.
Later on, he was diagnosed with high-grade diffuse large B-cell lymphoma (DLBCL) rich in T cells, with high proliferative index.
Laboratory testing showed mild pancytopenia (hemoglobin level: 9,9 g/dl; Ht: 31,4% WBC: 7,320/mm3, neutrophils: 700/mm³ - 9,6%, lymphocytes: 700/mm³ - 80,3%; Platelet count: 99,000/mm³; Albumin: 3.0 g/dL, Lactate dehydrogenase (LDH): 392 U/L/ triglycerides: 194 mg/dL, ferritin: 721,8 ng/mL.
Coagulogram showed increased prothrombin time (17.6 seconds, decreased prothrombin activity 59%, INR 1,44%), increased activated partial thromboplastin time (42,7 seconds, R=1.26). Liver profile, hepatitis and HIV serologies were negative.
Immunophenotyping by flow cytometry revealed decreased NK counts (0,80% - 26 cells/mm³). Myelogram showed hypocellularity (granulocytes 24%) and maturation delay in promyelocytes and neutrophil myelocytes.
Genomic sequencing (NGS) for familial hemophagocytosis demonstrated a compound heterozygous mutation of RAB27A and uniallelic mutation of UNC13D.
Conclusion: This report presents the first report of leishmaniasis inducing hemophagocytosis in a GS2 patient, subsequently affected by a DLBCL. This patient is nowadays waiting for an allogeneic bone marrow transplantation.
Immediate STAT5A phosphorylation (pSTAT5A) upon T cell receptor stimulation is critical event in T cells proliferation. Here we present a simple and sensitive flow cytometric – based assay to assess T cell proliferation. Given the critical role STAT5A phosphorylation in T cell proliferation, we decided to investigate a phosphorylation of STAT5A as an indicator of T cell proliferation.
We determined pSTAT5A in T cell from 19 adult healthy donors stimulated with either CD3/CD28 or PHA.
After stimulation, T cells displayed a strong long-lasting phosphorylation of STAT5A, reaching a peak value after 24 hours. The median fluorescence intensity (MFI) of pSTAT5A increased from 112 ± 17 to 512 ± 278 (CD3/CD28) (24 h) and to 413 ± 123 (PHA) (24 h), the IL-2 receptor-α (CD25) expression was greatly enhanced and after 72 h T cell proliferation amounted to 52.3 ± 10.3 % (CD3/CD28) and to 48.4 ± 9.7 % (PHA). Treatment with specific STAT5 and JAK3 inhibitors resulted in a complete blockage of phosphorylation of STAT5A, CD25 expression, and suppression of T cell proliferation.
Compared with currently available methods, pSTAT5A is well suited to predict T cell proliferation. Moreover, due to its simplicity and robustness, the flow cytometric based pSTAT5 assay is especially appropriate to rapidly assess primary immune deficiencies (PIDs) associated with STAT5 defects including autoimmune diseases, CD25 deficiency and T cells proliferation defects.
Male 8 months of age, consaguineous parents, two brothers died at an early age, one brother stillborn and two maternal uncles died before 10 months due to infectious diseases. Healthy brother of 15 years. Product of fifth pregnancy without perinatal complications, birth weight 3325 grams, size 51cms. Without immunizations. By family history at month of age, subpopulations of lymphocytes and immunoglobulins are requested. Rx with absence of thymic silhouette. No positive data on physical examination. Receives prophylactic treatment and IgGIV. With a clinical evolution of a single episode of diarrhea at 3 months of age resolved in 24 hours. Growth and development appropriate for age (p50). Without infectious diseases.
To present a case of a new mutation of gen IL-2RG in a Mexican patient with X- Linked severe combined immunodeficiency
Evaluation family history of patient was a fundamental tool for the suspicion of an immunodeficiency.
The mutation IL2RG NM_000206 c.667G> T, p.V223F was reported
The use of the family history of the patient was a fundamental tool for the suspicion of an immunodeficiency, the prenatal diagnosis of mutations of men at risk and the subsequent genetic counseling of the parents are essential for an opportune treatment.
The patient was not a candidate at (HSCT) and at 6 months of age he was sent to St. Jude Hospital to correct the genetic defect with genetic therapy. Systemic adenovirus infection was diagnosed and died at 8 months of age, with only one dose of gene therapy administered.
Inborn errors of immunity (IEI) represent a wide spectrum of primary immunodeficiencies (PID) and immune dysregulatory diseases, often with underlying genetic causes. PID genetic panels permit better characterization of a patient’s underlying immune abnormality, potentially leading to improved treatment. We analyzed the demographics of patients undergoing genetic testing, how successfully genetic causes for IEI were identified, and whether a genetic diagnosis changed patient treatment and care.
We categorized patients into phenotypes based on clinical presentation and supporting non-molecular laboratory tests, then assessed whether treatment/care changed after genetic testing via next generation sequencing of PID gene panels.
From 2013-2018, 105 complex patients (80% of whom were followed by multidisciplinary teams) received immunologic genetic testing, while having the following clinical phenotypes based on IUIS categories: Immune Dysregulation (27%); Predominantly Antibody Deficiencies (24%), Autoinflammatory (13%); Combined Immunodeficiency (14%); Complement Deficiency (2%); Phagocyte Deficiency (3%), and uncategorized (16%). 8% of the patients had various malignancies. Potential genetic abnormalities (predicted disease-causing variant related to clinical phenotype) were detected in 44/105 (42%) patients; 22 of these (21% of all patients) received a molecular diagnosis. Clinical diagnosis changed for 15/22 patients diagnosed molecularly and for 2/20 patients with a variant of unknown significance (VoUS). Altogether, 29 patients underwent management changes, and 11/42 patients with significant molecular findings underwent further functional testing of their immune system.
Genetic panel testing, a continually evolving diagnostic tool, provided valuable, treatment-guiding information for 25% of the immunologically complex patients in this cohort. VoUS, especially if consistent with clinical phenotype, remain clinical challenges.
Chronic mucocutaneous candidiasis (CMC) is a heterogenous group of primary immunodeficiency diseases characterized by chronic and recurrent Candida infections primarily involving the nails, skin and mucous membranes. Impaired IL-17 T-cell immunity is known to be one of the mechanisms of this disease, as Th17 cells and their effector cytokines IL-17 and IL-22 have critical functions for candidial host defense via epithelial cells. Gain-of-function (GOF) mutations in the human signal transducer and activator of transcription 1 (STAT1) gene cause an impaired Th17 cell production and can cause CMC.
A two-year-old girl presented to our hospital at the age of 1,5 years with failure to thrive, recurrent bacterial respiratory tract infections, diarrhea and recurrent oral thrush, not responding well to local treatment. Oral mucosa swab repeatedly showed Candida albicans. She was born as the second child of healthy, non-consanguineous parents of Serbian origin. Initial immunological screening revealed a normal white blood cell count and normal serum immunoglobulines. Response to vaccination with Pneumovax 23 was normal. Further workup showed normal T cells with low Th17 cell counts (0,08% of CD4 T cells) and impaired T cell function. Subsequently a genetic workup was performed which showed a GOF mutation in the STAT1 gene. This mutation is reported to be pathogenic for CMC.
Recurrent oral Candidiasis after the age of one year is an alarm sign and indicative for immunodeficiency disorders such as CMC. It is important to perform an immunological workup including genetic testing for the involved genes in such cases.
We report a 21-year-old patient who has no history of consanguinity, immunodeficiency, miscarriages or infant deaths in the family. At the age of five, he was diagnosed with combined immunodeficiency, and since then he has suffered from multiple conditions including recurrent and chronic severe respiratory and GIT infections, vitiligo, autoimmune polyendocrinopathy, and surrenalian failure. IgG, IgA and IgM hypogammaglobulinemia and CD3+, CD19+ and CD16+CD56+ lymphopenia have been detected in the patient. Patient shows signs of severe malnutrition (27 kg, 1.45 m) caused by chronic recurrent Campylobacter diarrhoea which relapses despite antibiotic therapy and gut microbiota transplantation.
NGS panel targeted at primary immunodeficiency related genes was used to examine the patient DNA sample
We detected two missense variants in RAG1 gene in trans configuration. Variant p.His612Arg has been previously reported in milder phenotypes of combined immunodeficiency and it shows only reduced amount of the protein RAG1 with at least partially retained VDJ recombination. The second variant p.Arg897Gln has not been described yet, however, it has not been found in population databases, and computation prediction tools evaluated the variant as pathogenic. As a nonsense variant in the same amino acid position has been described in cases of SCID, we suggested this missense variant might be connected with a milder phenotype that we observed in our patient.
In conclusion, we detected two hypomorphic missense mutations in RAG1 in a patient suffering from CID, severe recurrent diarrhoea and failure to thrive.
H.G. and A.C. contributed equally.
Supported by: AZV NV16-34414A
Papillon–Lefèvre syndrome (PLS) is an infrequent autosomal recessive inherited disorder characterized by palmoplantar hyperkeratosis, frequent cutaneous and systemic pyogenic infections, susceptibility to bacterial infections, intracranial calcifications, and mental retardation and destructive periodontitis beginning in childhood, premature loss of permanent teeth, caused by mutations in cathepsin C (CTSC) gene.
Here, we described six cases with Papillon-Lefevre Syndrome.
Genetic analysis revealed mutations in cathepsin C (CTSC) gene the patients.
Patient 1: A 13-year-old female patient referred with liver abscess who was admitted abdominal pain and fever. She has had recurrent skin abscess, palmoplantar hyperkeratosis. Her 22-year-old sister had destructive periodontitis and she had palmoplantar hyperkeratosis.
Patient 2: A 10-year-old female patient had onychomycosis on feed nails that referred from dentist followed destructive periodontitis. Her 9-year-old brother had palmoplantar hyperkeratosis, premature loss and severe inflamation of teeth.
Patient 3: A 12-year-old female patient referred with recurrent nasal polyposis that was treated to asthma. She had palmoplantar hyperkeratosis in her examination and her sister also had hyperkeratosis.
Generally, these patients were referred to dentistry for dental complaints, but when they were ascertained about their history that was observed recurrent and resistant infections. Consequently like these our cases, patients with severe periodontitis should also be evaluated with immunological parameters.
Mutations of recombination activating gene (RAG) 1/2 in humans are associated with a distinct and broad clinical phenotypes reach from severe combined immunodeficiency (SCID) to Omenn syndrome or a combined immunodeficiency with autoimmunity. To define clinical heterogeneity of RAG2 G35A mutation, in families of different origin.
A next-generation sequencing of 200 genes associated with primary immunodeficiency identified RAG2 G35A mutation.
We present three patients with RAG2 G35A mutation in two distinct families. Two years old male of Arab origin with homozygous mutation was diagnosed as T-B-NK+ SCID. His male sibling with heterozygous mutation was diagnosed as a leaky SCID and they are doing well with regular IVIG therapy. The third patient with a leaky SCID phenotype was Turkish and died because of severe hemophagocytic syndrome.
Clinical heterogeneity of these three patients and also their parents with the same RAG mutation was striking. Clinical heterogeneity of any specific mutation of RAG2 should be related to the environmental factors.
NFKB2 mutation defined as common variable immunodeficiency type 10. Our aim is to draw attention to NFKB2 mutation could be a combined immunodeficiency.
A next-generation sequencing of 200 genes associated with primary immunodeficiency identified a heterozygous mutation NFKB2.
The patient is 13-year-old female who presented cough, recurrent infections at 6-year-old. In her medical history, she had recurrent respiratory tract infections and failure to thrive since 1-year-old, her all nails were atrophic and breaking since 3-year-old. Her hairs were totally loss, and she had psoriasiform eruptions, possibly due to severe autoimmunity. Hypoglycemia was detected when the patient was admitted with seizures, at the age of 10-year-old. Endocrinological evaluation revealed a central hypothyroidism. Her mother died due to T cell lymphoma. She had recurrent respiratory tract infections and bronchiectasis in her history.
This case and her mother suggest that NFKB2 mutations should be accepted as combined immunodeficiency.
Recently, the 23-valent IgG-assay was suggested as screenings assay to identify poor responders to pneumococcal polysaccharide (PnPS)-vaccination with the serotype-specific assay as a second-line test. However, in a low pre-test-probability general hospital setting predicting good responders could be more valuable to reduce the number of samples needing serotyping.
Serotype-specific PnPS antibody-assays were performed for suspected immunodeficiency in two Dutch general hospitals (Jeroen Bosch Hospital, ‘s-Hertogenbosch; Elisabeth Tweesteden Hospital, Tilburg). 23-valent PnPS antibody-assays were subsequently performed in archived material. Data were analysed using receiver operating characteristic curves (AUC) and agreement indices (ICC).
Sera of 284 patients (348 samples) were included; 23-valent IgG-titres and the corresponding sum of PnPS-serotype specific antibodies showed moderate correlation (ICC=0.63). In 232 conjugated-pneumococcal-vaccine-naïve patients (270 samples), a (random) 23-valent IgG-titre could discriminate between samples with and without ≥7/11, ≥7/13 or ≥6/9 pneumococcal serotypes when both cut-off values 0.35 and 1.0 μg/ml were used (AUC 0.86 and 0.92, respectively). All patients with a pre-immunisation-titre ≥38.2 μg/ml and post-immunisation-titre ≥96.1 μg/ml, while none with a post-immunisation-titre ≤38.5 μg/ml exhibited a good response to PnPS vaccination. Using these breakpoints as screening test to predict good responders, only 24% of patients would require further serotyping, opposed to 68% if this 23-valent IgG assay would have been used to predict poor responders.
In a low pre-test probability setting, the 23-valent IgG-assay proved to be a reliable screening test for good responders in conjugated-pneumococcal-vaccine-naïve patients, reducing the overall number of patient samples needing further serotyping, thus reducing overall costs of pneumococcal vaccination response assessment.
Autoimmune lymphoproliferative syndrome (ALPS) is a chronic non-malignant lymphoproliferative disorder caused by mutations in the genes involved in programmed cell death. It is inherited as an autosomal dominant pattern with variable penetrance. Here we present first Macedonian case of ALPS, caused by a novel heterozygous mutation in FAS gene.
Genetic analysis included a targeted resequencing in the proband on MiSeq personal sequencer using Illumina TruSight One kit. Direct DNA sequencing of FASexon 9 was performed for the proband, her parents and her grandparents.
Here, we report a 14 months old Macedonian girl whowas referred to our departmentfor the examination of hepatosplenomegaly. Family history provided data forsplenomegaly and subsequent splenectomy in patients’ mother at the age of 17, as well as suspicion of spherocytosis. Genetic analysis showed no pathogenic variants in the genes associated with spherocytosis. However, a novel pathogenicvariant c.913dupA, p.Thr305AsnfsTer16 in exon 9 of FASgene was revealed. The same mutation was present in the patient’s mother, but not in her parents (proband’s grandparents). Thus, the pathogenic FASvariant has arisen as a de novoevent in the proband’s mother. Additional clinical and laboratory investigations confirmed the presence of specific biomarkers for ALPS.
A first-line NGS analysis allows identification of genetic defect and initiation of appropriate clinical examinations to promptly reach the clinical diagnosis in patients with rare diseases. Reverse phenotyping in our case provided prompt and accurate diagnosis and early initiation of specific therapy.
Our study was carried out with 1cc peripheral blood samples taken from premature babies born in the 35-38 week range. The patient group consisted of 32 patients who were followed up at the Erciyes University Ophthalmology Department's retinopathy of prematurity (ROP).
Immature monocyte cells and endothelial stem cells were characterized by flow cytometry. The following markers CD34+, CD31+, CD133+, CD116+, CD144+, CD146+, CD309+ cell surface expression levels were measured
It was found that CD146, CD309, CD133 markers whose surface receptor expression levels were expressed at a higher level in the patient group than in the control group. In addition, the expression levels of these markers were determined on the day of diagnosis and 15 days after diagnosis. The level of expression at the time of diagnosis was higher than the level of measurement after diagnosis and treatment. Decreased surface receptor expression levels were observed after treatment.
It was found that CD146, CD309, CD133 markers on monocytes were useful marker for the clinical follow up of ROP patients.
The design of specific next generation sequencing panels has allowed to diagnose patients with a specific phenotype a timely and cost-efficient manner. Chronic mucocutaneous candidiasis (CMC) has been described as part of the spectrum of patients with primary immunodeficiencies (PID). Here we report our experience with a specific gene panel applied to paediatric and adult patients with CMC in our setting.
NGS was performed using an AmpliSeq strategy on an Ion Torrent PGM platform. The panel included six genes related to CMC (STAT1, TRAF3IP2, CARD9, IL17F, IL17RA e IL17RC).
Eleven patients were included in this study and one paediatric patient was found to have a compound heterozygous mutation in TRAF3IP2. This patient is a 6 year old girl born to non-consanguineous healthy parents. CMC appeared in the first year of life and has been controlled since then with intermittent treatment with fluconazole. She did not suffer from any other infections or autoimmune diseases.
The mutations have not been previously reported. Whilst one is a nucleotide deletion (c.1335delA) resulting in a stop codon (p.Lys445fs*11) the second mutation (c.1325A>G) leads which a different amino acid (Asp442Gly) and is, following the used theoretic algorithms, pathogenic. The patient showed increased IL17 levels after stimulation with PMA and Ionomycin.
By using a specifically designed NGS panel we were able to identify a patient with ACT1 deficiency an extremely rare PID. Although further functional testing, the presence of CMC suggests the pathogenic effect of these mutations
Interleukin-12 receptor β1 (IL-12Rβ1) deficiency is a recessive defect predisposing to infections mainly with Salmonella and mycobacteria with a mortality around 30%. IL-12Rβ1 accounts for about half of all cases of Mendelian susceptibility to mycobacterial disease reported worldwide. We identified 10 patients. The United States has a low consanguinity rate, low tuberculosis rate and BCG vaccination, all factors that might affect clinical presentation
Serie of cases
c.512A>C, p.Q171P c.1442A>G, p.Y481C
Died (10 years)
c.512A>C, p.Q171P c.1442A>G, p.Y481C
Alive (50 years)
Died (42 years)
Alive( 9 years)
Alive (17 years)
Alive (24 years)
c.1623_1624delGCinsTT p Q542X
Alive (25 years)
Alive (21years)Infection resolved
* Clin Infect Dis. 2011 Feb 15;52(4)
** J Allergy Clin Immunol. 2010 Jan;125(1):264-5
4I & 4II ; 8I & 8II siblings
In the United States IL-12Rβ1 deficiency is associated with disseminated infections including unusual organisms. US IL-12Rβ1 deficiency is likely underrecognized in part because of presentations with infections other than mycobacteria.
Severe combined immunodeficiency (SCID) disorders may be detected, in newborn screening programs, using quantitative PCR assays to measure T-cell receptor excision circles (TRECs), a byproduct of correct T-cell development. However, in addition to SCID patients, other T-cell deficient phenotypes such as 22q11.2 deletion syndrome (DS), 22q11.2 duplication syndrome, CHARGE syndrome and trisomy 21 are being detected
We present our experience with the detection of 22q11.2 DS and duplication syndrome in a series of 103,971 newborns screened within the newborn screening program in Catalonia (Spain) since January 2017.
Nineteen positive cases were detected (low TRECs) and 5 cases turned out to be copy number variations (CNVs) of the 22q11 region when investigated with array CGH technology (four deletions and one duplication). 2 cases were diagnosed prenatally while the remaining 3 newborns were diagnosed postnatally due to persistent low TRECs levels and mild lymphopenia (not fulfilling SCID criteria) despite being asymptomatic.
Newborn screening for SCID allows the detection of other entities, such as 22q syndrome which unexpectedly should be included in a prompt proactive follow-up and an adequate management of information and expectations for the families by a multidisciplinary team
Patients with Primary Immunodeficiencies (PIDs) may suffer from increased susceptibility to infection, autoinflammation, autoimmunity, or lymphoproliferation. The broad range of clinical manifestations, the large number of known defects, and the complexity of diagnostic procedures complicate the accurate diagnosis of PIDs. We applied whole exome sequencing (WES) to detect mutations in patients with PID.
WES was performed on 369 individuals from 350 families with a high rate (>70% ) of consanguineous marriage. Analysis focused on >300 known or candidate PID genes. Candidate genes were further identified based on clinical data, family history, and immunophenotyping. Confirmation of WES findings was done by another method (Sanger sequencing, MLPA, Gene scan assay).
Disease-causing mutations were identified in 207 (59%) families, whereas no molecular explanation could be recognized in 143 (41%) families. In most of the cases (~80%) mutations were novel, and mainly found in DOCK8 (n=13), ATM (n=10), RAG1 (n=9), WAS (n=6), RAB27A (n=6), ADA (n=6), and IL12RB1 (n=6) genes. Mutations in other PID-causing genes such as JAK3, UNC13D, NCF1, LRBA, RAG2, RFXANK, HAX1, STK4 were found in ≤5 patients each. Novel mutations were found in 2 recently described genes (OTULIN & RASGRP1) and several novel candidate genes were identified. Follow-up segregation was done in >80% of the families.
WES is a cost-effective way to screen for known PID genes and a powerful tool to discover novel PID-causing genes. It allows for early and accurate diagnosis, thereby improving treatment decisions and the quality of life of PID patients.
Anhidrotic ectodermal dysplasia with immunodeficiency (EDA-ID) is rare disease which is characterized by hypohidrosis, dental abnormalities and immunodeficiency accompanying with non-infectious inflammatory disease. It is known to be caused by mutation of KIBKG and NFKBIA.
The medical record of EDA-ID patient was reviewed.
An 8-year-old girl was admitted because of fever. She presented with acute pyelonephritis by K. pneumoniae at two months of age and suffered from pneumonia by fungus, P. jirovecii and cytomegalovirus at her age of 5 months. She had took steroid since the age of 20 months under the diagnosis of juvenile idiopathic arthritis. At her age of 33 months she had open arthrotomy for osteomyelitis of elbow which was caused by M. tuberculosis. At the age of 6 years she was treated because of M. tuberculosis and nontuberculous mycobacteria (NTM) infection again. At the age of 7 years, she experienced disseminated zoster infection involving skin and brain, and non-infectious uveitis. In this time she suffered from septic shock by K. pneumoniae and pneumonia by NTM and candida. The levels of immunoglobulin G/A/M were normal but IgG2, IgG3 and IgG4 were low. While number of B cells was below 1%, proportions of class switched memory cells and naïve cells were normal. Genetic analysis for Mendelian susceptibility to mycobacterial diseases was failed but re-analysis for combined immune deficiency revealed NFKBIA mutation and she was diagnosed with EDA-ID.
We report the first case with autosomal dominant EDA-ID in Korea who suffered from serious recurrent infections by K. pneumoniae and NTM.
Reticular Dysgenesis (RD) is a rare autosomal recessive immunodeficiency, characterized by the combination of Severe-Combined-Immunodeficiency(SCID) with agranulocytosis and sensorineural deafness. Discovered in 2009, RD is caused by a mutation in the gene encoding adenylate-kinase-2(AK2). In this paper we describe a novel AK2 mutation in a newborn female presenting SCID and RD.
RH was born in January 2019 at 37+6 weeks from an apparently non-consanguineous family. She presented normal APGAR but low-birth-weight, severe leucopenia, hypoglycemia, and abnormal immunology tests (Table 1-2). She failed neonatal hearing test and in her 4th day of life, she was diagnosed with sepsis due to omphalitis.
A bone marrow aspirate was in keeping with severe congenital neutropenia (Table 3), whereas AK2 DNA-sequencing showed a homozygous mutation for the variant c.308G>C, causing a missense change p.(Arg103Pro) at the protein level with deleterious in silico predictions. The RD diagnosis was confirmed, and urgent bone-marrow transplantion has been undertaken.
RD accounts for <2% of all SCID cases, with an annual incidence estimated at 1/3,000,000-1/5,000,000, higher in consanguineous families [2,3]. Mutations in the AK2 gene, located on 1p35.1, are responsible for RD. Until now, AK2 mutations were found in 30 patients from 27 mainly consanguineous families . The variant described has not been reported in the literature and it is absent from the gnomAD population database, although the p.(Arg103Trp) variant has been reported.
The only effective treatment for RD is bone marrow transplant with an overall reported survival of about 68%.
Congenital abnormalities of genes related to the immune system cause variety of clinical symptoms, called inborn errors of immunity (IEI), and more than 300 causal genes have been identified. As a result of the advances in genetic analysis, wide varieties of clinical symptoms in each gene were recognized. Comprehensive genetic approaches, such as whole exome sequencing (WES), are becoming more important at clinical situation.
We performed WES for 141 patients, with their families in 84 cases, of IEI who were undiagnosed by conventional candidate gene sequencing. Patients’ age was between 0 and 56 y.o. (Median; 13 y.o.). Patients consisted of 50% of antibody deficiencies, 19% of immune dysregulation, 10% of combined immunodeficiencies, and other variable subcategories of IEI.
We identified IEI causative mutations of known genes in 23%, candidate mutations in 25%, and no candidates in 52% of the patients. Novel mutations were identified in several known genes, including ICOS, HOIL1, CARD11, and EXTL3, with typical clinical symptoms.
Diagnostic rate was higher in patients whose disease onset was at childhood (32%; onset between 1-6 y.o.) and whose duration of the symptoms was longer (58%; duration > 20 years). Diagnostic rate in known genes was equivalent between single case study and familial study, but the latter had an advantage for narrowing down candidate or novel genes.
WES is useful for diagnosing IEI patients, especially for searching novel disease causal genes. We identified several potential mutations which needed functional analysis for proving its pathogenicity.
Primary immunodeficiency diseases (PID) are more than 400 rare immune disorders, in which diagnostic delay is about 8.8 years with up to 50% of people with PID undiagnosed worldwide. With the PID Early Diagnosis (PED) project, our team will promote selected cost-effective and patient based actions to improve an early diagnosis of PID in the era of the European Reference Network.
The PED project is organized as follows: (1) Promotion of newborn screening (NBS) for severe combined immunodeficiencies (SCID) in the three involved regions; (2) Creation of a computer-based algorithm to allow early diagnosis of PID in primary care (PIDCAP project) (3) Design of a dedicated clinical pathway (PDTA) for PID; (4) Development of an online educational tool for non-immunologists and patients.
The PED project is a patient-centered and doctor driven initiative that works into integrated practice units. NBS for SCID and a pilot phase with around 300.000 individuals of the PIDCAP project are already implemented in Catalonia. A PDTA has already been organized in Marche Region (Italy) with the subsequent approval by the Health Administration. PED is closely working with the Italian Association for PID (AIP), the Catalan Association for PID (ACADIP), the Barcelona-PID Foundation, and BUBBLE ID (PID patient organization Ghent).
This combination of efforts constitutes a very powerful initiative that is pivotal for early diagnosis of PID. Pharmaco-economic analysis and dissemination activities to promote the incorporation of these strategies into international guidelines need to be carried out.
Primary immunodeficiency diseases (PIDs) are rare syndromes in infants and children. Skin alterations as one the most prevalent manifestation in these patients could arouse our suspicion to PIDs. As the number of studies investigating the spectrum of skin alterations in PIDs is significantly limited, this study aims to determine the types and prevalence of such manifestations. .
This article reports a 3-year lasting cross-sectional study conducted at Mofid children’s hospital in Iran. Participants were 212 patients (110 men, 102 females) whose PIDs were diagnosed by clinical immunologists and their skin lesions were described by dermatologists.
Skin disorders were detected in 95 patients among which 61 patients shown skin manifestations as a primary symptom.The types of PIDs among these 95 patients were as follows: 40 cases of combined immunodeficiency, 9 cases of humoral immunodeficiency, 30 cases of congenital defects in phagocyte, and 16 cases of other PIDs. Skin infections with prevalence of 72.6% were the most skin disorders followed by eczematoid skin lesions with an occurrence rate of 25%. Other skin manifestations included: erythroderma, granolumas, pigmentary changes, dysplasia of hair and skin, autoimmunity and vasculitis. Some of these skin lesions have given practitioners clues for diagnosing PIDs: partial albinism and silvery hair in all patients with chediak-higashi (5 cases) and griscelli syndrome (2 cases) ,and erythroderma in all of the infants with Omenn syndrome (5 cases).
Our findings support other studies in the way that a proper understanding of skin manifestations relevant to PIDs could lead to an early diagnosis of immunodeficiencies.
Background: IFN regulatory factor 2 binding protein 2 (IRF2BP2) was identified as an IRF-2-dependent transcriptional corepressor binding to the C-terminal repression domain of IRF2. IRF2BP2 also could bind to the C‑terminus of nuclear factor of activated T cells (NFAT1) and act as a regulator of NFAT-responsive genes transcription. IRF2BP2 was described as an important transcriptional cofactor regulating various biological systems including cell cycle, apoptosis, immune responses, cell differentiation, inflammation and angiogenesis. More recently, it has been shown that IRF2BP2 mutations could cause autosomal‑dominant common variable immunodeficiency (CVID). CVID as a syndrome comprises a heterogeneous group of diseases, characterized by recurrent infections due to significant hypogammaglobulinemia.
Methods: Whole exome sequencing and targeted next‑generation sequencing was performed with genomic DNA isolated from whole blood.
Results: In our study we identified four novel monoallelic IRF2BP2 variants in five patients within a CVID cohort. Novel monoallelic missense mutations were detected in one male patient (c.352C>T; p.P118S) and two affected sisters from non‑consanguineous parents (c.1645T>G; p.C549G). One patient was identified with a stop‑gain mutation (c.1615_1616delinsT; p.K539Yfs*41), which is predicted to cause a truncation of protein length due to a premature termination of translation. Another patient harbored an in‑frame deletion variant (c.293_295delAGC; p.Q94del).
Conclusions: We identified novel IRF2BP2 mutations in a family with autosomal dominant CVID and in three sporadic CVID cases. Monoallelic IRF2BP2 mutations may cause monogenic CVID with different clinical manifestations and onset.
Immune globulin replacement therapy (IGRT) is indicated for the treatment of primary antibody deficiency (PAD). When clear indications of PAD cannot be established, the need for IGRT can be challenging to determine.
A survey administered by Edgar in the UK, was adapted to investigate the prescribing patterns of US allergists/immunologists when strict diagnostic criteria for CVID, XLA, and other well-defined PIDs were not fulfilled. A/I’s were asked to rank the importance of factors used in decision making to commence IGRT as well as IGRT dosing.
203 Immunologists completed the survey. Clinical assessment of immune deficiency was the most important factor in IGRT. Although 92% of A/I assessed antibody response to vaccine challenge, they relied upon this only to support clinical assessment. 31% assessed high resolution CT scan to rule out the presence of Bronchiectasis (BE). When BE was present, A/Is were 2.4 times more likely to prescribe prophylactic antibiotics and significantly higher starting doses of IGRT.
There is a wide diversity in the approach of allergists/immunologists in the US in determining the need for IGRT for immune deficiency. Although the presence of BE conveys worse prognosis, diagnostic testing for BE in atypical ID was underutilized. When assessed, the presence of BE impacted therapeutic decision making.
Antibody deficiencies and complement deficiencies are the most frequent primary immunodeficiencies (PIDs) in adults and are mainly revealed by recurrent and/or severe bacterial infections. The objective of this study is to evaluate a systematic research strategy of PIDs in adults with unexplained bacterial infections.
A regional prospective study was conducting in 15 centers (NCT02972281). Main inclusion criteria were recurrent benign bacterial respiratory tract infections (RTIs) (group 1), severe bacterial RTIs requiring hospitalization (group 2), and/or invasive infections documented with encapsulated bacteria (group 3). Main exclusion criteria were all local (including tobacco use) and general associated conditions which could explain infections. If required to confirm or assess an antibody deficiency, response to polysaccharide antigens was assessed by serotype-specific ELISA (7-16 serotypes) after PPV23.
From March 2015 to April 2019, 96 patients were included (33 males, median age 54 years), and full data were available in n=78 at the time of the analysis. Thirty-two antibody deficiencies were diagnosed, giving an estimated frequency between 33.3% (n=32/96) to 41% (n=32/78). Specific Polysaccharide Antibody Deficiency (SPAD) was the most frequent diagnosis by far (n=28/32), and was made in 14, 7 and 7 patients from groups 1 to 3, respectively. Outcome after diagnosis was available in n=25. Depending on infectious history, SPAD patients received antibiotic prophylaxis (azithromycin) (N=4) and/or immunoglobulins replacement therapy (N=6), the latter being dramatically efficient in all cases.
After having ruled out other PIDs, SPAD should be screened in patients with unexplained recurrent and/or severe bacterial infections.
Early identification of genetic defects for the primary immunodeficiency(PID) patients is very important follow up and treatment modalities. In order to determine the genetic defects of the patients, a next generation sequencing gene analysis was performed by using the primary immunodeficiency panel containing 266 genes in the immunology laboratory of the Pediatric Hospital of Hacettepe University in 180 patients with PID.
We have found responsible the manifestation of genes for the PID disorders in the 100 patients primary immunodeficiency according to clinical and laboratory criteria were evaluated by targeted NGS PIDv1 panel, Ion torrent platform Ion PGM and software was Ion reporter 5.10.
We detected responsible mutations in 100 out of 180 patients with patients with immunodeficiencies were evaluated and results were obtained by performing NGS analysis. 4 patients had PIK3CD, 3 patients had TNSF12-TNSF13, NFKB2, 2 patients had TNFRSF13B, GATA2, 1 patient had CYBA and TNFRSF13B, 1 patient had PRKDC and MCM4, 1 patient had PSTPIP1 and STIM1, 1 patient had PSTPIP1 and TCF3, 1 patient had STIM1 and CARD11, mutation in STIM1 and CD19 genes in 1 patient, mutation in 1 patient CD27, CTPS1, DCLRE1C, IL17F, IL1RN, IL2RG, INO80, MCM4, MKL1, NCF1, NOD2, PIK3R1, POLE, RLTPR, STAT1, STAT3 GOF , STK4, TBX1, TCF3, TERT and UNC13D genes have been identified.Early diagnosis and effective treatment is provided by the next generation sequencing method in most patients with PID.
Genetic defects determined by these analyzes show that rare diseases are not rare for the same family.
Background: Serum electrophoresis, total protein, and albumin determinations have a variety of applications in clinical practice, but their full potential is yet to explored. The evaluation of calculated globulin (CG) (total protein – albumin) and gamma fraction (GF) (from protein electrophoresis) values can provide relevant data on humoral immunity. The aim of this study was to investigate the correlation between CG and IgG, and GF and IgG levels, by age range.
Methods: A multicenter prospective, 2-year study was initiated testing for CG, protein electrophoresis, and IgG levels in pediatric and adult patients.
To date 1079 patients have been evaluated (Table 1). A linear relationship between CG and IgG, GF, and IgG levels was found across eight pediatric age ranges, adults, and the pooled analyzed data (Figures 1A-J, 2A-J). Calculated globulin and GF cut-off values were established to detect IgG levels below the 3rd percentile of normal ranges for each age group and presented acceptable accuracy for most age groups. (Table 2).
The mean difference between IgG and GF values was significantly different from zero only in the ages ranges 1-2 and > 18 years (Figure 3).
CG and IgG values, and GF and IgG correlate in a linear manner. CG and GF are promising screening tests to detect antibody deficiencies. The collection of additional samples will power this study in determining the cut-off values for both pediatric and adult age ranges.
Acknowledgments: The authors would like to acknowledge CSL Behring, Shire, and Jeffrey Modell Foundation for support.
Severe combined immunodeficiency with the presence of B lymphocytes (Nezelof syndrome) is manifested by a pronounced defect of cellular immunity with lymphopenia and thymic dysplasia. This condition is defined as a lymphocytic, normo-plasmocytic and normo-globulinemic aplasia.
Aim: evaluation of morphopathological changes in Nezelof syndrome
were evaluated data (medical records, morphopathological data, immunohistochemical staining) of 36 patients aged 0-18 years diagnosed at the Institute of Mother and Child from Moldova with primary immunodeficiency postmortem to detect any Nezelof syndrome.
Nezelof syndrome was detected in 4 patients (11.1%). It is characterized by thymic hypoplasia and dysplastic changes defined by the presence of concentrically arranged epithelial cells and the total lack of Hassall corpuscles and its predecessors. There was also no corticomedullary segregation. Thymic parenchyma was composed only of a reticular stroma with total lymphocyte depletion (fig.1). Also, in the spleen and the lymph nodes, besides lymphocyte depletion, there were numerous plasmocites. The same changes were observed in the intestinal lymphoid follicles, especially the presence of plasmocites.
Thymic hypoplasia and dysplastic changes, manifested by the presence of pseudoglandular structures of the reticulo-epithelium, lack of Hassall corpuscles, and depletion of lymphocyte from the lymphoid tissue are morpfopatological data about Nezelof syndrome.
Wiskott-Aldrich syndrome (WAS) is a rare, recurrent X-linked pathology, characterized by the triad: thrombocytopenia, eczema and recurrent immunodeficiency. WAS usually manifests in infancy, in most cases the first clinical features are hemorrhagic manifestations.
Aim: To describe two boys and 1 girl with WAS genetically confirmed with absolutely different onset of symptoms.
We reviewed medical records and blood counts, phenotyped peripheral blood lymphocytes.
We describe 2 boys (P1 and P2) and 1 girl (P3) with early-onset of symptoms and mild cellular abnormalities. P1 from the age of one month has frequent severe respiratory infections (bronchiolitis, pneumonia, pneumonia with P. jirovecii) and from 4 months he also has eczema. P2 from the age of 1.5 months has high tendency to bleeding with haemorrhagic colitis, ecchymosis and petechiae, from the age of 3 months he is frequently hospitalized for respiratory infections, predominantly pneumonia. P3 at 3 months is hospitalized for pneumonia and haemorrhagic rash, after that monthly mother addresses with diffuse haemorrhagic rashes on the child skin. All patients have severe thrombocytopenia with normal MPV.
Despite an uncommon onset and a normal MPV, the association of severe thrombocytopenia with infections requires WAS suspicion and diagnosis.
Neutropenia/lekopenia is common in childhood and the etiologies include not only acquired causes, such as infection and drugs but also inherited or acquired genetic alterations. Of the genetic causes, most well-known are the congenital neutropenia mutations, Shwachman Diamond Syndrome. On the other hand, there are patiets who have none of these underlying pathologies. Herein we report a series of patients who had mitochodrial deletion as an underlying pathology in neutropenia/lekopenia investigations.
The patients who had persistent neutropenia and/or leukopenia for at least three times were investigated for ELANE2, HAX1, G6PC3, SBDS1 and FISH analyses for myelodysplatic syndrome and were found negative for all were further analyzed with MLPA for mitochondrial deletions. The patients who had Person syndrome were excluded.
A total of 4 patients were found to have mitochondrial deletion of approximately 948 bp with MLPA assay, all in heteroplasmic state. The ages of the patients varied as 13m,16m,11y,13y and the age of onset was 10m,9m,10y,9y, respectively (M/F=1/3). DEB was negative in 2 of the patients and one of the patients were evaluated with WES for nuclear genome and was found only heterozygous for FANCG. WBC were 6300, 8100, 4200, 3300, respectively and ANC 400,300,900 and 1700. All had normal lactate/pyruvate ratio. None had finding in cardiac, auditary, ophtalmological evaluations. Two had erytroid vacuolization in bone marrow examination. None had myeloid stage arrest or dysplasia. One had megaloblastic changes in myeloid/ertrid lineages.
Mitochondrial deletions might be the underlying pathology in unexplained leukopenia/neutropenia. This might cause premature hematopoietic aging.
Evaluation of phagocyte respiratory oxidative burst using dihydrorhodamine test (DHR-test) allows a fast diagnosis of Chronic Granulomatous Disease(CGD). DHR-test often employs phorbol myristate acetate (PMA) and E.coli as standard stimuli of NF-kB signaling pathway. PMA signals through Protein Kinase C (PKC), whereas E.coli triggeres Toll-like Receptors (TLRs)-mediated activation and probably other pattern recognition receptors. Patients with Toll-IL-1R(TIR) deficiencies and CGD usually suffer pyogenic infections. However, the specific functional tests for TIR deficiencies are usually available only in specialized laboratories. Herein we aimed to assess the capacity of DHR test to screen for TIR deficiencies in a diagnostic setting.
Four patients with a definitive diagnosis of TIR deficiency (two IRAK-4- and two MyD88-deficient), 3 healthy family members with heterozygous IRAK-4 genotypes (HFM), and 10 healthy control subjects (HC) were analyzed by DHR-test with PMA and E.coli.
Gating on neutrophils, the Stimulation Index (SI) = (MFI-DHRstimulus/MFI-DHRnegative control) was calculated. All enrolled individuals showed normal results (SIPMA>30) in DHR-test with PMA.TIR-deficient patients showed a marked reduction of DHR-test responses upon E. coli stimulation (mean SIE.coli:45.3) compared with healthy controls (mean SIE.coli: 100.56) and HFM (mean SIE.coli:59.8). When the ratio between SIE.Coli/SIPMA was calculated, all TIR-deficient patients showed ratios <0.5 while 9/10 controls and all the heterozygous relatives displayed ratios >0.5 (Figure 1)
TIR-deficient patients show a specific impairment of E.coli DHR-test as opposed to PMA responses. This dissociation is not observed in CGD patients (both responses equally affected), nor in HFM. Therefore, DHR test using both PMA and E.coli could reveal TIR deficiency.
Rheumatoid arthritis (RA) is a chronic inflammatory disease that is characterized by severe tissue damage and chronic synovial inflammation. Several promising biomarkers need further development and refinement to attain sufficient sensitivity and specificity. In this study, we used a miRNAarray approach to identify new miRNA in exosome that are related to disease activity in patients with RA who showed inadequate response to treatment.
42 RA patients were included in the study. Disease activity was measured using the 28-joint disease activity score with ESR (DAS28-ESR). Patients with RA were stratified according to the following criteria: the clinical remission (CR) group (n = 22), DAS28-ESR < 2.6; and the non-CR group (n = 20), DAS28-ESR > 2.6. By exosome preparation, miRNA array, and Reverse Transcription-qPCR reactions, several miRNAs were as potent markers for disease activity.
After data processing for relative quantification of miRNA in exosome between the CR and non-CR groups, we identified 47 miRNAs with a relative fold change (non-CR/CR) > 2. To validate these results, five miRNAs were selected showing at least 2-fold change between the CR and non-CR groups. Both levels of hsa-miR-1915-3p and hsa-miR-6511b-5p were significantly increased in CR group; hsa-miR-1915-3p was 43.75 in the CR group and 24.68 in the non-CR group (ρ = 0.004), and hsa-miR-6511b-5p was 3.02 in the CR group and 2.45 in the non-CR group (ρ = 0.03).
hsa-miR-1915-3p showed promise as additional markers for evaluating disease activity in patients with RA.
Assessment of polysaccharide response to the 23-valent pneumococcal polysaccharide vaccine (PPV23) can be biased by previous exposure to the conjugate vaccine (PCV). We applied a modification to the existing pneumococcal IgG ELISA by pre-incubating serum with PCV to adsorb out PCV-specific serotypes and allow for detection of serotypes unique to PPV23.
Anti-pneumococcal capsular polysaccharide (PCP) IgG antibodies were measured using the VaccZymeTM anti–PCP IgG ELISA (The Binding Site Group Ltd, Birmingham, UK) in PCV-adsorbed and non-adsorbed serum samples. Paired (pre and post-vaccination) sera from 76 patients were analysed. For each sample, baseline anti-PCP IgG was subtracted from the post-vaccination value to measure vaccine responsiveness. Absolute change in titres and fold changes were compared between both methods.
PCV serotype-specific adsorption was confirmed using a multiplexed bead-based immunoassay performed on 10 paired samples. In PCV-vaccinated controls (n=28), pre-adsorption with PCV significantly reduced vaccine response compared to non-adsorbed sera [median titres: 6.41mg/L and 18.20mg/L, respectively; p=0.03 and median fold change: 1.23 and 1.89, respectively; p=0.01)]. In PPV23-vaccinated immunocompetent subjects (n=30), there was a significant difference in anti-PCP-IgG responses between the conventional and the modified ELISA [median values: 57.7mg/L and 38.01mg/L, respectively; p=0.04]. Antibody-deficient patients (n=18) displayed poor PPV23 responses. Although PPV23 responsiveness was not statistically different between both methods, we observed a trend for lower anti-PCP-IgG titres in PCV-adsorbed sera compared to non-adsorbed.
Pre-analytical modification to anti-PCP IgG ELISA by removing the PCV-specific serotypes potentially differentiates true polysaccharide response from memory response induced by previous PCV vaccination.
Measurement of pneumococcal IgA and IgM responses may identify antibody-deficient patients who are most at risk of infection. Here we measured the specific IgA and IgM response to Prevnar13® (PCV13) and Pneumovax®23 (PPV23).
Pneumococcal responses were measured using the VaccZyme™ pneumococcal capsular polysaccharide (PCP) IgA and IgM ELISAs (The Binding Site Group Ltd, Birmingham, UK) in control (median 59 years, range 16-86) and antibody-deficient (median 66 years, 44-86) patients recruited from the Immunodeficiency Unit at the Birmingham Heartlands Hospital, UK. Patients were vaccinated with either PCV13 (n=16 control, 10 antibody-deficient) or PPV23 (n=31 control, 18 antibody-deficient) and serum samples collected pre- and 4 weeks post-vaccination.
PCP-Ig responders (+) and non-responders (-) were defined from the lower 95th percentile range of the control population (for PPV23, PCP-IgA: 0.49U/mL and PCP-IgM: 24.6U/mL; for PCV13, PCP-IgA: 6.0U/mL and PCP-IgM: 6.4U/mL). For the PPV23 group, 6% were PCP-IgA-/IgM-, 44% were PCP-IgA+/IgM+ and 50% were PCP-IgA+IgM-. For PCV13, 40% were PCP-IgA-/IgM+ and 60% were PCP-IgA+/IgM+. For PPV23, significant positive correlation was observed between PCP-IgA and PCP-IgM (Spearman r=0.68, p=0.002). However, PCP-IgA-/IgM+ and PCP-IgA-/IgM- patients were associated with a more severe phenotype requiring IVIG replacement therapy (56%) compared to PCP-IgA+/IgM+ patients (44%). For PCV13, no significant difference in infection frequency and severity was observed between PCP-IgA-/IgM+ and PCP-IgA+/IgM+ patients.
The measurement of PCP-IgA and PCP-IgM potentially stratifies the patient cohort and provides further information to the clinician.
Measurement of pneumococcal IgG response to vaccination is a key test used to investigate humoral immunity, however, the relationship between IgG and IgG subclasses is not firmly established. Here we assessed the IgG and IgG2 responses to pneumococcal vaccination and clinical presentation in antibody-deficient patients.
Pneumococcal responses were measured using the VaccZyme™ pneumococcal capsular polysaccharide (PCP) IgG and IgG2 ELISAs (The Binding Site Group Ltd, Birmingham, UK) in control (median 59 years, range 16-86) and antibody-deficient (66 years, 44-86) patients recruited from the Immunodeficiency Unit at Birmingham Heartlands Hospital UK. Patients were vaccinated with either Prevnar13® (PCV13, n= 16 control, 10 antibody-deficient) or Pneumovax®23 (PPV23, n= 31 control, 18 antibody-deficient) and serum samples collected pre- and 4 weeks post-vaccination.
PCP-Ig responders (+) and non-responders (-) were defined from the lower 95th percentile range of the control population (for PPV23, PCP-IgG: 17.8mg/L and PCP-IgG2: 5.9mg/L; for PCV13, PCP-IgG: 27.5mg/L and PCP-IgG2: 8.9mg/L). Positive correlations between PCP-IgG and IgG2 were observed for both PCV13 (r=0.95, p=0.001) and PPV23 (r=0.92, p=0.001). In antibody-deficient patients, PCP-IgG responders were all IgG2 responders following PCV13 vaccination. However, 3 of 18 PPV23-vaccinated patients were PCP-IgG+/IgG2-. These patients had significantly lower total IgA, median 0.36g/L (range 0.36-0.6g/L) than PCP-IgG+/IgG2+ patients (median 1.09g/L, range 0.66-1.48g/L, p=0.03). Additionally, a greater proportion of PCP-IgG+/IgG2- antibody-deficient patients presented with recurrent infections (100% vs 86%) and required prophylactic antibody treatment (67% vs 57%) than PCP-IgG+/IgG2+ patients.
The identification of PCP-IgG2 non-responders may provide further stratification of patients with a proficient PCP-IgG response.
LPS-responsive beige-like anchor protein (LRBA) encodes widely expressed cytosolic protein which participates in polarized vesicle trafficking. Homozygous loss of function LRBA mutations involve immune deficiency due to the lack of immune regulation as a part of Tregopathies.
We present 49 years old female case with common variable immune deficiency. She has periodic hematuria, dysuria and cough attacks and she gets IVIG treatment regularly. She has background of 11 years of asthma, 3 years of rheumatoid arthritis and hypothyroidism.
We performed immune deficiencies research DNA sequencing panel (264 gene and 5241 amplicons) which concluded with homozygous LRBA mutation (p.Arg722His) at BEACH domain. Mutation is evaluated to be causative and we sequenced mother of the case and two healthy brothers for segregating the mutation. One of the brothers was found to be heterozygous for same mutation whereas mother and other brother were not carrier. We could not be able to sequence her father because he was not alive at time of tests. We hypothetically estimate father to be carrier, but our care remained obscure. We analyzed DNA sample with SNP array that revealed uniparental isodisomy (UPD) of whole chromosome 4.
Whole chromosome uniparental isodisomy is a rare condition. More commonly small chromosomes are involved as a part of unclear trisomy or monosomy rescue process. LRBA deficiency case with partial isodisomy has been reported previously. To our knowledge we report LRBA mutation to became homozygous state due to whole chromosome UPD for the first time.
The Wiskott-Aldrich syndrome (WAS) is an X-linked immunodeficiency condition characterized by microthrombocytopenia, eczema and recurrent infections. It is caused by mutations in the Wiskott - Aldrich syndrome protein (WASP) gene.
Objective: To describe epidemiological, clinical and laboratory data of children with WAS syndrome who were managed in pediatric hospitals Mustapha Pacha in Algeria.during the period 2015- 2019.
This study included children admitted with the diagnosis of WAS.
10 patients were diagnosed as WAS in 5 years. The ages at diagnosis ranged from 12 weeks to 18 months. The classic triad of thrombocytopenia with small platelets, recurrent infectious, and eczema was seen in only 4 patients; 2 had only infectious manifestations and 4 had only hematologic manifestations before diagnosis.
Immunological studies in all patients have revealed increase of IgA in 9. Mutations in the WASP gene were seen in 5 children,
Four patients had at least one autoimmune or inflammatory complication. Autoimmune hemolytic anemia (2 cases), inflammatory bowel disease (3 cases) and cerebral vasculitis in one case.
Prophylaxis antimicrobial therapy was used in all patients and 8 patients received IVIG replacement therapy. Two children underwent hematopoietic stem cell transplantation (HSCT) and 2 gene therapy. Two patients died from failure to thrive and cerebral candidiasis.
Diagnosis of Wiskott Aldrich syndrome should be considered in any male infant who presents with early onset thrombocytopenia, eczema, and recurrent infections. Treatment is mostly restricted to antibiotics, IVIG therapy. Current advances in HSCT and gene therapy provide treatments with highly favorable results.
The Wiskott–Aldrich syndrome (WAS) is a complex primary immunodeficiency disorder that is characterized by recurrent infections, thrombocytopenia, eczema, and autoimmunity and caused by mutations in WAS.
We describe the rare occurrence of Wiskott-Aldrich syndrome (WAS) in identical twin brothers disease is described
Monozygotic twin boys were born at 36 weeks of gestation following an uncomplicated delivery. After birth, evidence of thrombocytopenia was noted in both twins. Secondary to a concern for the possibility of neonatal alloimmune thrombocytopenia (NAIT), they were treated with intravenous immunoglobulin; however, follow-up demonstrated recurrent thrombocytopenia.WAS gene sequencing was completed which demonstrated deletion c482 del C.
A discordant phenotype has evolved in which one twin demonstrates asymptomatic thrombocytopenia, moderate infectious complications and the other symptomatic thrombocytopenia, severe infectious complications ( gastroenteritis, severe allergy)
Disease course deteriorated when the twin boys reached the age of 20 months. Considering the absence of an HLA identical relative and unrelated donor, the twins were referred to Institute san raffaele hospital Milan ( ITALY) where they are treated with gene therapy (GT).
At a follow-up of 20 months post-GT, the patienst are well, with normal peripheral blood counts,
Diagnosis of Wiskott Aldrich syndrome should be considered in any male infant who presents with early onset thrombocytopenia, eczema, and recurrent infections. The only curative therapy consists of hematopoietic stem cell transplantation (HSCT). HSC gene therapy has emerged as an innovative therapeutic strategy for various primary immunodeficiency disorders. WAS is a promising candidate disease for gene-therapy approaches.
The aim of this study was to estimate the disease burden of PIDs in a department of general pediatrics in Algiers and to appreciate the trends.
A retrospective single center study conducted in the department of pediatrics at Mustapha Bacha teaching hospital in Algiers. All cases of PIDs seen in our department between January 1st 2003 and June 30th 2019 were enrolled. PIDs were classified according to the International Union of Immunological Societies expert committee for Primary Immunodeficiency.
70 PIDs patients were identified with 40 boys. Mean age at diagnosis was 40 months. Parental consanguinity was found in 38% of cases. Main clinical manifestations were recurrent respiratory infections (55%), growth failure (45%), prolonged fever (40%), chronic diarrhea (32%) and eczema (25%). The represented categories were combined T and B cell immunodeficiency (34%), well define syndromes with immunodeficincy (23%), predominantly antibody deficiencies (21%), congenital defects of phagocyte (8.5%), diseases of immune dysregulation (7%) and autoinflammatory diseases (6%). Among combined ID category, SCID was the most common condition (24%) followed by CMH II deficiency (8.5%). The global mortality of our series was 27 % at a mean age of 31 months.
Children with recurrent infections, growth failure and chronic diarrhea should raise high index of suspicion on possible PID. In the absence of routine screening, physician awareness of the relative frequency of these disorders is critical to early diagnosis and treatment.
1) A 29 years old male. Maternal uncle died at 4 months of age with infections. Started with recurrent episodes of pneumonia at age 6 months. He was diagnosed at 6 years of age with Agammaglobulinemia. When he was 17 years, he was admitted in our institution with pneumonia, lung abscess and pericarditis.
2) A 19 years old male, brother of case1. He started at 3 months of age with multiple otitis. He presented two meningitis and pneumonia at age of 7. Agammaglobulinemia was diagnosed. He presented with cough, asthenia and low weight, hearing loss of the left side. Lung CT reported bronchiectasis.
3) A 6 years old male. 2 maternal cousins with PID (case1-2). He started at one year with otitis. When he was 4 years old he presented with a new episodic of otitis follow by gastroenteritis and then meningitis.
4) A 3 years old male. Brother of case 3. At 11 months of age, he developed herpes zoster
Four cases in a family with recurrent infections in whom a late diagnosis was made. Levels of immunoglobulins and Subpopulations B cells reported:
Affectation of both children of 2 sisters (case 1 and 2), children of different parents, make us suspect an agammaglobulinemia linked to X by a mutation in the BTK gene.
We report 4 male patients with XLA who presented with typical clinical findings and whose diagnosis was confirmed. Because the diagnosis was made late and only after many episodes of serious infections, two of them developed complications.
1. Male with a history of 3 maternal uncles transplanted by SWA, an uncle died from LMC. His condition started at 2 months of age with thrombocytopenic purpura in treatment with prednisone and immunoglubilin without recovery of platelet levels. He presented respiratory tract infection, diarrhea, digestive bleeding and oral candidiasis. HB reported thrombocytopenia; blood smears with small platelets; immunoglobulins with elevated IgE and IgA; lymphocyte subpopulation, IgG, IgM in normal parameters. Decreased WASp expression as well as proliferation of positive lymphocytes.
2. Male with history of 7 uncle maternal grandparents died at early age. His condition begins at 8 days of life with digestive bleeding and fever, antibiotics were administered. HB reported anemia and moderate thrombocytopenia; negative urine culture. Allergy to cow's milk protein was suspected. At 2 months of age after aplication of hepatitis B, rotavirus and pneumococcus vaccines, He started with intermittent fever for 10 days. BH report anemia and severe thrombocytopenia. Transfusions and immunoglobulin were administered. BMA negatively to malignancy. WASP
Presentation of two patients with SWA with diferent clinical spectrum.
case 1. Mild Spectrum of SWA according to the clinical classification. He presents persistent thrombocytopenia, eczema and infectious processes associated with immunodeficiency, however with a positive WASp expression.
case 2. Severe Spectrum of SWA according to the clinical classification. He presents persistent thrombocytopenia and neutropenia with a negative WASp expression.
Clinical spectrum of SWA is variable, it presents in 3 phenotypes ranging from severe immunodeficiency to neutropenia or thrombocytopenia linked to X symptoms of WASp expression in the hematopoietic line.
Acute lymphoblastic leukemia (ALL) is the most common childhood malignant disease. The definitive diagnosis is frequently delayed when it is mistaken with juvenile idiopathic arthritis (JIA).
Through our case reports we aim to emphasizes the importance of early bone marrow examination if there are any atypical features of JIA.
We would like to present three cases with ALL, initially diagnosed as JIA. First case, a girl 4 years old, presented with talocrural articulation pain. Her hematological variables were normal. No improvement with AIJS. The rheumatologist of adults thinking for atypical JIA treated her with corticotherapy and methotrexate. After 10 months clinical situation worsened and her hemograme presented severe pancytopenia.
Second case, a girl 2 years old presented to the orthopedist with limb pain. Good answer initially with AIJS, but relapse in three months. The work-up shows severe thrombocytopenia, leukocytosis, lymphocytosis and LDH elevation.
Bone marrow examination established diagnosis of ALL for all cases. For the first case, it was necessary bone marrow transplantation, because of the resistance to chemotherapeutic agents.
A paediatric rheumatologist should be involved early in the assessment of children with arthritis. Hematologic malignancies must be excluded before initiation of therapy for atypical JIA. Thrombocytopenia, anemia, lymphocytosis and increased LDH are suggestive for malignancy.