Background and Aims

Common variable immune deficiency (CVID) is one of the most common types of primary immune deficiencies (PIDs) which represents a potpourri of various diseases with a different underlying mutation which has common features. The clinical presentation does not necessarily point at a specific underlying defect and genetic study should be granted to every PID patient which might help in treatment and prognosis.

Methods

After consent, history and review of the patient’s chart were done.

Results

We are reporting a 17-year-old Saudi female diagnosed with common variable immune deficiency. She had a history of recurrent Idiopathic Thrombocytopenic Purpura at childhood. She had bronchiectasis due to recurrent lower respiratory infections. Furthermore, during adolescence, she had chronic intermittent diarrhea, unintentional weight loss, renal insufficiency, and generalized lymphadenopathy. However, lymph node biopsy was negative for Tuberculosis, viral, or malignancies like lymphoma. She had Sagittal sinus thrombosis, neurodegenerative disease which was complicated with epilepsy. During hospitalization, she had CMV viremia responded to Ganciclovir. Investigations showed leukocytosis, thrombocytosis, and panhypogammagllobinemia. MRI brain showed active demyelinating inflammatory white matter disease.
whole exome sequencing showed missense genetic mutation of NFkB1 (NFKB1: NM_001165412:exon17:c.1913A>T:p .K638I).

Conclusions

NFkB1 missense monogenetic mutation (OMIM: 616576) in CVID patients showed a very progressive course in most of the patients who identified before. However, in our patient it was associated with the autoimmune neurodegenerative disease this may be explained by a variable presentation of the disease even in the same family. WES is able to release an early diagnosis that predicts and improves morbidity and prognosis of suspected manifestations.

Background and Aims

Purine nucleoside phosphorylase (PNP) deficiency accounts for about 2% of severe combined immunodeficiency diseases. PNP deficiency is a variable disease with recurrent infections and neurodevelopmental delay; autoimmunity and malignancy which still occur in one third of the patients.

Methods

Case report and genetic diagnosis.

Results

We reported a 9-year-old Saudi female who was apparently healthy, presented at the age of 8 years with confirmed SLE that was poorly controlled with conventional therapy. During that time, she attained frequent sinopulmonary and varicella infections. Preliminary immunological workup showed severe lymphopenia and depressed lymphocyte proliferation assay. Genetic study revealed a homozygous missense mutation c.265 G>A in the NP gene, resulting in a substitution of glutamic acid to lysine at amino acid 89 of the NP protein (E89K). Hematopoietic stem cell transplantation was planned from a matched unrelated donor, however she developed focal seizures with secondary generalization. An EBV and Varicella meningoencephalitis was confirmed and failed to be cleared with appropriate antiviral therapy. Atypical malignant cells suggestive of lymphoma was discovered and was believed to be EBV induced. Suspicious lesions were exhibited on brain MRI and PET scan. Unfortunately, brain biopsy was not performed owing to the severe illness of the patient who subsequently passed away before HSCT at the age of 9 years due to multi-organ failure.

Conclusions

Our report expands the spectrum of clinical presentation of PNP deficiency as SLE being the solely presenting feature. Subtle psychomotor developmental delay and increased predisposition to viral infections in SLE patients may warrant investigating the PNP enzyme activity.

Background and Aims

STAT1 gain-of-function (GOF) mutations leading to defective Th17 development are the most common genetic cause of chronic mucocutaneous candidiasis (CMC). We have identified enrichment of the STAT1 V266I variant of unknown significance (VUS) in our cohort of patients with Common Variable Immunodeficiency (CVID). We aim to define the functional impact of this mutation.

Methods

Cell lines expressing wild-type STAT1, STAT1-V266I and the described GOF CMC-associated mutation STAT1-A267V were generated. Levels of basal and post-IFN-α stimulus of phosphorylated STAT-1 (pSTAT-1) and total STAT-1 were measured by flow cytometry in cell lines with and without ruxolitinib and in primary cells from patients and controls (healthy, other CVID and known STAT1 GOF). In cell lines, STAT1 translocation to the nucleus was assessed by confocal microscopy. IFN-induced expression of the STAT-1-dependent cytokine, CXCL10, was evaluated in primary cells.

Results

We demonstrate that the V266I STAT-1 VUS confers GOF as shown by increased levels of pSTAT1 and expression of CXCL10 compared with healthy and CVID disease controls. Similarly, cell lines expressing STAT1-V266I exhibited increased pSTAT1 and resistance to ruxolitinib treatment compared with wild-type STAT1 but less than seen in cells expressing STAT1-A267V. In comparison with STAT1-A267V, a clear defect of dephosphorylation was not seen in cell lines expressing STAT1-V266I but enhanced nuclear translocation after IFN-α stimulation was seen for both.

Conclusions

The V226I STAT1 VUS, enriched in our cohort of CVID patients, confers GOF suggesting contribution to disease susceptibility or pathogenesis.

Background and Aims

Autoimmune LymphoProliferative Syndrome (ALPS) is a rare autosomal dominant disorder characterized by inability to regulate lymphocyte homeostasis, resulting from a defect in lymphocyte apoptosis (programmed cell death).

Defective Apoptosis may be due to any component in the Fas/FasL pathway including: Fas, Fas Ligand, and Caspase enzymes like caspase 10 and others.

Our aim is to present a case of ALPS, which underline the importance of the molecular diagnosis in Primary Immune Deficiency Patients.

Methods

15 Year old boy with clinical diagnosis of Common variable immunodeficiency (CVID). With the following previous histories:

- Immune thrombocytopenic purpura (ITP) s/p rituximab 3 years ago.

- Crohn’s disease (CD). Diagnosed by Endoscopy and pathology report.

- Short stature. with No signs of Puberty

Acutely presented to our ER with history of increased diarrhea and shortness of breath.

Upon presentation patient was short, Pale, dehydrated and hypotensive with tachycardic and hypoxic, BMI: 10 kg/m2. His sexual staging was Tanner stage 1

CMV PCR was positive of 1,584.

Patient was started on ganciclovir. No CMV retinitis.

Colonoscopy: tiny ulcers in the distal rectum.

Intestinal Biopsies: SEVERE ACTIVE ULCERATIVE CYTOMEGALOVIRUS (CMV) PROCTITIS.

Results

Immunology workup: IgA level is low (<0.50), IgM level low (<0.25) also IgG trough level was low <3

Molecular Report: mutation in the gene encoding the Caspase 8 enzyme, which means he is a case of ALPS.

Conclusions

ALPS is a very rare disease can easily be confused with CVID , with recent advances in molecular genetics diagnosis, treatment options and prognosis improving for such patients.

Background and Aims

Familial Hemophagocytic Lymphohistiocytosis Syndromes (FHL) are autosomal recessive disorders with heterogeneous genetic origin that occur frequently in the first two years of life. The UNC13D mutation , responsible for %30-40 of all cases , causes FHL Type 3, in which Munc 13-4 protein defect is seen. In FHL Type 3, there is a lack of secretion of cytolytic granules by exocytosis and a significant decrease in NK cell activity.

Methods

Here we present clinical and laboratory characteristics ,treatment and outcomes in 3 patients from a single family.

Results

Three children (2year-old-girl, 13mo-old-girl, 3.5 mo-old-boy) of a consanguineous family; were referred to our clinic with fever, paleness and fatigue consecutively. All patients had very light-yellow hair, pale skin, fever and hepatosplenomegaly. Bicytopenia (anemia, thrombocytopenia), hypertriglyceridemia and hyperferritinemia were detected in laboratory and HLH was diagnosed. The first patient died due to heart failure in 9^th month of HLH treatment. The second and third patient underwent hematopoietic stem cell transplantation (HSCT) from HLA full matched sibling. Both of them are alive and well at +3 years and at +12 months, respectively. WES analysis revealed a known homozygous mutation in the UNC13D gene in all patients.

Conclusions

FHL is a disease with high relapses and mortality despite immunosuppressive therapy. Early diagnosis by genetic analysis and early HSCT are life-saving in these patients.

Background and Aims

Hermansky Pudlak syndrome type 2 is a rare autosomal recessive disorder resulting from functional mutations in the adaptor related protein complex 3,B1 subunit (AP3B1) gene. It is characterized by severe neutropenia, ocular albinism, interstitial pulmonary fibrosis, hemorrhagic diathesis and an absence of platelet dense granules.We describe a new case

Methods

Authors describe the phenotypic diagnosis and management of Hermansky Pudlak type 2 Syndrome in a patients followed in the pediatric immune-­hematology unit, Tunis.

Results

CM was a 8--year-old girl born from 2^nd consanguineous parents with family history of death of her sister at 7 –year-old in the context of respiratory distress and malignant varicella. The diagnosis was suspected after a history of recurrent cutaneous , ORL and respiratory infections, an episode of pneumocystis Jirovecii pneumonia and bleeding tendency with gingival bleeding and bruising. Clinical examination showed oculocutaneous albinism and finger clubbing. CBC reveal neutropenia (570/mm³) and normal platelet count. Bone marrow aspiration showed normal myeloid maturation. CT scan of the chest demonstrate pulmonary fibrosis with bilateral infiltrative lung disease. Diagnosis of HPD2 was retained in front of: Partial albinism, recurrent infections, pulmonary fibrosis Increased bleeding and neutropenia. The patient received Bactrim as secondary prophylaxis, granulocyte-stimulating factor since 2018 and she has a regular medical monitoring. Restrictive ventilation disorder was stable on spirometry and there wasn’t Pulmonary Hypertension at transthoracic echocardiography (19 year follow-up).

Conclusions

Hermansky Pudlak syndrome type 2 was rare and associated with poorly prognosis related to infections and pulmonary fibrosis.

Background and Aims

Massive splenomegaly can be caused by hematologic malignancy, lymphoproliferative disorders such as HLH, ALPS, Castleman disease, and various autoimmune diseases or PID.

Methods

We report the case of a 9 years old girl who presented since early childhood with easy bruising and bleeding from her gums with tooth brushing. Otherwise, she was completely asymptomatic with an unremarkable infectious history. After consulting for the first time at 5 years of age, she was discovered to have massive splenomegaly. She had pancytopenia and increased polyclonal immunoglobulins and CRP. A malignancy and storage disorder were excluded. The rest of the investigations were unremarkable, with normal bone marrow biopsy. Her flow cytometry was normal included double negative T-cells.

Results

Finally a whole exome sequencing revealed a heterozygous gain-of-function mutation in the p.G13C KRAS gene, which was somatic (absence of the variants in the cheek swab). The same mutation had been reported by our group before in a patient with Rosai-Dorfman and SLE.

Conclusions

RAS-associated autoimmune leukoproliferative disease (RALD) should be considered in the context of lymphoid organ expansion, cytopenia and autoimmune diseases, in particular in absence of the criteria for ALPS. Our two cases underline the variability of the phenotype in RALD. Despite, the mild form of the present case, a regular follow-up is needed given the risk of development of malignity and autoimmunity. More research should define whether broad-spectrum KRAS inhibitors targeting the KRAS mutations found in malignancy can have some potential applications for RALD.

Background and Aims

Mutation in the FAS gene is the main cause of autoimmune lymphoproliferative syndrome (ALPS). It causes defective cellular apoptosis and clinically manifests by lymphoproliferation, increased risk of lymphoma and autoimmune diseases. Here, we report a case of ALPS-FAS initially manifested by multilineage cytopenia in a patient attended at the Children´s Hospital –Brasilia/Brazil.

Methods

Laboratory and clinical data were reviewed from medical records. FAS sequencing was done by Sanger method and protein expression measured by flow cytometry.

Results

KRCS, male, 5yo, second child of consanguineous parents. No family history of immunodeficiency. At 3yo7mo he was hospitalized due to cutaneous rash, fever and pancytopenia. No infectious disease was identified. Bone marrow aspiration were negative for malignancy and the diagnosis of autoimmune hemolytic anemia was made, with response to oral corticoids. Due to the high levels of serum vitamin B12 and IgG, associated to lymphoproliferation and increased percentages of circulating CD3+TCRab+CD4-CD8-DNT cells (4%), ALPS was suspected. Genetic analysis confirmed FAS mutation c.748C>T p.R250*, which was inherited from his asymptomatic father (DNT=6.9%). Flow cytometry analysis showed low FAS expression on T cells of proband and his father. The mother and the sister have normal % of DNT (<1.5%).

Conclusions

The nonsense mutation FAS:c.748C>T results in a defective protein and its subnormal surface expression causing impairment in the apoptotic signaling pathway of lymphocytes. Although the proband and his father have the same mutation, they have different clinical manifestations. This is an intriguing query that could be related to environmental, other genetic factors or a trigger such as infections.

Background and Aims

Elucidating the genetic basis of immune diseases allows for important diagnostic accuracy for affected individuals and often produces greater insights into human immunity. Here, we describe a new immune syndrome arising from a gain-of-function (GoF) mutation in IKBKB, which encodes IKK2 of the NF-kB signalling pathway. Through whole-exome sequencing, we identified identical IKBKB variants in two probands from geographically distinct kindreds.

Methods

To confirm causal effect of mutation, we generated a CRISPR/cas9-engineered mouse model bearing the orthologous mutation. Cellular and biochemical analysis, including flow cytometry and western blot, was conducted using peripheral blood mononuclear cells (PBMCs) from probands, cultured fibroblasts, cell lines, and the CRISPR/cas9 mice.

Results

We confirmed that the mutation conferred GoF in both patients and mutant mice by analysing NF-kB signalling, which showed enhanced and constitutive proliferation of IkB. Cellular analysis of mutant mice and probands revealed an abnormal immunophenotype, specifically reduced naïve T cells, heightened propensity to T cell activation, and increased regulatory T cells. It is noteworthy that despite evidence for increased T cell activation, there is no evidence so far for increased inflammation or autoimmunity. This may be due to the concurrent increase in Tregs. Therefore, further analysis will be conducted to characterise in detail immune regulation in GoF IKBKB.

Conclusions

Overall, the mouse model revealed combined cellular features of immunodeficiency and dysregulation, consistent with the proband’s immunophenotype. Our study has led to the discovery of a novel human immunodeficiency and supports the use of mouse models to confirm function of novel mutations in rare immunological diseases.

Background and Aims

In patients with Primary Immunodeficiency Disorders (PID), Epstein-Barr-virus (EBV) can lead to lymphoproliferation. In some PID, genetics increases susceptibility to EBV infection. In our cohort of 55 patients with Common Variable Immunodeficiency Disorder (CVID) annually screened for plasmatic EBV-DNA, two patients resulted positive. Both developed lymphoproliferation.

Methods

Clinical case presentation

Results

#1-Patient was diagnosed for CVID at the age of 46y-o. Lymphadenopathy and splenomegaly were present. She is compound heterozygous carrier of two disease-related mutations on TACI. After 3 years of follow-up, EBV-DNA was isolated in blood, with fluctuating levels (450-3868genomes/mL). Two years after the first positive result, Burkitt lymphoma rose out, that remitted after chemotherapy. Blood EBV-DNA is actually undetectable.

#2-Patient had relapsing Evans Syndrome since 2004, at the age of 11y-o. In 2005, rituximab was given for relapsing AIHA. In 2010 diagnosis of ALPS was done (no mutations found in ALPS-related-genes). In 2015, CVID was diagnosed, but patient refused Igs supplementation. In 2016, EBV-DNA was isolated in blood (1580genomes/mL). In 2017, he developed AIHA refractory to Igs and steroids, responsive to rituximab (low-dose scheme) plus Igs replacement therapy. Blood EBV-DNA became undetectable. Six months later it increased to 23910genomes/mL. Patient developed fever and lymphoadenopathy. FDG-PET CT-scan is high suspected for lymphoma as scans done since 2008. The patient is heterozygous carrier of a variant on CTLA-4 gene of unknown significance.

Conclusions

CVID patients need periodic molecular screening for EBV-DNA. If positivity to EBV is found, intensive surveillance for malignancy arising is mandatory, especially in those patients genetically predisposed to EBV-infection.

Background and Aims

LRBA deficiency is one of the PID in category of the immune dysregulation that shows heterogeneity and present with with autoimmune cytopenia , enteropathy, interstitial lung disease, extra lymphoid lymphocytic infiltration, recurrent infections.

Here we want report 2 cases of LRBA deficiency with novel mutation report and the special presentation.

Methods

case histories:

Results

Case 1: A 5 yrs old girl from related parents with history of transient thrombocytopenia , ascitis, protein losing enteropathy ,FTT, interstitial lung disease without hypogamaglobulinemia and histroy of sibling death due to hepatosplenomegaly.Immunologic workup showed normal IGs, normal vaccine response, normal CD3, CD4, CD8,CD19, CD 16-56 in peripheral flowcytometery and normal lymphocyte transformation test (LTT) test.

But mutation analysis was done by primary Immunodeficiency Group ,Institute of Cellular Medicine in Newcastle University and showed novel homozygous deletion of 5 exons (exons 18-22, c.2166_2766del) in the gene LRBA, leading to a frameshift that is followed by a premature stop codon (p.V723SfsX25).

Case 2: A 17yrs old boy from unrelated parents with history of resistant hemolytic anemia, thrombocytopenia since 8 yrs old age with normal routine immunologic workup that showed interstitial lung disease with hypogamaglobulinemia responsive to IVIG replacement and rituximab 2 yrs ago . Mutation analysis was done in the Pishgam Lab in IRAN and showed a c4730-3T.G in intron 29 of the gene LRBA.

Conclusions

These special presentation without hypogammaglobulenima at the begining of the disease presentation and novel mutations in the LRBA gene emphsis on hetrogenetiy in phenotype and genotype of PID genes .

Background and Aims

B and T cell migration into B-cell follicles depends on the chemokine receptor CXCR5 and its ligand CXCL13. CXCR5 expression on mature B and follicular T cells is essential for T–B encounters and B-cells differentiation into memory or antibody-secreting B-cells.

B-cells differentiation is defective in common variable immunodeficiency disease (CVID) patients.

Methods

Therefore, we studied the expression of the chemokine receptor CXCR5 on total and B-cells subpopulations from smB- CVID patients group. The relationship between the expression of CXCR5 and CD21 in smB- CVID B-cells was also evaluated.

Results

The percentage of CXCR5+ B-cells was lower in smB- CVID patients than controls (85.61% vs. 93.23%; p<0.05). When we compared CXCR5 expression in B-cells subpopulations, differences were restricted to naive B-cells (85.17% vs. 95.33%; p<0.001). No differences were found neither in non-class switched nor in class switched memory B-cells. Percentage of CXCR5- B-cells in smB- CVID patients positively correlated with the percentage of CD21^low B cells and percentage of double positive CXCR5+CD21+ B cells was lower in smB- CVID patients than controls (67.11% vs. 90.86%; p<0.001).

Conclusions

We have found an increase of CXCR5- B-cells that correlates with CD19+CD21^low subpopulation in smB- CVID patients. CD21^low subpopulation is expanded in autoimmune diseases and also in a subgroup of CVID patients with autoimmunity. We hypothesize that CXCR5- naïve B-cells subpopulation in smB- CVID patients might display difficulties to gain access to secondary lymphoid organs and cooperate with Tfh-cells in a negative feedback loop.

Background and Aims

Primary immunodeficiency disease (PID) is an inborn error of the immune system, and is characterized by not only susceptibility to infection but also frequent combination with autoimmune diseases and malignancies, that may be the initial presenting symptom irrespective of a previous history, making the diagnosis a challenge.

Methods

We present a patient with multiple cytopenias as the first manifestations of a Artemis deficiency.

Results

Two years-old child came to our observation for severe hemolytic anemia. After administration of Rituximab, started four months after onset due to corticodependence, we observed a failed recovery of CD20 and a persistent hypogammaglobulinemia (normal B lymphocytes at pre-rituximab immunophenotyping).

At the age of 4, he developed an autoimmune thrombocytopenia responsive to treatment with IgEV and steroid therapy. Afterwards a significant increase in infectious morbidity (2-3 episodes/year with hospitalization) occured, in particular a “round pneumoniae”, responsive to treatment with antifungals. NGS panel for SCID/CID was started because the lymphocyte immunophentyping reveal low TCD4+ and persistent low CD20.

At the age of five, the patient was treated for a nasopharyngeal EBV-related large cell B lymphoma and the biopsy, performed on a persistent skin lesion of the ankle, showed a cutaneous CD8+ cytotoxic T-cell lymphoma.

The genetic investigation has subsequently identified a heterozygosity composed of 2 new mutations of the ARTEMIS enzyme (DCLRE1C(ARTEMIS):207_209delGTT;541_542insG:L70del;E181fs).

The patient performed haploidentical HSCT.

Conclusions

Autoimmune cytopenias that are refractory to treatments and affect multiple cell lines, even if not associated with recurrent infections, imply the suspicion of primary immune deficency.

Background and Aims

PI3Kδ is a heterodimeric complex containing a p110δ catalytic molecule and a p85a regulatory subunit encoded by the PIK3CD and PIK3R1 genes, which play a critical role in the regulation of immune responses.The heterozygous gain of function mutations of p110δ, and exon-skipping mutations of p85a cause hyperactivation of the PI3Kδ complex and cause APDS type 1 (APDS1) and APDS2. Patients present in the childhood with recurrent bacterial and viral sinopulmonary infections which often complicate with bronchiectasis. Autoimmune cytopenia and gastrointestinal findings are also frequently observed. There is increased risk of lymphoproliferative diseases, and lymphoma.

Here, we present a case with PIK3R1 defect diagnosed with CVID.

Methods

At 5 years of age, the patient was admitted to the hospital due to recurrent lung infections, pleural effusion, and the history of zona zoster infection. Intravenous immunoglobulin(IVIG)treatment was started with the diagnosis of CVID at 7 years of age because of hypogammaglobulinemia and absence of specific antibody response, . In addition to low immunoglobulin levels, B cell (CD19+) percentage and counts progressively decreased during follow-up. Thorax CT revealed millimetric nodular opacities in both lungs and mucus plugs.

Results

At the age of 20, the molecular analysis revealed mutation in PIK3R1 gene (c.712C> T, p. Leu238Phe).

Conclusions

APDS should be kept in mind in patients presenting with recurrent lung infections and inflammatory diseases.Molecular diagnosis provides clinicians to use mTOR or PI3Kδ inhibitors in the management of patients as a bridge therapy until HSCT is performed.

Background and Aims

Common variable immunodeficiency (CVID) is a primary immunodeficiency disorder of the humoral immunity which causes hypogammaglobulinemia. It is not a single disease and therefore a predisposition to infection and inflammatory conditions including systemic autoimmunity and lymphoproliferative complications are also commonly associated.

Morphea, also known as localized scleroderma, is an idiopathic inflammatory disorder that causes sclerotic changes only in the skin.

Methods

We present the co-existence of morphea and CVID.

Results

Here we present a very rare case of a middle-aged male patient diagnosed as CVID under regular IVIG treatment. No infectious complications developed during the five year follow up period. However, six months ago brown-white colored plaques on the skin on periumbilical, femoral and gluteal areas consequently occured. The findings in the biopsy of the plaque were compatible with the typical morphology of morphea and sclerosan dermatitits. Methotrexate 25 mg per week and low dose corticosteroid were initiated following the spreading of the lesions.

Conclusions

In our knowledge, this is the first case report presenting the co-existence of CVID and morphea. To clarify whether there is an association between these diseases, larger case series have to be revised. Dermatologists and immunologists may keep in mind this co-existence in PID.

Background and Aims

Recently, the impact of the gut microbiota on human health has become more apparent. While bacterial communities are widely studied, the fungal research lags behind. This study aims to analyze both bacterial and fungal microbiota composition in CVID disorders.

Methods

A group of 16 case-control couples living in the same household provided stool samples for gut microbial profiling using targeted 16S and ITS rRNA amplicon sequencing (Illumina). Data were analyzed and visualized using QIIME pipeline, R software and online tool Calypso.

Results

We revealed that CVID patients harbor less diverse and significantly changed bacterial but not fungal microbiota communities in their gut. Further, the same household factor strongly impacted our data. Individuals in couples shared more similar microbiota with each other than with strangers, and thus using paired case-control samples could provide a better resolution between disease-related dysbiosis and other environmental confounders. In the case of bacterial analyses, the household impact did not outweigh the influence of health status indicating the bacterial role in CVID pathology. In the case of fungal analyses, the household was the most significant diversity determining factor, while the influence of the health status was not reflected in fungal data suggesting that fungal contribution to CVID phenotype may not be relevant.

Conclusions

We suppose that bacterial microbiota dysbiosis in CVID disorders might have a biological relevance, which is not probably true for fungal microbiota.

Supported by: MUNI/M/1322/2015/; MUNI/A/1298/2018; CKTCH IG201802

Background and Aims

MALT1 deficiency is a rare disorder causing combined immunodeficiency due to impaired CBM-complex assembly in response to receptor stimulation, and secondary impaired downstream signaling with reduced NFkB activation. We describe a 5-monbth-old male who presented at 1-month of age with severe steroid-dependent erythroderma, FTT, recurrent bacterial infections and low IgG.

PIDD gene panel revealed two novel MALT1 mutations (c.6571C>T, p.R191X; c.1666-1668delGAG, p.Glu556del) with both parents carrying only the wild type alleles, suggesting either cis or trans two de-novo mutations. While the clinical presentation supported HSCT, functional evaluation was required to establish pathogenicity of the two mutations.

Methods

Flow-based IkBa degradation and P65 phosphorylation assays were performed pre and post-transplant, together with evaluation of cytokine production and lymphocyte immunophenotyping.

Results

Patient's PBMCs showed impaired IkBa degradation and significantly reduced P65 phosphorylation (Fig 1a,b). Immunophenotyping showed low regulatory T-cells (Fig 1c). However, and in contrast to previous reports, intracellular cytokine staining showed normal percent of IL17⁺CD4⁺ T-cells and increased percent of IL2⁺CD4⁺ T-cells, suggesting possible residual CBM-complex activity (Fig 1d,e). Repeated evaluation 4 months post alemtuzumab-based matched-sibling-donor transplant showed reconstitution of IkBa degradation and P65 phosphorylation (Fig 1f,g), and recovery of Treg immunophenotyping. Clinically, the patient is now 5 months post-transplant with stable mix donor chimerism, off immunosuppressants and IVIg and with complete resolution of his symptoms.

Conclusions

The normal IL17 and increased IL2 production suggest that different mutations could result in residual MALT1 activity and therefore clinical variability. In addition, mixed donor chimerism in the range of 45% is sufficient for complete clinical resolution.

Background and Aims

APDS [Activated phosphoinositide 3-kinase (PI3K) δ Syndrome] is a recently discovered form of primary immunodeficiency. It is induced by gain-of-function mutations in genes encoding PI3Kδ subunits and over-activation of the PI3K signaling pathway. As of April 2019, the cohort of APDS patients in the European Society for Immunodeficiencies (ESID) registry consists of 87 patients, with updates following. In this study, we report a 5-year-old girl with a mutation in the PIK3CD gene.

Methods

Target gene sequencing was performed to detect the genetic mutation in this patient.

Results

5-year-old female patient, full-term, birth weight 3500g, no family history of an immunodeficiency. At 3 months – BCG-itis, received Isoniazid and Rifampicin successfully. Since the age of 7 months has been diagnosed with recurrent cases of pneumonia, bronchitis, sinusitis, spread molluscum contagiosum infection. During examination: malnourished, multiple molluscum contagiosum lesions, lymphadenopathy, splenomegaly (+4 cm). CT demonstrates fibrosis in the left lung (S9-10), lymphadenopathy (chest) and severe splenomegaly. Laboratory data: WBC count 2,9*10 3/uL, platelets 109*10 3/uL, IgG 850 (701-1157 mg/dL), IgA 76 (66-120 mg/dL), IgM 155 (38-74 mg/dL), CD3+ 0,6 (1,8-3,0*10 3/uL), СD19+ 0,06 (0,35-1,43*10 3/uL). Epstein-Barr virus infection was confirmed by peripheral-blood PCR. Bone marrow biopsy: no data for myelodysplastic syndrome. Targeted sequencing: heterozygous splice site autosomal mutation in the hot spot of the PIK3CD c.3061G>A, p.E1021K. The patient received immunoglobulin replacement, Rituximab was prescribed.

Conclusions

Rituximab, Sirolimus, and inhibitors of PI3Kδ could be efficient for the treatment of APDS because the lymphoproliferative syndrome is leading. HSCT may be a curative treatment for these patients.

Background and Aims

EBV IN PID- A CASE SERIES FROM TERTIARY CARE HOSPITAL IN MUMBAI

Vijaya Gowri

Department of Immunology, BJ Wadia Hospital for Children, Mumbai

INTRODUCTION

EBV belongs γ1 Human Herpes virus family whose pathogenicity is critically dependent upon host control. Patients with PID show increased latent viral load in the blood and are at risk of fulminant Infectious Mononucleosis and EBV driven Lymphoproliferative disorder.

Methods

Clinical and Laboratory data of cases registered with BJ Wadia hospital for Children was analysed

Results

9 cases of EBV associated disease were identified, 6 were Male and 3 Females. Mean age at diagnoses 2years - 45years. Consanguinity present in 3 cases. 9/9 positive for antibodies to EBV-VCA. Antibodies to NA and EA in 4/9 cases. EBV-PCR was positive in 5 cases. 2 cases had Selective Ig M deficiency. Lymph node Biopsy EBER positive in 5 cases. Molecular diagnosis by NGS in 4/9 cases- 1 APDS, 1 RAG1/2, 1 XLP2, 1XLP1.

1 Male+1 Female - Infectious Mononucleosis; male child had a fulminant course and expired on Day 3 of admission.

4 cases of EBV driven LPD suspected as relapse of HL- managed with Rituximab and steroids.

1 case presented with recurrent H. ZOOSTER, madarosis, lymphadenopathy, lymphomatoid papulosis of skin. Skin , L.N biopsy EBER positive.

1 case presented in DIC with ongoing sepsis. EBV-PCR positive

Conclusions

Knowledge regarding the varied presentation of EBV along with relevant investigation and enumeration of EBER aids in diagnosis. NGS should be sent to identify PID aiding in CAEBV proliferation

Background and Aims

Sepsis outcome is determined by a balance between inflammation and immune suppression. We aimed to evaluate monocytes polarization and reprogramming during these processes.

Methods

We analyzed 75 patients with suspected/confirmed sepsis and 70 controls by analysis of CD14 and CD16 expression in blood monocytes (n=50 patients with procalcitonin level >0.5 ng/mL) and HLA-DR (n=25 patients with positive blood culture) using fluorescent labeled monoclonal antibodies and BD FACS CANTO II. Complete blood cell count, procalcitonin and C-reactive protein were evaluated.

Results

Intermediate monocytes CD14++CD16+ increased in high-procalcitonin patients compared to controls (p<0,001), while classical monocytes CD14++CD16- were reduced (p<0,001). Sepsis was confirmed by positive blood culture and clinical manifestations in 44% of these patients, while 56% showed strong inflammatory state confirmed by laboratory biomarkers. The latter subgroup showed a significant increase in intermediate monocytes and decrease in classical monocytes. Three-four days following the diagnosis of sepsis, HLA-DR expression in all monocyte subsets was lower (94,3%) compared to controls (99,4%) (p<0,05). Septic patients with the worst conditions showed higher incidence of secondary infections, long-time hospitalization and lower HLA-DR+ monocytes compared to septic patients with better outcome (88,4% and 98,6%, respectively) (p=0,05).

Conclusions

The dynamic nature of sepsis correlates with monocytes functional polarization and reprogramming from a pro-inflammatory CD14++CD16+ phenotype in non-septic/high-procalcitonin patients to a decrease of HLA-DR surface expression in patients with confirmed sepsis, which makes it a marker of immune paralysis and sepsis outcome.

Analysis of monocytes plasticity opens to new mechanisms responsible for pro/anti-inflammatory responses during sepsis, and new immunotherapies.

Background and Aims

Hemophagocytic syndrome (HPS) is described by an increase in macrophages accountable for extensive phagocytosis of hematopoietic cells. Secondary HPS arises commonly in the presence of infections, neoplasia, autoimmune disorders and immune disorders.

Here we present 2 cases with IKBKB and RAG2 deficiency that were developed hemophagocytic syndrome.

Methods

Next-generation sequencing of 200 genes associated with primary immunodeficiency identified homozygous mutations IKBKB and RAG2.

Results

Case 1. An 8-mounth-old male patient had followed with primary immune deficiency. He was referred to our department with fever not responding to antibiotic treatment for 10 days and hepatosplenomegaly. We found IKBKB homozygous mutation. His father, mother and his brother have also heterozygous IKBKB mutation.

Case 2. A 12-year-old male patient presented hepatomegaly, fever with unresponsive to antibiotic treatment and elevated liver enzymes. The patient was admitted three times with HPS attack. A leaky SCID was diagnosed with RAG2 homozygous mutation.

Conclusions

We reported here hemophagocytic syndrome with IKBKB and RAG2 mutations the first time.

In our cases, we think that HFS developed due to environmental factors with primary immunodeficiency.

Background and Aims

Anti-cytokine autoantibodies (ACAAs) neutralize cytokines and are therefore an important mechanism of disease pathogenesis. Neutralizing anti-IFNγ autoantibodies result in susceptibility to mycobacterial and intracellular infections, and high titers of these autoantibodies are associated with adult-onset immunodeficiency in the South-East Asian population. Anti-IL-17A, IL-17-F, IL-22 and IFNα autoantibodies have been associated with chronic mucocutaneous candidiasis, and are found in nearly all patients with autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy (APECED), while ACAA directed to IFNα a.o. can also be present in patients with hypomorphic RAG mutations. Here we present an Indonesian boy, born in 2016, with recurrent eczema and onychomycosis, who developed an ulcer of 3cm at the site of the injection 3 weeks after BCG vaccination. The aim of this study is to determine if ACAA are the underlying mechanism causing the onychomycosis and the atypical response to the BCG vaccination.

Methods

serum ACAA were measured in the patient serum using a Luminex based in-house assay and compared to data from the child’s parents, an APECED patient and a healthy control.

Results

The patient was positive for ACAA against IFNγ, -IL-17A and to a lesser extend IL-17F. ACAA against IL-22, IFN-α were not detected. The pattern differed from APECED where high levels of anti-IL17A, IL-17F, IL-22 and IFNα were detected, with low levels anti-IFNγ autoantibodies.

Conclusions

To our knowledge this is the first child positive for anti-IFNγ autoantibodies. The anti-IFNγ and anti-IL-17A autoantibodies might explain the clinical phenotype, which we are currently exploring along with exome sequencing to identify a potential genetic defect.

Background and Aims

There is an increasing appreciation in the complexity of managing patients with common variable immunodeficiency (CVID) characterized by immune dysregulation and autoimmunity. Despite high potential for developing malignancy, treatment recommendations remain poorly standardized. We present a case of CVID characterized by autoimmunity, lymphoproliferation and a small B-cell monoclonal population that responded to rituximab.

Methods

A 39-year-old Caucasian male with CVID complicated by diffuse lymphoproliferation, granulomatous disease and autoimmune cytopenia developed worsening manifestations eight years after the diagnosis.

Results

Axillary lymph node biopsy revealed granulomas consistent with CVID, with a small CD10 positive B-cell monoclonal population on flow cytometry. Bone marrow biopsy was unremarkable. Genetic analysis for CTLA-4 haploinsufficiency and PIK3CD gain-of-function mutations was negative. Given high risk of lymphoproliferative disease, he was commenced on rituximab induction therapy. Patient declined maintenance oral immunosuppressants. Progress CT imaging ten months later showed improvement in pulmonary granulomas, near-resolution of lymphadenopathy and reduction in splenomegaly. His neutropenia resolved, with improvement in thrombocytopenia. His disease remains stable on monthly intravenous immunoglobulin replacement.

Conclusions

There is a paucity of guidelines on the management of CVID characterised by immune dysregulation and autoimmunity. Literature evidence for treatment options is largely based on case series and case reports. Our case illustrates the effectiveness of rituximab in prompting regression of lymphoproliferation and autoimmune cytopenia. Patients with evidence of immune dysregulation regardless of identifiable genetic mutations are at particularly high risk of malignancy. It is paramount that they are vigilantly assessed and consistently monitored for development of malignancy.

Background and Aims

Selective IgM deficiency (sIgMD) is classified under primary humoral immunodeficiencies and characterized by low serum IgM (<2SD for age), normal IgG-IgA levels. Our aim was to define immunologic and clinical features of sIgMD.

Methods

We assessed a retrospective medical record of patients who admitted to Pediatric Immunology department. Patients who repeatedly (at least twice in a 6-month period) fulfilled the definition of sIgMD were enrolled into the study.

Results

Out of fifty five patients, thirteen patients were diagnosed as PID during the follow-up. Most of the patients presented with infection. Seventeen patients (40%) have no additional disorder or disease.Seven patients (16%) had allergic disorders. Six patients (14%) had chromosomal anomaly or syndrome (22q11.2 deletion (n=3), trisomy 21 (n=2), 1p deletion, CHARGE syndrome, Cohen Syndrome). Six patients (14%) have autoimmune/inflammatory diseases, such Sjogren‘s syndrome, Behcet’s disease, immune thrombocytopenic purpura, Crohn disease, Guillain Barre syndrome, diabetes mellitus. Three patients (7%) have developed malignancy (myeloid cell leukemia (n=2), tubular adenoma (n=1)). Thirteen patients, who developed PID,were diagnosed as combined immunodeficiency (CID) (n=6), common variable immunodeficiency (n=2), autoimmune lymphoproliferative syndrome (n=2), chronic granulomatous disease (n=1), adenosine deaminase deficiency (n=1), congenital neutropenia (n=1).

Conclusions

The ratio of sIgMD is found as %0.15 in our immunology out-patient clinic. SIgMD could be asymptomatic. However genetic disorders, allergic and autoimmune/inflammatory diseases may accompany. We observed that some patients get diagnosis of PID during follow-up period and most of the diagnosis were CID. Thus, patients with sIgMD should be followed regularly in immunology clinics.

Background and Aims

Common variable immunodeficiency (CVID) is the most prevalent symptomatic type of human primary immunodeficiency disease (PID). Clinically, CVID is characterized by increased susceptibility to infections and a wide variety of automimmune and rheumatologic disorders. The most common rheumatologic manifestations are juvenile idiopathic arthritis (JIA) and adult rheumatoid arthritis (RA). The frequency of rheumatologic diseases in patients with CVID is 5-13%. The most prevalent rheumatologic diseases seen in patients with CVID are RA (2-3%), JIA (1-13%), Sjogren's syndrome (1-8%) and SLE (1%). We report a rare case of JIA in patient with CVID.

Methods

Case Report : 7-year old male visited pediatric rheumatology clinic. He complaint recurrent otitis media and sinusitis since 4-year old age. Recently he developed Rt wrist joint swollen with pain.

Results

Tc-99m HDP WBBS shows : increased bony uptake in Rt carpal bones, both 2nd 3rd MCP and 3rd PIP joints, suggesting arthritis. UltraSonography : synovial thickening with increased vascularity of the Rt carpometacarpal, intercarpal and radiocarpal joint without visible joint effusion, JIA most likely. CBC 6,900/mm3 Hb 11.9 g/dL platelet 423k (neutrophil 2% lymphocyte 74% monocyte 22%) ESR 14mm/hr. CRP 12.5 mg/L. IgG <50 mg/dL IgA <10 mg/dL IgM <10 mg/dL IgE <10 mg/dL. C3/C4 134/69. CH50 195. T cell (CD3) 98% Th cell (CD4) 63.5% Ts cell (CD8) 33.9%. Th/Ts ratio 1.87. B cell (CD19) 0.0 %. NK cell 1.9 %.

Conclusions

Rheumatologic complications can be the presenting symptom of immunodeficiency prior to the definite diagnosis of CVID. Particularly when accompanied by infectious and autoimmune complications.

Background and Aims

IL-6 excess is central to the pathogenesis of multiple inflammatory conditions and it is targeted in clinical practice by immunotherapy that blocks the IL-6 receptor encoded by IL6R. While the consequences of excessive IL-6 signaling in humans have been well established, the effects of impairment of IL-6R have not yet been described. Here we studied two unrelated patients with homozygous mutations in IL6R, presenting with recurrent infections, abnormal acute phase responses, elevated IgE, eczema and eosinophilia.

Methods

Peripheral blood mononuclear cells were assessed for their responsiveness to IL-6, IL-21, IL-27 through downstream STAT3 phosphorylation by flow cytometry. PBMCs from both patients were also used to assess the composition of differentiated T-helper cell subsets as well as cytokine release upon stimulation by flow cytometry. Single cell RNA sequencing was performed to for granular assessment of the immune cell phenotype

Results

Our results reveal the role of IL6 signaling on the differentiation of T helper subsets, indicated by diminished but present Th17 and Th1 populations. Similar to STAT3 deficient patients, B cell development was also impaired reflected by reduced percentage of memory B cells. In addition, pathological effector Th2 cells associated with chronic eosinophilic inflammation were elevated in both patients, in concordance with severe atopy and elevated IgE.

Conclusions

This study identifies a novel primary immunodeficiency, clarifying the contribution of IL-6 to the phenotype of patients with mutations in IL6ST, STAT3 and ZNF341, genes encoding different components of the IL-6 signaling pathway, and alerts us to the potential toxicity of targeting the IL-6R.

Background and Aims

TCR/CD3 complex is crucial for the development and regulation of T cells. In humans, CD3D, CD3E, and CD3Z gene defects cause severe immune deficiency and present early in life with increased susceptibility to infections. By contrast, CD3G mutations lead to milder phenotypes, mainly characterized by autoimmunity.

Methods

Bearing recurrent sinopulmonary infections without opportunistic infections compatible to hypogammaglobuliemia but normal PHA lymphocyte proliferation, a male 36-year-old adult receives genetic analysis after regular IVIG over 15 years. His lymphocyte subsets, CD3 expression, T regulatory (Treg) cells and suppression are assessed. To comprehensively review this rare disease, we analyze the phenotypes, genotypes, treatment and prognosis from a PubMed search to hopefully guide optimal management.

Results

In contrast to the previous CD3G mutations presenting as autoimmunity, the novel CD3G mutation maintains sufficient Treg number and suppression makes him free of autoimmunity of autoimmune thyroiditis, inflammatory bowel disease, and pancytopenia. CD27+memory B cells are almost absent. Pubmed research reveals 7 Turkish and 2 Spanish patients (5 unrelated families). They are the splicing mutations 80(-1)G>C (in 14), missense mutations c.1G>A (2), and nonsense mutations c.250A>T (2). Three only present with isolated autoimmune thyroiditis without significant infections. Only our patient has neither any autoimmunity nor detectable autoantibody. Three mortalities were severe infection at 31 months, post-transplant viral pneumonia at 17 months and graft vs host disease (GvHD) at 47 months.

Conclusions

With the novel CD3G mutation, the patient presents as predominantly B cell deficiency mimicking the CVID phenotype and lacking the recognizable autoimmunity. This finding expands the phenotype in patients with CD3G mutations.

Background and Aims

Subcutaneous immunoglobulin (SCIG) is increasingly utilized in primary immunodeficiency (PID). Understanding patient treatment experiences is critical to improve outcomes. We analyzed Immune Deficiency Foundation (IDF) survey data to evaluate relationships between SCIG training, infusions, and patient-reported outcomes.

Methods

Multivariate logistic models identified predictors of high scores (top third) in Treatment Satisfaction Questionnaire for Medication (TSQM) domains (convenience, side effects, effectiveness, and global). Independent predictors were determined by backward selection of covariates significant in univariate analyses.

Results

Among 366 SCIG respondents, favorable training characteristics drove higher odds (p<0.05*, <0.01**) of being top third for TSQM domains including: convenience (confidence post-training: Odds Ratio [OR] = 3.0** and absence of training barriers: OR = 2.2*); side effects (confidence post-training: OR = 2.04*); effectiveness (no training barriers: OR = 2.4**); and global (trainer competence: OR = 3.5**). Efficient infusions increased odds of high TSQM domain scores: convenience (infusion preparation <20 minutes: OR = 1.95**); side effects (infusion preparation: OR = 1.88**, actual infusion: OR = 1.70*); and global (infusion preparation: OR = 1.76*). Age (<18 years) and treatment experience ≥ 2 years also increased odds of high TSQM domain scores. Compared with least favorable, those with most favorable training/infusion characteristics had higher predicted probabilities of high TSQM domain scores: (convenience, 55% vs 5%; side effects, 75% vs 5%; effectiveness, 44% vs 24%; global, 50% vs 7%).

Conclusions

Results suggest that improvements in SCIG training and infusion characteristics can drive better patient outcomes including convenience, reduced side effects, effectiveness and overall satisfaction.

Background and Aims

Background:Bare II lymphocyte syndrome is characterized by the absence of expression of HLA class II molecules. It is the result of a mutation in the genes encoding one of the 4 elements that regulate the expression of HLA class II molecules. Patients present recurrent infections characteristic of combined immunodeficiency.

Methods

Methods:
Child is two years old. At 12 months presented protracted diarrhea, enterorrhagia, failure to thrive . He presented multiple pulmonary and gastrointestinal infections and required gastrostomy and parenteral nutrition. At 18 months he presented non-infectious hepatitis. Several months later he had intestinal intussusception that it reduced by manual in a laparoscopy procedure.

Results

Results:
Lung CT scan showed imagen suggestive a lipoid pneumonia or pneumonia by Pneumocystis jirovecii. Intestinal MRI showed thickening of distal ileum, caecum, similar an inflammatory bowel disease (IBD), probable Crohn disease. Gastrointestinal biopsies ruled out BID.Flow cytometry: CD3+ 49. 60%/1858 cel/uL, CD4+: 7. 35%/275 (low), CD8+: 40. 47%/1515 , BCD19+: 44. 58%/153. IgA 0. 0 mg/dL, IgG 49, IgM 110, IgE 0. 10 IU/ml. It was observed total absence of the expression of MHC Class II molecule in T lymphocyte and monocyte in our patient.

We performed the mutation analysis of genes (NGS)encoding CTIIA, RFX5,RFXAP, RFXNK. We report a new mutation in CIITA gene cr16:c. 925C>T in exon 9;p. (Arg309) probably a pathogenic variantnot yet reported in the literature.

Conclusions

Conclusion:
Bare class II lymphocyte syndrome went confirmed by absence of the expression of MHC Class II molecule in T lymphocytes and Monocytes in our patient and the identified new mutation in CIITA.

Background and Aims

Recent findings in PANS suggest a relationship between a post-infectious response and behavioral changes, which may be a form of autoimmunity, through molecular mimicry, resulting in various neurological symptoms. We’ve identified several common immune defects in PANS patients which suggests a new immune deficiency. Given our findings, we hypothesized that an immune memory defect is the underlying mechanism leading to PANS (Melamed I. Immunother Open Acc. 2016;2:2).

Methods

Based on this hypothesis, we proposed a study to explore the efficacy of IVIG [Octagam 5%] for PANS treatment. The primary objective was evaluation of IVIG efficacy over a period of 6 months (6 infusions) based on scores of 6 different assessments, including the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Secondary objectives included evaluation of the immunomodulatory effect of IVIG on key biomarkers associated with PANS, including assessment of toll-like receptor (TLR) functionality at baseline and following IVIG.

Results

Statistically significant reductions in symptoms from baseline to end of study were seen in all 6 assessments measured. CY-BOCS results demonstrated statistically significant reductions in obsessive compulsive symptoms, representing > 50% improvement, sustained 8 weeks after the final infusion. In addition, there was a statistically significant upregulation of TLR function in response to IVIG treatment, which we believe may occur to better address inflammatory processes.

Conclusions

In patients presenting with PANS, which may be associated with an underlying immune deficiency mechanism, IVIG [Octagam 5%] successfully mitigated psychological symptoms and upregulated TLR function.

Background and Aims

Pathogenic variants in the protein kinase C delta (PRKCD) gene cause autoimmunity, humoral immunodeficiency and recurrent infections. Previously described patients showed B-cell lymphopenia with normal T-cell numbers, dysgammaglobulinemia and impaired class-switching without notable pulmonary manifestations.

Methods

Chart review and clinical care of patient.

Results

A Palestinian male with consanguineous parents presented at 15 months with joint swelling, splenomegaly, rash and fevers. Elevated inflammatory markers and positive ANA, anti-phospholipid, anti-Smith, and anti-double stranded DNA antibodies were noted. At 6 years, he developed immune-mediated cytopenias (positive DAT and anti-neutrophil antibodies). CD3, CD4 and CD8 absolute values were decreased; T-cell proliferation to antigens was reduced. CD19 absolute value was normal; IgG and IgM were low. Alpha/beta CD3+CD4-CD8- T-cells were 13.7% but pathogenic variants in FAS were not identified. Mycophenolate improved his lymphoproliferation and cytopenias. His course was complicated by frequent fungal/bacterial infections (sinusitis, orbital cellulitis and pneumonias) resulting in bronchiectasis and chronic atelectasis requiring azithromycin treatment and daily chest physiotherapy. At 18 years he was referred for further immunologic evaluation with genetic testing revealing a novel homozygous PRKCD variant (c.1872+1G>A). Reduced class-switch (CD19+CD27+IgD-) and total memory B-cells were noted. IVIG replacement was initiated.

Conclusions

Our patient expands the clinical, immunologic and genetic phenotype of PRKCD deficiency by showing prominent pulmonary manifestations, displaying quantitative & qualitative T-cell deficits in-addition to B-cell abnormalities, and harboring a novel pathogenic variant. Undefined immunologic dysregulation patients should be regularly assessed for newly discovered genetic alterations given the ever-changing genetic landscape of immunodeficiency conditions.

Background and Aims

IL-12 receptor deficiency is a well-characterized primary immunodeficiency that leads to infections mainly with mycobacteria and Salmonella. The aim of the study is to report manifestations and causes of vasculitis complicating IL-12 receptor deficiency.

Methods

This is a retrospective study including patients with IL-12 receptor deficiency who developed vasculitis during a follow up of 10 years.

Results

Among 14 children affected by IL-12 receptor deficiency, three have developed vasculitis. They were two boys and one girl. Vasculitis was diagnosed at the age of 8 months, 22 years and 3 years, respectively. Edema and purpuric eruptions were present on the lower extremities in three patients. One patient had acute ischemia by thrombosis of the left humeral artery. Skin biopsy showed leukocytoclastic vasculitis. Serologic tests for vasculitis (rheumatoid factor, antinuclear antibody, and antineutrophil cytoplasmic antibodies were negative in all cases. Infectious tests revealed Salmonella Enteritidis in blood and stool cultures of two patients. In these two cases, the successful treatment of septicemia using antibiotics was accompanied by the disappearance of Vasculitis. Vasculitis relapsed in one patient in the same territory, concomitant with a recurrent Salmonella sepsis. Limb amputation was performed in another patient after the failure of the discharge with aponeurotomy.

Conclusions

Clinicians should be aware of possible infectious causes of vasculitis in IL-12 receptor deficiency patients. Patients should be first tested for specific Salmonella infection. In addition, autoimmunity was also reported as a possible cause of vasculitis in these patients.

Background and Aims

Background

LPS Responsive Beige like Anchor Protein (LRBA) is a BEACH Domain Containing Protein that was first fully cloned in mouse and human in 2001. LRBA mRNA is expressed in almost all cell types with an elevated expression in immune cells. LRBA deficient patients have inadequate proliferation of B cells and defective autophagy resulting in hypogammaglobulinemia and autoimmunity. Here we present the first Indian cohort of LRBA deficiency.

Methods

Clinical and immunological phenotype, therapeutic approach and outcome of 3 patients from 3 different families were assessed retrospectively in this study.

Results

Demographics: Age of first symptom varied from 10 months for homozygous mutation to average of 4 years for the heterozygous one. All patients had autoimmune cytopenias with age of onset around 3 years of age.Clinical phenotype: The most common clinical manifestations was organomegaly and autoimmunity. Autoimmunity mainly presented as immune mediated cytopenia. One child had family history of autoimmunity. One patient had insulin dependent diabetes mellitus with celiac disease.Infectious profile: All patients had at least one documented infectious episode. 2 episodes of viral infections were seen, EBV and severe chickenpox.Immunological phenotype:The only non-immunosuppressed patient had a normal lymphocyte subset analysis. All 3 patients had a normal immunoglobulin assay at presentation, one child developed hypogammaglobulinemia after rituximab. Therapeutic Approach:As abatacept is too costly and non-affordable in our patient cohort we used sirolimus for all 3 patients. All children have no side effects to sirolimus therapy so far. None of them have undergone HSCT.

Conclusions

Sirolimus can be effective as single drug with good disease control in LRBA deficiency.

Background and Aims

Adult-onset immunodeficiency with susceptibility to intracellular microbes due to inhibitory and neutralizing auto-antibodies against IFN-γ (AutoAbs-IFN-γ) constitutes a phenocopy of Mendelian susceptibility to mycobacterial disease (MSMD). The majority of cases are adults of Asian descent.

Methods

By flow cytometry, we evaluated expression of IFN-γR1, IL-12Rβ1 and phosphorylation of STAT1 on PBMCs from an adult patient with mycobacterial infections. We also evaluated the presence of auto-antibodies against IFN-γ and their biological activity.

Results

Patient is a 52-year-old male from Paraguay (Amerindian origin). He presented loss of weight, fever, night sweats, lesions compatible with erythema multiforme, adenomegalies and hepatosplenomegaly. Chest CT showed a bilateral micronodular interstitial pattern, multiple paratracheal lymph nodes, osteolytic lesions in sternum and left costal arch at D10 level. Histoplasma capsulatum was isolated from cultures of skin lesions and knee synovial fluid specimens and serological test for H. capsulatum was also positive. After 1 year, acid-fast bacilli were detected by Ziehl Neelsen stain in lymph node puncture-aspiration and culture was positive to Mycobacterium avium. After 7 months the patient suffered Herpes Zoster Ophthalmicus in his left eye. Expression of IFN-γR1 on monocytes or IL-12Rβ1 expression on PHA-stimulated lymphocytes was normal. IFN-γ/IFN-α induced STAT1 phosphorylation on PBMCs was similar to healthy control. However, high titer of AutoAbs-IFN-γ was detected in patient. Patient plasma showed a neutralizing biological activity on downstream cytokine production by incubating with normal donor PBMCs stimulated with LPS and IFN-γ.

Conclusions

We present the first South American patient with high titers of AutoAbs-IFN-γ associated to MSMD phenotype.

Background and Aims

Several case reports have described immune-hematological abnormalities in genetic syndromes and metabolic diseases that are currently not included in IUIS and ESID classifications. In these rare conditions, the incidence of such manifestations is unknown. Therefore, we performed a retrospective survey study.

Methods

All members of the Italian Primary Immunodeficiency NETwork (IPINet) were invited to report patients with defined chromosomal aberrations or genetic lesions (excluding genetic syndromes or metabolic diseases included in the IUIS or ESID Classifications).

Results

Eighteen patients from 3 centres (10 males, 8 females; median age of presentation 2.5 years [range 0-23 years]) have been enrolled so far (Table 1). We observed clinical manifestations and/or immune abnormalities in eight patients with genetic syndromes and 10 patients with metabolic diseases (shown in Table 1). The most important clinical manifestation prompting the immunological evaluation was recurrent infections (10/18, 56%). Immunoglobulin isotype and B cell deficiencies were the most common immunological abnormalities reported (11/18, 61%; Table 2), requiring IVIG replacement therapy in 4 patients.

Conclusions

Our survey shows that many genetically inherited syndromes and metabolic diseases that are not included in IUIS and ESID classifications are associated with immune-hematological abnormalities. Although airway infections can also be secondary to other causes (e.g. aspiration or structural abnormalities), a significant number of patients also have an antibody deficiency that may benefit from specific treatments (e.g. immunoglobulin replacement). Therefore, our study suggests that immunological investigations should be performed if patients with genetic syndromes and metabolic diseases present with recurrent infections.

Background and Aims

PIDs are often associated with autoimmunity due to dysregulation of the immune system as a whole. Clinical phenotypes are heterogeneous and often overlapping and, while in most patients a monogenic cause of disease has been identified, recent advancements made in genetic analysis, in particular with the introduction of high throughput techniques, reveal that a polygenic cause is likely. Our aim is to investigate the genetic background of patients with signs of immunedysregulation and autoimmunity, and to evaluate the pathogenicity of gene variants identified through extensive functional studies.

Methods

We selected nineteen patients, referring to the Haemato-Oncology Department of A. Meyer Children’s Hospital, with signs of immunedysregulation and autoimmunity and we performed extended immunophenotyping and Next Generation Sequencing (NGS) analysis of 50 PID-associated genes.

Results

In six patients we identified a single gene as responsible of the clinical feature. In particular, we identified two patients with STAT3 GOF, one with an activating PIK3CD mutation, and three patients harboring mutations in CTLA4, RAG1 and FAS genes, respectively. Most of them also harbor variants in multiple genes and some of these are recurrently mutated in more then one patient: WAS, DOCK8, CASP10, CASP8, NFATC2 and FCGR3A. Further studies are ongoing to validate the effect of gene variants identified.

Conclusions

Our results suggest that the old hypothesis, based on a single gene mutation as cause of disease, should be revised in favor of the concept that "is the sum that causes the effect" and that a different point of view on PIDs seems inevitable.

Background and Aims

Systemic lupus erythematosus (SLE) is a complex autoimmune disease marked by wide range of system dysfunctions. Traditionally we used to think that autoimmune disease arise as a result of failure of adaptive immune system to distinguish self and nonself antigens. Howerer, as in many inherited immunodeficiencies, frequently we see that inherited innate genetic mutation play pivotal part in autoimmune phenotype as well. DNASLE13 is endonuclease that is intimately involved in digestion of apoptotic micropatricles associated DNA and in prevention of anti-DNA antibody formation. When mutated, triggers SLE development. Aim was to describe patient with early-onset hypocomplementemic urticarial vasculitis who developed SLE at age 10,5y, with skin, lungs, heart, gastrointestinal, hematopoetic, serosal membranes, musculoskeletal and kindey involved , and positive ANA, anti-dsDNA, hypocomplementemia and lupus anticoagulant.

Methods

next-generation sequencing (NGS) was performed on TruSightOne sequencing kit (4813 genes) for all autoinflamatory diseases and interferonopaties. Results were confirmed by Sanger sequencing.

Results

NGS of patient revealed homozygous mutation in exon 6 of DNASE1L3 gene (Deoxyribonuclease 1 Like 3) : one-nucleotid deletion NM_004944.3:c.643delT in egzon 6 of the, state. Mutation was described in HGMD base as disease causing mutation of SLE. In silico predictive analysis showed it as patological mutation (Mutation taster, CADD Phred 35, ACMG criteria). Mutation in DNASE1L3gene are SLE causing mutation (OMIM #614420).

Conclusions

we identified patient with DNASE1L3 mutation causing lupus erythematosus in patient with early-onset hypocomplementemic urticarial vasculitis syndrome pointing to dysregulation of nucleic acid sensing and degradation.

Background and Aims

Severe γδT-lymphocytosis (γδTL) in patients with primary immunodeficiency (PID) is suggestive of T-cell lymphoma but is also found in rare cases of atypical combined immunodeficiency (CID). We report two closely related patients with CID and γδTL.

Methods

Retrospective analysis

Results

Patient 1: 21-year old male with recurrent diarrhea, hypoalbuminemia, recurrent pneumonia and bronchiectasis. He is receiving intravenous immunoglobulin (IVIG) therapy since age 6 months. At age 15 years autoimmune hemolytic anemia (AIHA), occasional neutropenia and thrombocytopenia ensued. Flow cytometry (FC) of peripheral blood detected CD8-positive absolute (970-1,310 γδT-cells) γδTL with irregular immunophenotype and decreased number of switched B-memory cells (SBMC). Clonal expansion of T cells was recorded, and T-cell receptor excision circles (TRECs) were absent. FC of bone marrow revealed significant decrease of mature and increase of immature B-cells. Patient responded to systemic steroids and increased frequency of IVIG. He showed no evidence for malignancy with a 6-year follow-up period.

Patient 2: 5-year old male who had since birth recurrent respiratory distress. At 10 months he developed severe AIHA with a partial response to steroids and IVIG. FC showed severe T-lymphopenia with relative γδTL (26-31%/T-cells) and low number of SBMC. Complete absence of TRECs was found. He received myeloablative matched sibling hematopoietic stem cell transplant and recovered.

Whole exome sequencing was unrevealing in both patients.

Conclusions

This report supports the assumption that severe clonal γδTL in patients with PID can directly result from disordered lymphopoiesis and exist without malignant transformation. The cases may be related to CID with immunophenotypically rare clonal γδTL.

Background and Aims

Backgroud: VEO-IBD represents a unique and growing subset of patients with inflammatory bowel disease (IBD). Some VEO-IBD patients present with immunodeficiency and possess loss of function genetic mutations involving immune pathways that cause their IBD. A search for Mendelian causes of IBD is likely most beneficial when the presentation involves extra-intestinal autoimmunity or involves intestinal histopathology that is atypical for IBD. A previously healthy 7-month-old male infant, with no family history of consanguinity presented with profuse bloody diarrhea and associated protein loss. VEO-IBD was suspected. He progressed to small bowel obstruction that requires two intestinal resections. Histopathology showed a necrotizing vasculitis suggesting PAN. He was treated with methylprednisolone, cyclophosfamide and then mycophenolate with a good clinical response. Invitae Primary Immunodeficiency Panel and then whole exome trio sequencing performed by Dr. Kotlarz group, did not report any mutations suggesting VEO-IBD.

Methods

Case report

Results

Case report

Conclusions

Conclusions: PAN should be consider in children with a suspicion of VEO – IBD as a differential diagnosis. Our understanding of necrotizing vasculitis has evolved over time. In addition to PAN and ANCA –associated vasculitis, a broad range of diseases is now recognized with different etiopathogenesis such as monogenetic diseases: DADA2, familiar Mediterranean fever, SAVI , RAG1 
or RAG2 and TAP deficiency . In our patient, we did not find any mutation of VEO-IBD nor other secondary necrotizing vaculitis. The sequencing results of this patient are been frequently re – assessed by the International VEO-IBD Consortium.

Background and Aims

The clinical manifestation of primary immunodeficiencies with a defect in antibody formation can be caused not only by severe long-term infectious lesions, but also by autoimmune diseases.

Methods

Twenty-two patients were diagnosed with primary a- (hypo)gammaglobulinemia. The course of the disease of the 15 patients was manifested by frequent infections (infectious phenotype, IP). Two people were diagnosed with Crohn's disease, five patients - rheumatoid arthritis (autoimmune phenotype, AP).

Results

A comparison of the parameters of immunity showed that in patients with AP, the number of T cells expressing the HLA DR more (AP -18 ± 2.1%, IP - 9 ±1.7%), and the number of T-reg is less than of patients with IP (AP 0.6 ± 0.3%, IP-1.1 ± 0.6%), which also demonstrates index Treg/СD4: AP-1.5 ± 0.4%, IP-3.7 ± 0.8%. In the conditions of the autoimmune manifestation, in comparison with infectious, expression of TLR2 (AP-80 ± 5%, IP-42 ± 3%), TLR4 (AP-60 ± 5%, IP-21 ± 7%), HLA DR (AP -80 ± 7%, IP-40 ± 4%) with monocytes, also the synthesis of IL-6 (AP-14 ± 2.6 pg / ml, IP-2.6 pg / ml), IFN-γ (AP -93 ± 5.9 pg / ml, IP - 78 ± 8.3 pg / ml) increases, while the serum content of IL-17 (16 ± 3.3 pg / ml) was determined only in patients with AP

Conclusions

The clinical manifestation of autoimmune processes of patients with a-(hypo)gammaglobulinemia is associated with weakening of T-immunosuppression, increasing of the activational indexes of T-lymphocytes and antigen-presenting cells, increasing of the production of proinflammatory mediators

Background and Aims

Ataxia-telangiectasia (AT) is a multisystemic neurodegenerative disorder characterized by ataxia, telangiectasia, and immunodeficiency. Although elevated serum levels of IgM with decreased IgA and IgG levels have been reported in about 10% of the AT cases during their course of the disease, it is a rare finding at the onset and may cause to delay of diagnosis or misdiagnosis as hyper-IgM syndrome.

Methods

A 6-years-old boy referred our clinic due to hypogammaglobulinemia. He had been followed up with an autoimmune thrombocytopenia and hemolytic anemia at the age of 1.5 years. He was born to consanguineous parets and had history of recurrent sinopulmonary infections. Physical examination revealed growth retardation and mild gait disturbance.Serum IgG and IgA levels were low and IgM level was 519 mg/dl. CD19 lymphopenia was detected. AFP level was high and diagnosis of ataxia-telangiectasia was confirmed by detecting ATM homozygous mutation. The patient was treated with IVIG replacement, prophylactic antibiotic and antifungal.

Results

During the follow-up, neurological findings and telangiectasias progressively increased. The patient is still followed up without infection or hemolysis by IVIG replacement and prophylactic antibiotics.

Conclusions

Since cerebellar ataxia and ocular telangiectasia may not be present in infancy, the diagnosis of AT may be delayed during this period. Also the patients presenting with elevated IgM serum levels may be misdiagnosed as HIGM syndrome. As in this case, the diagnosis of AT should be kept in mind in patients with primary immune deficiency with abnormal neurological findings and autoimmunity.

Background and Aims

CTLA-4 is an inhibitory receptor expressed on Treg cells. Haploinsufficiency of CTLA-4 cause severe loss of tolerance and autoimmune disease, hypogammaglobulinemia, recurrent infections, and lymphoproliferation.

Methods

Four years old girl, born to consanguineous parents (second-degree cousins) with a history of autoimmune cytopenia presented with reccurent sinopulmary infection, growth retardation and hepatomegaly. Coombs positive hemolytic anemia, polyclonal hypergammaglobulinemia and CD4 lymphopenia were detected. DNT cells and burst test were normal. The patient was treated with IVIG replacement, prophylactic antibiotic and antifungal. Autoimmune hemolytic anemia was improved with steroid treatment. The genetic analysis was sent but the patient died of infection. Nine years later CTLA 4 mutation was detected in the sent blood samples when CLTA4 mutation was defined in 2014.

Results

Nine years old male patient referred to our clinic due to lymphopenia with a history of dermatitis, recurrent lymphadenomegaly and autoimmune hemolytic anemia. Physical examination revealed bilateral inguinal lympadenomegaly and splenomegaly. Skin biopsy was compatible with psoriasiform spongiotic dermatitis. CD4 lymphopenia was detected but immunoglobulin levels and DNT were normal. Abdomen ultrasonography revealed splenomegaly and hypoechoic areas consistent with lymphoproliperative disease in the spleen. The patient was treated with IVIG replacement, prophylactic antibiotic and antifungal. Genetic analysis revealed CTLA 4 mutation.

Conclusions

CTLA4 mutations are characterized by immune dysregulation syndrome including extensive T cell infiltration in a number of organs, including the gut, lungs, bone marrow, central nervous system, and kidneys. CTLA 4 mutation should be considered in the differential diagnosis of immune dysregulation in patients with autoimmunity and lymphoproliferation.

Background and Aims

Patients with deficiency of the x-linked inhibitor of apopotosis (XIAP) may present with inflammatory bowel disease (IBD) and predisposition to hemophagocytic lymphohistiocytosis (HLH). Predominant inactivation of the wildtype x-chromosome has been identified as cause of symptomatic x-linked conditions in females. Inflammation-induced reprogramming of Xiap^−/− T_reg cells can be prevented by blockade of the IL-6 receptor (IL-6R) in mice.

Methods

A girl presented with very early onset IBD, dermatitis, two episodes of immune dysregulation (5/8 HLH criteria) with spontaneous remission, flares of autoinflammation with fever and elevated markers of inflammation. Infliximab, adalimumab and anakinra only resulted in limited short time effect on IBD and stool-frequency up to 10 times per day, still requiring frequent hospitalization. The introduction of the humanized monoclonal interleukin-6 (IL-6) antibody tocilizumab resulted in absence of fever, resolution of dermatitis, decrease of stool-frequency to 3 times per day, normal activity level, and substantial reduction of corticosteroids.

Results

Diagnosis of XIAP deficiency was established by strongly reduced expression of XIAP in peripheral blood mononuclear cells assessed by flow cytometry. Sanger sequencing of the corresponding gene BIRC4 identified a heterozygous nonsense mutation (c.664C>T; p.Arg222*). An extremely skewed x-inactivation with wildtype inactivation nearly 100% of cells was revealed by HUMARA assay. Introducing the IL-6 antibody tocilizumab lead to substantial reduction of inflammatory activity. SCT from a matched unrelated donor as curative treatment is planned.

Conclusions

Tocilizumab may be considered as treatment alternative in children with XIAP-deficiency. It may help to reduce inflammation and IBD symptoms.

Background and Aims

Analyzing rare human patients with inborn errors of immunity may shed light on critical genes and pathways controlling differentiation and/or function of the innate and adaptive immune system.

Methods

We performed genetic and cellular immunologic analyses involving two patients from unrelated families with shared phenotypes of immunodeficiency with defective lymphocytic responses, autoimmunity and malignancy

Results

We identified two distinct homozygous mutations in the gene encoding CD137, leading to reduced or loss of protein expression. Lymphocytic responses crucial for immune surveillance, including activation, proliferation, cytotoxicity and differentiation were impaired. Genetic reconstitution of CD137 reversed these defects.

Conclusions

CD137 deficiency is a novel inborn error of human immunity characterized by combined immunodeficiency associating autoimmunity and Epstein-Barr virus (EBV)-induced lymphomagenesis. Our findings elucidate a functional role and relevance of CD137 in human immune homeostasis and surveillance.

Background and Aims

Primary immunodeficiency (PID) are genetically inherited defects of the immune system that occur in approximately 1 in 2000 live births. PID patients are a heterogeneous group with increased risk of recurrent pathogenic infections and/or inflammatory disease. Inflammatory disease can be organ specific or systemic, and is caused by a dysregulated immune response. Patients suffering from immune dysregulation have increased morbidity and mortality, and often require specialized and urgent care. Due to the heterogeneity of the disorders it is impossible to develop a common treatment protocol, and current treatment usually reflects organ-specific immunosuppressant treatment used in other inflammatory diseases. To promote precision diagnosis, we aim to gain insight in the underlying inflammatory processes in the tissue in PID immune dysregulation.

Methods

We utilized an innovative and powerful multiparameter analysis method, imaging mass cytometry, to visualize the inflammatory response in tissue biopsies from 4 patients with immune dysregulation in the gut. Patients had either a PI3KR1, STAT1, or STAT3 variant.

Results

Inflamed intestinal and colon tissue biopsies showed metabolic activity through elevated phosphorylated-S6, as expected in inflamed tissue. However, we detected differences in the types of cells infiltrating the gut (CD8⁺ cytotoxic T cells, memory T cells), and in the local inflammatory cytokine responses (IL-17, IFNgamma, IL-10) between the different patients with immune dysregulation.

Conclusions

We show that tissue inflammation in patients with immune dysregulation in the gut is heterogeneous, which emphasizes that understanding the nature of tissue inflammation is vital for precision diagnosis and, consequently, targeted treatment for PID patients with inflammatory immune dysregulation.

Background and Aims

CVID is characterised by recurrent infections, for which patients receive IRT. Besides infections, CVID patients are prone to develop immune dysregulation (ID) and commonly use immunomodulating medication. The adaptive immune system has an important role in the pathophysiology of CVID and ID and shifts in both the T – and B-cell compartments have previously been described. This study further characterises the phenotype of CVID patients with ID and investigates the effect of IRT.

Methods

For this longitudinal study, 89 CVID patients were included and immunophenotypical data was collected. To cluster cell types principal component analysis (PCA) was performed, followed by paired sample analysis to calculate mean differences in individual cell types after IRT initiation. Finally, non-linear mixed model analysis was used to analyse possible confounders and the effect of ID.

Results

PCA consisted of four components, although none of these clustered on IRT the naive T-cell component clustered on ID. B-cells were lower after IRT initiation (298.59 vs 382.05, p<0.001), and there was a remarkable switch from naive to effector/memory in both the CD4 and CD8 T-cell compartments from ID patients, which was stable over time. Via multivariate analysis no remarkable confounders were found.

Conclusions

IRT reduces the number of B-cells in patients with CVID, without changing the subtype ratio. This possibly means that future study design does not need to correct for IRT status. Moreover, this study further implicates the effector/memory T cells as an important marker for ID that is stable during disease progression.

Background and Aims

Heterozygous mutations in cytotoxic T-lymphocyte-associated-antigen4 (CTLA-4) gene is often associated to immune dysregulation syndrome characterized by increased cancer susceptibility. We describe 3 CTLA4 mutation carriers identified among a cohort of 17 CID/CVID patients.

Methods

Immunophenotypical, functional and molecular studies

Results

Two mutation carriers (Pt1 and Pt2) were affected presenting decreased naïve-CD4+ T-, Treg-, NK-, memory B -cells with increased CD21low B cells, Tfh-, effector-memory CD8+ T –cells and a chronic EBV viremia. Pt1 was admitted to our Hospital for a gastric cancer with a previous history of IBD, diabetes mellitus, polyarthritis. Pt2, currently 35y has hypogammaglobulinemia and thrombocytopenia treated with high doses of Ig and corticosteroids at the age of 13y. She developed melanoma and uterine myofibromas in adult age. Parents with the same mutations, developed milder clinical manisfestations in older age (Pt1-father autoimmune thyroiditis and Pt2-mother’ ndd-cholangitis).NGS revealed two heterozygous mutations in CTLA4 gene. Marked and mild decrease of CTLA4 upregulation assessed on activated memory Treg cells were observed in Pt1-2. Finally, Pt3 carries p.T17A polymorphism that has been reported associated to nephrotic disease. He was admitted at 16y to our Hospital for lymphoadenopathies, hypogammaglobulinemia, persistent fever, and chronic EBV-viremia. At 10y he had nephrotic syndrome treated with Mabthera.

Conclusions

Early genetic diagnosis could change clinical history and management of CTLA4 patients conditioning the choice of a proper-targeted therapy. As reported in a large study cohort (Grimbacher et al) chronic EBV viremia and lymphoproliferation frequencies in these patients, should be carefully monitored to avoid a worsening of the disease and cancer onset

Background and Aims

RAS-associated autoimmune leukoproliferative disorder (RALD) is a very rare and sparsely characterized non-malignant condition occurring in patients with somatic, gain-of-function mutations in NRAS or KRAS. We here present a 2-year old boy with somatic NRAS mutation followed due to delayed development, recurrent respiratory tract infections and liver dysfunction, who was acutely admitted with severe edemas, dyspnea, fatigue, and minor bleedings.

Methods

Flow cytometric analyses of BM, PB and lymph node.

Results

Laboratory test revealed persistent thrombocytopenia, leukocytosis with monocytosis and hypergammaglobulinemia with multiple autoantibodies, which all had been present from 8 months of age. Repeated BM assessments showed JMML-like phenotype without blast cells. CT scan showed hepatomegaly and systemic lymphoid tissue expansion. A sigmoid biopsy displayed mononuclear cell infiltrates. Flow cytometry revealed many CD14+CD16+ non-classical monocytes (63% of monocytes in lymph nodes, 30% in PB) and B-cell lymphocytosis but only 2.4% CD3+TCRαβ+CD4-CD8- DNT cells, suggesting the diagnosis of RALD.
Additional phenotyping showed activation of neutrophils and B cells, maturation, activation and exhaustion of the T cell compartment and numerous FOXP3+ regulatory T cells (Figure), indicating an immune dysregulation of both myeloid and lymphoid lineages. Furthermore, two small populations of immature mCD3-cyCD3+ T cells were found in PB and lymph node.

Conclusions

We show increased activation of myeloid and lymphoid cell subsets, and a marked increase in regulatory T cells in addition to clinical and laboratory characteristics of RALD. Treatment with steroids and sirolimus was initiated, but inhibition of the Ras pathway (e.g. with selumetinib) could be another potential target.

Background and Aims

Chronic granulomatous disease (CGD) is an inherited immunodeficiency predisposing to recurrent invasive infections and non-infectious granulomatous disease. Autoimmune manifestations, mainly discoid lupus erythematosus (DLE), have been described in CGD patients and reported in about one quarter of X-linked carriers. However, systemic lupus erythematosus (SLE) has been rarely reported as a prominent feature of CGD patients.

Methods

We report on a case of familial SLE revealing late-onset X-linked CGD.

Results

A 15-year-old man from a non-consanguineous French family developed photosensitivity with typical malar rash eruption, Raynaud phenomenon, peripheral synovitis and cutaneous vasculitis. Isolated lupus anticoagulant was detected and SLE was diagnosed. Hydroxychloroquine treatment led to clinical improvement. Past medical history was remarkable for recurrent skin abscesses. Familial history taking revealed maternal SLE and Sjögren syndrome. 15 years later, at the age of 30, the patient was admitted for prolonged fever and cough. CT-scan revealed lingular condensation and left pleural effusion. Burkholderia multivorans grew up from the thoracentesis specimen. Lung infection resolved after prolonged antibiotic therapy. Dihydrorhodamine test (DHR) showed severely impaired respiratory burst in the patient’s leukocytes (1% activity). Her mother showed a typical mosaic pattern. X-linked CGD was genetically confirmed with the finding of CYBB missense mutation in the this kindred.

Conclusions

Familial SLE belongs to the spectrum of X-linked CGD. Autoimmune manifestations can be at the foreground of the clinical picture with only secondary development of typical infectious manifestations. Infections in SLE patients may point to an underlying primary immune defect.

Background and Aims

Introduction

The X-linked inhibitor of apoptosis (XIAP) deficiency, also known as the X-linked lymphoproliferative syndrome type 2 (XLP-2) , is rare primary immunodeficiency.We report a patient who had XIAP gene defect and presented with very early onset inflammatory bowel disease and recurrent hemophagocytic lympohistiocytosis (HLH).

Methods

Case Report

The patient who had chronic diarrhea and history of HLH was referred to our hospital for further evaluation at 8 months of age. Chronic diarrhea was started when he is 40 days old and he suffered from a HLH episode at two months of age.

In his follow up ,bone marrow aspiration was done due to prolonged fewer and hemophagocytosis was detected. Pulse methylprednisolone (mpz) and intravenosus immunoglobulin( 400 mg/kg/day) was administered. We continued with 1mg/kg mpz colonoscopy revealed , multiple, lineer ulcers covered with white membranes in the rectum.

Results

In the follow-up we performed next generation sequencing analysis for primary immunodeficiency diseases, and a homozygous c.518G>A (p.Trp173Ter) XIAP gene defect was found.

Conclusions

XIAP deficiency should be considered in patients presenting with very early onset inflammatory bowel disease and recurrent HLH. Early diagnosis and hematopoietic stem cell treatment will decrease the risk of life threatening complications.

Background and Aims

Chediak-Higashi syndrome (SCH) is a rare autosomal recessive genetic disorder characterized by oculo-cutaneous albinism, immunodeficiency responsible for recurrent infections, and late neurological deterioration. The pathognomonic sign is the presence of giant intracytoplasmic granules in most of the cells of the organism. In 85% of cases, CHS patients develop the accelerated phase characterized by an Hemophagocytic Lymphohistiocytosis syndrome responsible for a high mortality rate.

Methods

They are four children followed in the pediatric department of the CHU Mustapha of Algiers for Chediak-Higashi syndrome between 2014 and 2017.

Results

These are 3 boys and 1 girl with an average age of diagnosis of 3.2 years. Consanguinity is found in all cases as well as a family form (2 brothers). Clinically, oculocutaneous albinism is present in 3 children and melanoderma with a highly pigmented iris in 1 case. Silver gray hair is present in all patient.

The peripheral blood smear allowed to make the diagnosis by showing the intra-cytoplasmic giant granulations in all the patients. Microscopic study of the hair found deposits of melanin in irregular clods in the hair shaft in favor of Chediak-Higashi syndrome. All patients with signs of lymphohistiocytic activation were put on HLH 2004 protocol. One child received an allogeneic marrow transplant but died six months later. The remaining three patients are still alive and clinically stable.

Conclusions

Chediak-Higashi syndrome is a rare disease, the diagnosis is suspected in a child with oculocutaneous albinism with recurrent infections. The only current effective treatment of haematological and immunological abnormalities remains allogeneic bone marrow transplantation.

Background and Aims

Good Syndrome, report of two cases.

The GS (Thymoma and Serum IgG decrease by two standard deviations below the mean for age.) accounts for 0.2% of immune deficiencies; it affects the population between the 4^th and 5^th decades of life.

Hypogammaglobulinemia occurs as paraneoplastic syndrome in 5-10% of all thymomas. GS clinical manifestations include symptoms such as dysphagia, chest oppression, chronic cough and superior vena cava syndrome; recurrent sinopulmonary, urinary tract, gastrointestinal or skin infections.

In 30% of cases, GS coexists with autoimmunity. GS treatment includes thymectomy and human gammaglobulin every 3-4 weeks.

Methods

Case 1: 47-year-old male patient with a history of chronic sinusitis, history of tinea corporis with torpid evolution, chronic cough and dyspnea. On diagnostic workup, an anterior mediastinal tumor was found. The patient underwent surgical resection. Six months later, he presented with urinary sepsis with no isolated germs, and blood culture positive for Morganella morganii, accompanied by reactive arthritis and hypogammaglobulinemia. The patient was started on intravenous immunoglobulin with clinical improvement.

Results

Case 2: 78-year-old female patient with a history of pneumonia, candidiasis, oral lichen planus and bronchiectasis. She had undergone a chest CT scan to evaluate symptoms of dyspnea, with an anterior mediastinal tumor. Surgical resection was practiced. Her laboratory tests reported hypogammaglobulinemia. She was started on intravenous gammaglobulin with clinical improvement.

Conclusions

Good syndrome should be considered in all patients with thymoma, even in the absence of symptoms or after surgical resection. An opportune diagnosis will impact on quality of life and prognosis.

Background and Aims

We present 4 clinical cases presenting periodic fevers with autimmune diseases& lymphocytes clonal expansion, in which the Epstein barr virus is considered the principal triggering factor.

Methods

Case1:57year-old male patient, hospitalized in our unit for periodic fever and severe asthenia.

Past history:Severe handicapping rheumatoid arthritis(RA)with recent lupus.

Case2:78year-old female patient, hospitalized for severe asthenia, dysphonia+pharyngeal pain+periodic fever.

Case3:85year-old male patient, good general condition, presented with periodic fever for years and episodic severe pancytopenia.

Case4:70-year-old malepatient, admitted for recurrent episodes of asthenia+weight loss+ febrile leuko-neutropenia.

Past history:Hypertension, type 2 diabetes, RA treated with METHOTREXATE stopped for 2years because of neutropenia.

Results

Case1:We noted severe anemia+leucopenia+hyperferritinemia. PCR Epstein barr virus(EBV)positive.

Anti-nuclear antibodies(Ab), anti-DNA& anti CCP Ab were positive.

T-cell large granular lymphocytic leukemia(T-LGL)was confirmed.

Good outcome under Corticosteroides+METHOTREXATE.

Case2:Severe inflammatory anemia, hyperferritinemia(43256 Ug/l)+glycosylated ferritin<10%.

Monoclonal immunoglobulin IgG lambda. serum PCR-EBV:3.3log.

Bone marrow aspirate:granular hyperplasia+hemophagocytosis.

Bone marrow biopsy:reactional plasma cell hyperplasia.

PETscan:lymphadenopathies+hypermetabolic splenomegaly.

We conclude at adult STILL disease due to EBV complicated by haemophagocytic lymphohistiocytosis syndrome(HLH).

Favorable outcome under corticotherapy.

Case3:Infectious, autoimmune, autoinflammatory, hematological analysis were negative except positive PCR-EBV(3.8log).

Bone marrow biopsy:negative.

Spontaneous favorable outcome at each episode with no specific treatment.

Case4: Anti-CCP Ab highly positive. PCR-EBVpositive(6 log)+IL6. IgG4 elevated(2.14g/l).

PETscan:Intense diffuse osteo-medullary hypermetabolism.

Bone marrow biopsy:REACTIONAL T-LYMPHOCYTOSIS+HLH.

Abnormal CD8+&CD4+T-lymphocyte.T-cell receptor gene rearrangement concluding to T-LGL leukemia.

Good response to GANCICLOVIR then steroides+METHOTREXATE.

Conclusions

EBV is implicated in various hematological&autoimmune conditions.

We think that there is specific EBV genomic integration site also in acute T-cell LGL leukemia & not just in NK-LGL leukemia

Background and Aims

ARPC1B deficiency results in defective Arp2/3 actin filament branching and is associated with heterogeneous systemic disease. Here, we present the first case of ARPC1B deficiency in Algeria.

Methods

Data was collected from the patient's file during hospitalization in our pediatrics department. To elucidate the genetic etiology, whole exome sequencing has been conducted.

Results

We reported 10-year-old boy from the Northwest of Algeria who was born as second child of consanguineous parents and admitted for a severe, refractory inflammatory bowel disease. The patient presented with early onset chronic diarrhea at the age of 2 months, failure to thrive, and recurrent invasive infections such as pneumonia and otitis media. Physical examination at admission revealed superficial vasculitis in both lower limbs .

Laboratory work up showed thrombocytopenia and signs of combined immune dysregulation, including elevated IgA level, T cell lymphopenia, and reduced numbers of naïve T cells. Colonoscopy depicted a severe colitis reminiscent of UC.
A genetic screen revealed a homozygous mutation of the ARPC1B gene . Clinical management included treatment with corticosteroids and prophylactic antibiotics for this particular immune deficiency were initiated, along with a dedicated follow-up .this patient repsonded to treatment

Conclusions

Our study undescored that ARPC1B deficiency should be considered among the panel of primary immunodeficiencies in young patients with very early onset inflammatory bowel disease .