A 5-year-old girl presented with three episodes of otomastoiditis caused by Candida species. The last episode was complicated with persistent Staphylococcus Aureus cervical lymph node abscess. She was treated with transtympanic drains, mastoidectomy and long-term antibiotics and antifungal therapy, as well as drainage and curettage for the cervical abscess.
Immunological work-up consisted of standard blood analysis, lymphocyte proliferation test and respiratory burst assay. Subsequently, based on the results, genetic testing for chronic granulomatous disease (CGD) (CYBA, CYBB, NCF1, NCF2 and NCF4) and myeloperoxidase deficiency (MPO) was performed, as well as histochemical staining of leukocytes.
General immunological testing was normal, except for a very weak response in the respiratory burst assay (<10% at multiple testing), suggesting CGD. However, gene testing for CGD was negative. Subsequently, MPO expression on neutrophils was absent. Analysis of the MPO gene showed a homozygous splice site mutation in intron 11 (c.2031-2A>C), producing an abnormal precursor without the enzymatic activity. Subsequent familial screening revealed the same mutation in her younger brother presenting with recurrent oral candidiasis.
MPO deficiency should be considered in patients with recurrent Candida infections and reduced respiratory burst. It is the most frequent congenital phagocytic cell disorder leading to an increased risk of infections with Candida and Aspergillus species. The majority of patients are asymptomatic or only exhibit minor infections, but some will develop major infections, especially in presence of concomitant diabetes mellitus. Our patient was successfully treated with a prophylactic dose of fluconazole.
CHAPLE syndrome was recently described as a cause for early-onset protein losing enteropathy (PLE) and thrombosis secondary to biallelic CD55 mutation. We describe a 39-year-old female with adult onset intermittent gastrointestinal symptoms and hypoalbuminemia who was referred for evaluation of hypogammaglobulinemia.
Targeted CD55 gene sequencing, confirmatory CD55 flow assay and B and regulatory T cell (Treg) immunophenotyping.
The patient presented with intermittent diarrhea and hypoalbuminemia at the age of 25. Symptoms subsided spontaneously after two years, but at the age of 35 the patient presented again with superior mesenteric vein thrombosis, PLE, hypoalbuminemia and hypogammaglobulinemia. Endoscopy studies showed occasional lymphangiectasia and physical examination was significant for peripheral edema and clubbing. Targeted CD55 sequencing was performed and revealed a novel homozygous c.976C>T mutation, resulting in C-terminus truncated protein (p.Gln326X). Accordingly, CD55 staining showed near absent CD55 expression with maternal carrier showing reduced CD55 MFI at around 50% compared to healthy control (Fig1A). In addition, B cell phenotyping showed skewed B cell maturation with reduced percent of CD38highCD24high naïve cells and most cells expressing a CD38lowCD24high memory phenotype (Fig1B). Treg phenotyping showed reduced proportion of FOXP3posCD25high cells and an increased proportion of FOXP3negCD25high activated CD4+ (Fig1C).
CD55 deficiency can cause adult onset PLE and could be easily screened by whole blood CD55 staining. In addition, CD55 deficiency is associated with abnormal B and Treg phenotyping. The patient is awaiting Eculizumab treatment.
STAT3 gain of function (GOF) mutated patients are characterized by short stature, early-onset multisystem autoimmune disease, lymphoproliferation, susceptibility to bacterial, viral, fungal, and mycobacterial infections. We present the treatment response of a patient with STAT3 GOF mutation and a severe clinical phenotype.
12 year-old boy was admitted for severe eczema that started at age one month. At two years of age he developed recurrent respiratory tract infections. He received high dose steroids for interstitial lung disease which resulted in severe steroid toxicity. On referral to the immunology service, his physical exam revealed very short stature, cushingoid aspect, severe eczema, rhonchi in lower lung fields, clubbing and hepatosplenomegaly. A previously described GOF missense mutation in STAT3 [c.C1938A (p.N646K)] was identified , and its GOF attribute was verified by hyperphosphorylated STAT3 in response to IL-6 signaling. Combined therapy with tociluzumab and ruxolitinib was initiated. After initiating the therapy, his steroids could be tapered off without worsening his lung functions. By the fifth month of the therapy his skin eczema and lung functions were improved, and his oxygen requirement was decreased.
STAT3 GOF disease should be considered in cases of immune dysregulation with features of severe eczema, short stature, lymphoproliferation and interstitial lung disease and concomitant autoimmunity.
Combinatorial inhibition of the JAK-STAT pathway may provide more effective disease control and outcome.
Chronic Mucocutaneous Candidiasis (CMC) is chronic, recurrent, noninvasive candida infections of the skin, mucous membranes, and nails. CMC is seen in patients with primary immune defects affecting innate and adaptive immune responses involving Th17 pathway. Here, we described three patients with IL17RA deficiency, ACT1 deficiency and STAT1 gain of function mutation presenting with chronic mucocutaneous candidiasis as different genotypes of CMC.
We presented here three patients with CMC
Case-1:10 year old girl has been followed for fungal infection in the mouth and folliculitis in the trunk since the age of 1 and diagnosed with ACT 1 deficiency.
Case-2:8 year old male patient was applied for the treatment resistant oral candidiasis since the first year of life and diagnosed with IL17RA deficiency.
Case-3:8 year old male patient was applied due to recurrent oral candidiasis at the age of 2 and candida esophagitis was developed at the age of 7. Previously identified heterozygous STAT1 gain of function mutation was detected in the molecular analysis of the patient.
Mutations affecting the innate and adaptive pathways of fungal immunity have been reported increasing our understanding of fungal immunity. Treatment of CMC patients can be quite complex depending on the symptoms mostly requiring long-term antifungal therapy.
Defining the underlying molecular defect would be essential since STAT1 gain of function mutations may be associated with high mortality and morbidity due to the accompanying findings and JAK inhibitors can be used in the treatment of patients with severe symptoms.
CVID courses with infections, autoimmunity, benign lymphoproliferations, and increased incidence of malignancies, configuring a state of persistent immune activation and alterations in oxidative metabolism. There is evidence that paraoxonase-1 (PON-1), a factor controlling oxidative stress and tissue damage, is implicated in disease severity and survival. Our objective was to relate arilesterase (AA) activity, genotypes and alleles of PON1-L55M polymorphisms to disease severity and survival.
We analyzed 101 adult patients for demographic data, comorbidities, mortality and survival. PON1 genotyping (PCR-RFLP) and AA were compared to 130 healthy controls (p <0.05).
Genotypic distribution was similar between groups and AA was lower in patients, which may contribute to intense inflammatory state. Patients with 55MM-genotype presented a more severe disease due to higher frequency of lymphadenopathy, splenomegaly, hepatomegaly, portal hypertension, sepsis, neoplasms and deaths compared to LM/LL-genotypes. This difference was not due to deleterious characteristic of the MM-genotype, but a protective role of the 55L allele, since patients with at least one copy of it (LM or LL) had lower prevalence of malignancies, hepatomegaly, sepsis and deaths. They also presented greater survival rates in relation to disease time and diagnostic delay. Risk of death was lower in patients with L-allele and higher in patients with chronic obstructive pulmonary disease, lymphadenopathy, neoplasms, splenomegaly, hepatomegaly and sepsis.
Our results suggest that 55L-allele may play a protective role in CVID, since patients with 55LL/55LM-genotypes presented lower prevalence of hepato/splenomegaly, portal hypertension, malignancies, sepsis and deaths, along with higher survival, compared to those with 55MM genotype.
The IgG antibody response against polysaccharide microbial antigens is enriched for IgG2 antibodies. Lower IgG2 concentration has been found to be a risk factor of death after community acquired pneumonia. Infection is a major cause of death during the first year after heart transplantation. We evaluated the prevalence of IgG2 insufficiency in heart recipients before transplantation and its relationship with the risk for development of severe early deadly infections.
119 patients evaluated in a single center were included. IgG2 assessment was performed at the time of inclusion in waiting list. Prospective follow-up was performed to identify early deadly infections during the first month after transplantation (n=11, mainly bacterial infections). Definitions: IgG2 deficiency, IgG2 <115 mg/dL; IgG2 insufficiency, IgG2 115-272 mg/dL.
Forty-six (38.7%) patients disclosed IgG2 insufficiency. Early deadly infections were more prevalent among patients with IgG2 insufficiency (RH 2.68, 95% CI 1.10-6.53, p=0.029). Use of mechanical ventilation, pre-transplant infections and pre transplant use of ventricular assist devices were risk factors of early deadly infections. In multivariate regression analysis IgG2 insufficiency remained in the model (RH 4.18, 95% CI 1.20-14.47, p=0.024). IgG anti-pneumococcal polysaccharide antibody levels were significantly lower in patients with IgG2 insufficiency before transplantation, at day 7 and day 30 after transplantation.
Pre-transplant IgG2 insufficiency is a risk factor of early deadly infection after heart transplantation. This new immunological definition warrants evaluation in a multicenter study.
Infection is the first cause of death during the first year after heart transplantation according to the registry of the international society for heart and lung transplantation (2018). A complex secondary immunodeficiency (CSID) may affect a small number of heart recipients after transplantation and predispose them to severe or recurrent infections. We aimed to analyze the prevalence of this immunological complication in a cohort of heart recipients performed in a single center.
Prospective cohort follow-up. The CSID was defined as severe or recurrent infection requiring hospitalization including more than one type of microorganisms (i.e. bacterial + invasive fungal or bacterial + CMV disease) persisting after 6 months. Immunoglobulins, IgG subclasses, specific antibodies, C3, C4 and MBL complement factors and lymphocyte subsets were performed at 30 days after transplantation to define the combined secondary immunodeficiency status. A follow-up of 12 months was required to recruit patients.
200 heart transplant recipients were evaluated. A total of 12 (6%) patients were found to have severe or recurrent infections persisting more than 6 months. IgG, IgA, IgM, IgG1, IgG2, anti-pneumococcal polysacharide antibody, anti-CMV antibody levels, CD3, CD4 and CD8 cells/uL were lower in these patients as compared with the rest of the cohort. In multivariate regression models IgG levels remained as the most strong predictor.
A CSID status including humoral and cellular immunity parameters was demonstrated in a small group of heart transplant recipients. A continuous highly specialized immunological monitoring is warranted after transplantation to detect this severe complex clinical setting.
Gene polymorphisms leading to lower serum levels of MBL, have been associated with an increased risk of infection. This study evaluates for the first time the correlation between functionally relevant MBL2 gene polymorphisms and serum MBL concentration in a cohort of heart recipients and risk of development of CMV infection after transplantation.
160 adult heart recipients were evaluated. Universal prophylaxis with gancyclovir was administered. CMV antigenemia and viral load were prospectively evaluated at distinct times after transplantation during the first year. Genotyping of MBL was done by a polymerase chain reaction/sequence-based typing technique. MBL serum concentration was evaluated by ELISA.
During follow-up 30 patients (18.8%) developed CMV infection. Frequencies of the MBL genotypes in our patients was similar than that described in Spanish population. There was a good correlation between the MBL genotype and pre transplant serum concentrations of MBL. Patients with low and intermediate expressing MBL genotype were at higher risk of developing CMV infection during the first year after transplantation as compared with patients with the high-expressing genotype (RH 3.02, 95% CI 1.24-7.34, p=0.0146). After transplantation, patients with CMV infections showed significantly lower serum levels of MBL at day 30 as compared with recipients who did not developed CMV infection (559±443 vs 1233±920 ng/mL, p<0.001; T-2-tailed test). Pre-transplant and day 7 serum MBL tended to be lower in heart recipients who developed CMV infection.
Under the immunosuppressive clinical setting of heart transplantation MBL genotype and MBL serum levels were associated with high risk for development of CMV infection.
Immunosenescence is typified by expansions of late-differentiated pro-inflammatory T-cells and a diminished naïve repertoire. The “Immune Risk Profile” (IRP) characterized by a CD4/CD8 ratio < 1 and latent cytomegalovirus (CMV) infection from the Swedish OCTA/NONA studies in octagenarians and nonagenarians is predictive of two-year mortality. This study examines IRP and T-cell subsets in patients with immune disorders.
Sixty-three patients under follow up by the Royal Free Hospital Immunology Department (London, UK) were identified on the hospital’s pathology database from routine investigations requested by the attending Immunologist. Patients were separated to IRP (Case) and non-IRP (Control) populations based on IRP definition of CD4/CD8 ratio <1. Case-control statistical differences were analysed for T-cell subpopulations, serum immunoglobulin levels and herpesvirus infections; as well as for ongoing immunological diagnoses, comorbidities and treatments detailed in clinic letters.
Nine patients were IRP positive (Mean age = 56) with a corresponding control mean age of 53. IRP individuals had larger CD8+CD28- (% absolute CD8+: 40.9 vs 25.6; p = 0.01) and CD4+CD28- populations (% absolute CD4+:15.22 vs 2.89; p = 0.003); and diminished CD8+CD25+ populations (% absolute CD8+: 2.17 vs 14.05; p <0.0001) compared to controls. CMV infection, neoplastic disease, auto-inflammation/autoimmunity and systemic immunosuppression were significantly associated with IRP positivity.
IRP positivity is associated with expansions of CD4+28- and CD8+28- cells and diminished CD8+CD25+ populations. Latent viral infections, auto-inflammation/autoimmunity, neoplastic disease and systemic immunosuppression is likely to facilitate T-cell subpopulation skewing towards the IRP.
Registries are useful tools for better understanding the epidemiology of primary immunodeficiencies (PID) and to address the issues on morbidity, mortality, treatment efficiency and outcomes of the patients.
The Czech registry (CzR) of PID was established in 2012. Presented data were collected from 18 centres (2012-2018).
CzR contains data of 1,066 patients (558 females, 508 males). Antibody deficiencies were the most common group of PID (625) [CVID (376; 60.4 %), IgG subclass deficiency (80; 12.8 %), symptomatic selective IgA deficiency (45; 7.2 %) and XLA (35; 5.6 %)] followed by well-defined immunodeficiencies (180) [Di George syndrome (140; 77.8 %), Wiskott-Aldrich syndrome (9; 5.0 %), hyper-IgE syndrome and Nijmegen breakage syndrome (7; 3.9 %), chronic mucocutaneous candidiasis (5; 2.8 %), X-linked lymphoproliferative syndrome (2; 1.1 %), ataxia telangiectasia (1; 0.6 %)], complement disorders (177) [HAE type I (145; 81.9 %), type II (21; 11.9 %), type III (1; 0.6 %), C2 deficiency (7; 4.0 %)]. Other diagnoses (84) were: phagocytosis disorders (28) [CGD (18; 64.3 %), specific granule deficiency (4; 14.3 %), myeloperoxidase deficiency (2; 7.1 %) and LAD syndrome (1; 3.6 %)], combined immunodeficiencies (26) [different forms of SCID were reported in 17 patients], autoinflammatory syndromes (19), hemophagocytic syndromes (8) and T-lymphocyte deficiencies (3).
It is difficult to determine how many patients have not been entered into the database or have not been identified yet. Nevertheless, the spectrum of PID in the Czech national registry does not differ significantly from the data in the European Registry (ESID).
Primary immunodeficiencies (PIDs) are characterized by an increased risk of autoimmune diseases, especially autoimmune cytopenias. Among patients with CVID cytopenias are 100-to 1000-fold higher than in the general population. Idiopathic thrombocytopenic purpura (ITP) being the most frequent cytopenia, it prevalence is about 20%.
We present three cases of patients, whose predominant feature was a chronic and recurrent course of the ITP.
Patient No 1: a 18-month- old girl had ITP and skin erythroderma from the neonatal period and frequent respiratory infections. Next generation sequencing (NGS) detected missense mutation RAG1 and diagnosed severe combined immunodeficiency (SCID). Now, the girl is 7 months after HSCT.
Patient No 2: a 4-year-old boy had ITP and enlarged spleen and very high triglyceride concentration. Finally, diagnosed chylomicron retention disease. He has symptomatic treatment.
Patient No 3: a 6-year-old-boy had ITP and agranulocytosis, fever, colitis, hepatosplenomegaly, tumour in mediastinum and multiple autoantibodies. He has missense mutation CTLA-4. Currently, the boy is 9 months after HSCT.
Idiopathic thrombocytopenic purpura, especially chronic and recurrent, requires the extension of diagnostics towards primary immunodeficiency. Improving awareness and early genetic diagnosis of primary immunodeficiency, such as SCID or CTLA-4 deficiency, is important for initiating correct treatment, improving clinical outcomes and quality of life of these patients.
Familial hemophagocytic lymphohistiocytosis (FHL) is caused by defective cytotoxicity of CD8+ T and NK cells, which leads to uncontrolled activation of T cells and macrophages.
The description of an uncommon presentation of FHL in a 62 years old woman.
Patients and Methods
We report the case of a patient referred for evaluation to our clinic by a history of a cerebellar syndrome of subacute onset, with inflammatory lesions of the brain and posterior fossa that improved after corticosteroid treatment. During these episodes, the patient presented as well pancytopenia and hepatosplenomegaly, without signs of hemophagocytosis in bone marrow, not fulfilling other HLH criteria. After evaluation in clinic, we performed an inmunological study, including immunophenotyping, perforin expression and degranulation assessment. Genetic study was performed by Next Gen Sequencing (NGS) with a customised panel of more than 400 genes, including all described immunodeficiencies.
Our patient has no significant elevation of soluble CD25. Presented greatly reduced numbers of NK cells, with normal perforin expression but displayed defective degranulation with impaired NK cells expression of surface CD107a upon K562 cell-mediated stimulation. The genetic study revealed a homozygous mutation in the STXBP2 gene.
FHL is commonly seen in the paediatric age with intense and eventually life-threating instauration of HLH that requires intense immunosupression. Atypical forms with CNS presentation and no systemic expression have been described in literature. Clinical onset in adulthood is clinically challenging and requires for adult specialist, as in this case, a high level of awareness.
Predominantly Antibody Deficiencies (PAD) are the most frequent type of PID. Respiratory comorbidities are common in these patients and contribute to their morbidity and mortality. A better understanding of this condition could help to develop preventive and therapeutic strategies. This study aimed characterizes the respiratory compromise in these patients attended at the biggest Colombian Children’s Hospital.
We conducted a review of electronic medical records for patients with PID treated at HOMI Fundacion Hospital la Misericordia between 2014-2017 focusing on the respiratory comorbidities that they presented clinically or radiologically at time of PID diagnosis. Patients with PID were identified in our institutional database using ICD-10 codes and categorized following IUIS2017 Phenotypic classification.
A total of 73 patients with PAD were included in this study. The median age (P25-P75) in these patients was 28 months (7.5-52 months) and male/female ratio 25/48. The 78.1% of patients presented at least one episode of pneumonia before the PAD diagnosis, 84.2% of these required critical care management; wheezing was identified in 29 patients (39.7%), and 11 patients (15.1%) required long-term oxygen therapy. All patients had a chest X-ray, which showed air trapping in 67.1%, followed by consolidation (65.8%) as main findings. HRCT was available in 68 patients with consolidation as the main finding (33.8%) and bronchiectasis only in 7 patients (10.3%).
In these pediatric patients with PAD, pneumonia and wheezing are the major respiratory comorbidities. Within the radiological findings, consolidation was the most frequent and the bronchiectasis rate was similar to local previous reports.
Patients with common variable immunodeficiency (CVID) frequently present raised serum levels of liver enzymes and/or mild hepatomegaly. Fibroscan® is an ultrasound-based transient elastography (TE) method that is widely employed for monitoring liver stiffness in chronic liver diseases but has never been used to evaluate liver involvement in CVID. We performed a cross-sectional study to assess liver involvement in a cohort of adult CVID-patients by the use of Fibroscan.
Haematological exams, liver enzymes, hepato-splenic ultrasounds and Fibroscan® were performed in 77 adult CVID patients. Immunological and clinical features of patients were recorded from medical charts (Table 1).
|Study Population (n = 77)|
Clinical phenotype*, n
Fibrosis score, n (%)
F0/F1: no to mild fibrosis
F2: moderate fibrosis
F3: severe fibrosisF4: cirrhosis
33.8% (26/77) patients had elevated liver stiffness values ranging from moderate fibrosis to cirrhosis. Fibroscan® values were linearly correlated with ALP, γGT, spleen longitudinal diameter and peripheral blood counts (no correlation with BMI, AST, ALT, total proteins, albumin, bilirubin and hemoglobin was observed) (Fig. 1). Fibroscan® values were higher in subjects with polyclonal lymphoproliferation and enteropathy (Fig. 2), and patients with both these manifestations were more likely to present pathologic TE values (OR: 7.14) compared with those without anyone of these phenotypes (Fig. 3).
Fibroscan® is a pivotal tool to be used in association with clinical and laboratory data to estimate liver disease and guide therapeutic interventions in CVID.
Primary antibody deficient (PAD-)patients form a heterogeneous group -clinically, immunologically as well as genetically- ranging from milder (e.g. IgG-subclass deficiency) to severe (e.g. X-linked agammaglobulinemia) disease. PAD-patients suffer from recurrent infections but may also have autoimmune and lymphoproliferative comorbidities. There is insufficient consensus about PAD-subgroup diagnoses (e.g. CVID-definition); often the genetic background has not been elucidated. A standardized description of PAD-phenotypes is lacking. All this impairs the formation of homogeneous PAD-patient cohorts.
The Human Phenotype Ontology (HPO) immune mediated disorders consortium is therefore re-evaluating and completing the PAD-related HPO-terms to allow efficient data exchange and matching of phenotypically similar PAD-patients for future research.
After a first meeting regarding goal and methods of the HPO-consortium, subgroups related to different primary immunodeficiency (PID-)categories were started to define PID-relevant terminology using the HPO-website, literature, and ESID, IUIS and OMIM classifications.
As a principle, it was decided to build the PAD-related HPO-tree based on as unambiguously interpretable items as possible only, thereby avoiding the ongoing variance in PAD-subgroup definitions. E.g., ‘hypogammaglobulinemia’ was deleted as HPO-term, and replaced by separate HPO-terms such as ‘decreased total IgG (or IgA or IgM) in blood’, subdivided in ‘transient’ vs. ‘chronic’, and ‘(near) absent’ vs. ‘partially decreased’. (The full new PAD-related HPO-tree will be shown during the meeting.)
The PID-related HPO-consortium has set out to improve classification of heterogeneous PAD diseases for research purposes through an accurate and less ambiguous description of the phenotypes. Once accepted, this PAD-related HPO-tree will empower future multicenter clinical research and related genetic discoveries.
Any disorder that develops during the development or differentiation of B cells may cause hypo / agamaglobulinemia by affecting immunoglobulin production from plasma cells.
The clinical , laboratory characteristics of patients, mutations detected inCD79A gene are shown in Table 1.
Patient1 A 12-month-old girl was admitted with recurrent bronchiolitis and neutropenia. She had been suffering from recurrent diarrhea since 15 days old. There was no consanguinity between parents(coming from same village) She was found to have agammaglobulinemia, CD 19 <1%. IVIg treatment has begun.
Patient2 A 13-month-old male patient presented with progressive muscle-weakness without focal neurological deficit. He had been suffering from recurrent pneumonia and otitis media from 8 months of age and the laboratory evaluation revealed agammaglobulinemia, CD19 <0.1%. VIg therapy was initiated. Muscle weakness improved in thefirst 3 months after IVIg. Dermatomyositis-like skin findings were detected at 2 yearsofage. He died attheage of 8 due to pneumonia. Since there was no relationship between the parents, BTK mutation was found to be negative.
Patient3 A 15-month-old girl applied with the complaints of URTI, pneumonia and diarrhea. She had URTI at 3 months ofage for the first time and had recurrent pneumonia and needed iv.antibiotic treatment and hospitalisations in thefollowing period. There was consanguinity. Immunologicalevaluation revealed agamaglobulinemia, CD19 0%.IVIg replacement therapy was started.
Igα-deficiency leads a block in the transition from pro-B cell to pre-B cell during B cell differentiation. Enteroviral infections, growth retardation, neutropenia, recurrent bronchitis, otitis, diarrhea, and vaccine-related polio may occur during the course of the disease.
Peritoneal dissemination is the primary metastatic route of ovarian cancer (OC) and a common progression route of gastrointestinal cancer (GC). Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) represents a potentially curative treatment for peritoneal carcinomatosis. However, these patients suffer from infectious complications after the surgical procedure. We aimed to assess the immunoglobulin(Ig)G, IgA and IgM serum levels in samples obtained before and 24 hours after the CRS-HIPEC procedure. We further correlated these data with the peritoneal cancer index (PCI) of the patients.
IgG, IgA and IgM levels were determined by nephelometry in ninety patients diagnosed with peritoneal carcinomatosis and treated with CRS-HIPEC. Patients were grouped according to their primary cancer. The extension of peritoneal dissemination was classified using the PCI which is a quantitative indicator of tumour involvement estimated from the size of the tumour nodules and its distribution along the peritoneal surface.
Although, IgG levels were within the normal range before the surgical procedure (840±26 mg/dl), they were lower 24 hours after surgery (490±20 mg/dl; p<0.0001). Similar results were found when OC (890±43 vs. 450±32 mg/dl; p<0.0001) and GC (800±32 vs. 510±26 mg/dl; p<0.0001) were evaluated separately. These results were also similar when IgM and IgA were evaluated. Furthermore, immunoglobulin levels, specially IgG, correlated inversely with the PCI.
CRS-HIPEC can be considered as a new cause of secondary hypogammaglobulinemia. Quantification of serum immunoglobulins might contribute to identify an increased risk of infectious complications in these group of patients, especially in patients with a higher burden of cancer.
Netherton syndrome is an autosomal recessive congenital ichthyosiform dermatitis associated with elevated immunoglobulin E and atopic dermatitis presentation. We report two 8-months-old babies of identical twin brothers presenting with symptoms of Netherton syndromes and also are associated with hypogammaglobulinemia.
The peripheral blood samples were taken at follow up visits, and sent for isolation of cells and serum. The immunoglobulin levels were enumerated by immunoassay. The specific IgE levels were measured by fluoroenzyme immunoassay (ImmunoCAP kit). The cells were prepared for flow cytometry for calculating subtypes.
Two identical twin brothers were presenting as severe atopic dermatitis-like eczema over whole body since 3-months-old. Since 5-months-old, they had frequent wheezing and upper airway symptoms. Despite failure to thrive, they also had trichorrhexis invaginata of their hairs. The eosinophil counts were 7695 to 15120/uL, about 40 to 46% of white blood cells. The IgE levels were 2086 to 5448 IU/mL. The IgG/A/M levels were less than 200mg/dL, less than 6 mg/dL, and 35 to 53 mg/dL respectively. IgG subclass 1 were low. The complement levels were normal. The CD4 and CD8 T cells, B cells, and CD16/CD56 (NK) cells were all within normal range. The hypogammaglobulinemia had persisted for more than 7 months and the patients were receiving IVIG therapy.
Recurrent sinopulmonary and cutaneous infections had been reported in Netherton syndrome but a true immunodeficiency had not been identified. We reported the twins presenting as typical Netherton syndrome, and a rarely recognized hypogammaglobulinemia.
Introduction: Primary Immunodeficiencies (PIDs) registries, in an international, national and regional level, are essential to improve the epidemiological analyses, disease knowledge, physician awareness and timely referral to specialists.
Aims: To collect updated local data on distribution and disease burden of PID in Northern Greece.
Methods: The medical charts of 392 patients with PIDs diagnosed at our center during the last 25 years were reviewed.
Results: More than half of patients (51.3%) were diagnosed with antibody deficiencies (IgA deficiency:103, CVID:41, XLA:11, other/unclassified:46). Ninety-eight patients (25.2%) were diagnosed with autoinflammatory diseases (FMF:95, MVK:1, CAPS:2, TRAPS:1), and 6.8% with Well Defined PIDs (Wiskott-Aldrich:5, DiGeorge:9, Ataxia-telangiectasia:3. Hyper-IgE-STAT3:6, other:4). The remaining cases were distributed in Complement Deficiencies (5.4%), Combined Immunodeficiencies (4.3%, SCID:9, Hyper-IgM-CD40L:3, MCHII:4, DOCK8:1), Diseases of Immune Dysregulation (3.8%, ALPS-FAS:7, APECED:5, IPEX-other:3) and Defect of Phagocytes (3%, x-linked-CGD:6, LAD:2, MSMD:2, other:2). Consanguinity was recorded in 1.8% (7 cases) and 44 patients (11.2%) were recorded to be familial cases. A genetic defect was known in 161 of 398 patients (including 85 of 98 children with auto-inflammatory diseases).
Conclusions: In agreement to the literature data, in our study, the antibody deficiencies represent the largest main category of PID. On the contrary, the proportion of auto-inflammatory diseases is higher than reported by registries in other countries, due to the co-existence of the Pediatric Rheumatology Referral Center in our Department and the higher prevalence of the FMF in the Mediterranean Region. Finally, the low proportion of CIDs may be due to low parental consanguinity n our cohort.
Introduction: CVID represents the most common symptomatic PID with a high variability in clinical presentation.
Objectives: To record the clinical phenotypes of CVID patients diagnosed at our Referral Center during the last 20 years
Methods: Forty-one patients with CVID (male:23), diagnosed according to the recent ESID criteria, were evaluated. The age at diagnosis was 6-33 years (median: 17years) and the duration of follow-up 1-19 years. (median: 7.5 years)
Results: The major phenotypes of CVID patients at diagnosis were: a) increased susceptibility to respiratory infections (80.5%), [infections only (26.8%), with bronchiectasis/interstitial lung disease (19.5%), in association with autoimmunity with or without lymphoproliferation (24.3% and 9.7%, respectively)], b) autoimmune cytopenias or lymphoid malignancies only (14.6%) c) enteropathy only (4.8%). More than one autoimmune disorders presented 26.8% of the patients, with thrombocytopenia and thyroid disease representing the most common diseases. Four CVID cases was diagnosed after rituximab use for the treatment of idiopathic thrombocytopenic purpura (2 patient) and Non-Hodgkin lymphomas (2). The lag time to diagnosis was 6.5 years (1-14 years). Genetic analysis was performed in 16/41 patients and TACI mutations were detected in 2 of them (12.5%)
Conclusions: The infections were the only manifestation in just 1/3 of the patients with CVID. Autoimmune cytopenias in association with lymphoproliferation was the most common presenting or/and major manifestation of the disease. Rituximab might be a triggering factor for CVID emergence and patients with hematologic autommunity or malignancies should be closely monitored for immunoglobulin levels, both before and after rituximab treatment.
Down syndrome (trisomy 21) is the most common and well-known chromosomal disease. In recent studies, it has been reported that the findings in the immune system are consistent with intrinsic defects rather than accelerated aging. T cell, B cell and Thymus dysfunction are expected immune system disorders. The aim of this study was to evaluate the immune status of patients with Down syndrome.
A total of 96 (58 female/38 male) patients who were followed-up in our Pediatric Immunology and Medical Genetics departments were included in the study. Total lymphocyte counts, immunoglobuline levels, vaccine responses (Anti-Hbs, Anti-Tetanus antibody), number of infections, using of antibiyotic prophylaxis, intravenous immunoglobulin (IVIG) were questioned.
The mean age was 5.90 ± 2.97 years. Forty-eight patients (50%) continued follow up. They were determined increase of IgG, IgA and decrease of IgM levels in times. Total lymphocyte, CD3 lymphocyte counts were found lower under 2 years, CD4 lymphocyte counts were found lower under 5 years and CD19, lymphocyte counts were found lower in all ages. There were no differences in CD8 and NK cell numbers. The antitetanose antibody positivity and the infection rate were found 44% (22/50) and 5.76 ± 2.0/year at initial presentation respectively. Using of prophylactic antibiotics and IVIG were found to have decreased frequency of infection.
In conclusion, since immunological disorders in Down syndrome cannot be explained by a single immunopathology; the patients should be monitored immunologically and further advanced tests should be performed.
Although sideroblastic anemias may be associated with different etiologies, general abnormality is deterioration of mitochondrial heme biosynthesis in bone marrow erythroid cells. Biallelic mutations in the TRNT1(CCA-adding transfer-RNA nucleotidyl-transferase) gene have been shown to cause a syndromic form congenital sideroblastic anemia associated with B-cell lymphopenia, hypogammaglobulinemia, growth retardation and periodic fever syndrome(SIFD).
A 7-year-old boy presented with complaints of frequent upper respiratory tract infections and bronchitis since 6-months of age.He was the second-child of consanguineous healthy parents and followed-up by Hematology Department because of anemia for 4-years.Iron deficiency,hemoglobinopathies and immune hemolytic anemias were excluded.
Physical examination findings on admission were as follows; weight and height percentiles were 10%,the liver was enlarged to 4cm and the spleen to 2cm palpabl below the costal margins. Laboratory investigations showed anemia (WBC 5590/mm3,Hb 8.2g/dl, Htc 24%,MCV 57fl,platelet 306000/mm3), anisocytosis,poikilositoz and ring sideroblasts in peripheral smear, hypogammaglobulinemia (IgG464mg/dl, IgM29mg/dl, IgA20mg/dl), negative Direct-coombs-test, normal lymhocyte subsets (CD3+67%,CD19+6%,CD3+CD4+28%,CD3+CD8+35%,CD3-CD16/56+14%) and inadequate specific-vaccine responses. Thorax CT showed nonspecific pulmonary nodules.The patient was followed-up with the preliminary diagnosis of common variable immunodeficiency and received regular intravenous-immunoglobulin replacement.A mild increase in immunoglobulin levels was observed with age.Targeted next-generation sequencing of a comprehensive IonAmpliSeq™PrimaryImmuneDeficiencyResearch Panel detected a homozygous mutation(c.914A>T,p.Asp305Val) in TRNT1 gene at the age of 14-years.
SIFD is due to loss-of-function mutations in the TRNT1 gene. Childhood TRNT1 disease/SIFD(OMIM#612907) is included in the antibody deficiencies group in IUIS Primary Immunodeficiency-2017 classification. The patient was presented to emphasize that TRNT1 disease should be considered in the differential diagnosis of anemia and hypogammaglobulinemia.
Hyper-IgM is a rare disorder of immune system.The defect is in CD40 ligand ,so T-helpers couldn’t alter IgM to other immunoglobulin types.The lack of immune antibodies and impaired immune memory cause a lot of particular infection diseases plus autoimmunity and other irrelevant problems, such as malignancy.Among different types of HIGM, x-linked one is the most common disorder characterized by male patients and female carriers in the family.Clinical manifestations are different, even in a single family.The common ones are recurrent respiratory bacterial infections,especially byencapsulated microorganisms, infectious diarrhea, failure to thrive, autoimmune disorders, anemia, thrombocytopenia and neutropenia. Malignancies are one of their problems too.
Here, we report 7 patients of a family with a single pathology and positive genetic study. All cases are male and the x-linked pattern is vivid in their relationship algorithm.
The x-linked type is the most common one. In this report we emphasize on the importance of the family history taking in patients which have sever immunodeficiency disorders. We present patients of a single family with recurrent infections history, which couldn't be diagnosed without precious history taking and genetic study was positive for them.(CD40LG NM_000074,Intron 1,c.156+2T>C)
According to the high numbers of the patents in this family, it would be a great example of x-linked patterninHIGM and the effect of history taking on diagnosis and rapid treatment. We couldn't find such a great numbers in any articles of familiar cases. We hope, this report helps to understand this importance.
X-linked agammaglobulinemia (XLA) is a primary immunodeficiency caused by mutations in the gene for Bruton tyrosine kinase, resulting in an increased susceptibility to a variety of infections. Vaccine-associated paralytic poliomyelitis (VAPP) is a rare adverse event of Oral Polio Vaccine (OPV) due to mutation or reversion of the vaccine virus to a more neurotropic form.
Through our case report we would like to highlight that VAPP may be a first presentation of X-linked agammaglobulinemia.
A 5 month old boy presented at our hospital with fever, irritability, generalized hypotonia and abdominal breathing fifteen days after the second dose of OPV. No previous infections before the vaccination. The initial cerebrospinal fluid examination showed pleocytosis (196mm3); lymphocytosis 95% and neutrophils 5%. The electro-diagnostic (ENG) examination of the right leg indicated remote distal axonal neuropathy of the deep peroneal nerve. No abnormalities were observed in the brain and spinal MRI. His first faecal specimen was positive for Sabin type 3 strains. Laboratory evaluation revealed low levels of IgM, IgA. CD19+B and CD20+B cells were less than 1% of the lymphocyte population. The BTK gene analysis of the patient’s DNA revealed the presence of the mutation c.[1922G>A] p.[R641H].
A negative history for recurrent infections does not exclude the presence of a primary defect in the immune system. VAPP may be the first presentation of some primary immunodeficient patients. Introduction of neonatal screening programs for some immune deficiency states, such as SCID and XLA, could help in preventing an inadvertent exposure of affected patients to OPV.
Carriers of X-CGD have two populations of neutrophils resulting in a mosaic pattern in respiratory burst testing. There are increasing reports on photosensitivity, discoid lupus and autoimmunity in female carriers.
We present SLE and other autoimmune manifestations in 5 female-carriers in family of an index patient with X-CGD.
Case-1:Patient’s mother, 32years-old, diagnosed with SLE for 11years. She had a history of deep venous thrombosis(DVT) at age of 11, and second DVT in her left leg during her pregnancy at 21years. She was tested for antiphosfolipid syndrome, Sjögren and SLE. She developed discoid lesions on face at age 29. For the last 3 years, her only symptom is a photosensitive rash on face. Anticardiolipin IgM/IgG are positive, ANA and anti-dsDNA are negative.
Case-2:Patient’s grandmother, 59years-old, has swelling and joint pain in fingers and toes for 3 years, diagnosed with rheumatoid arthritis and SLE.
Case-3:Patient’s aunt, 24years-old, diagnosed with SLE for 7years. She had multiple hospital admissions for joint pain, thrombocytopenia. She has recurring aphtous stomatitis and discoid rash. Laboratory testing showed she had 3+ANA, positive anti-histone antibodies, anti dsDNA and nucleosome.
Case-4:Patient’s aunt, 18years-old, diagnosed with SLE. She was first hospitalized at age 9 for recurrent arthritis. At age 17, she had pain, ecchymosis, swelling in leg with DVT. Recently, her renal biopsy revealed 2nddegree lupus nephritis. ANA and anticardiolipin antibodies are positive.
Maternal female members of X-linkedCGD patients should be tested for carrier status and monitored for autoimmune diseases. Genetic counselling and consultation with rheumatology for autoimmune manifestations is required.
CGD is a rare primary immunodeficiency with predisposition to autoinflammatory and granulomatous complications predominantly of lungs and gastrointestinal tract (GIT).
75 patients with CGD were observed.
Autoinflammatory complications developed in 44 (58%): lung granulomas in 28 cases, inflammatory small intestine/bowel disease – 9, liver granulomas – 7, other localizations – 11, combined damage - 14. Patients with lung granulomas had respiratory insufficiency, increased of leukocyte, neutrophils and CRP levels, infiltrative lung lesions on CT examination. Morphological findings showed focuses of lymphoid and large epithelioid cells infiltration with giant multinuclear cells. Nine patients with inflammatory bowel diseases had mild diarrhea, growth retardation, hypoproteinemia, increase of leukocyte, CRP, calprotectine levels. Endoscopy examination: inflammatory, erosive, sometimes with hemorrhage focuses in bowel and/or small intestine. Morphology: lymphocyte, plasmocyte, neutrophil infiltration of lamina propria with giant multinuclear cells. Combined lung and GIT and/or other localizations was observed in 14 cases. Treatment included budesonide, prednisone, sulfasalazine (in bowel involvement) and rapamycin. The last was used in partial effect or severe adverse reactions to glucocorticoids. Rapamycin was used in 5 cases with good effect and without adverse events. Rituximab in combined therapy was used in one case with lung granuloma with CD20+ cells infiltration.
The rare complications were uveitis (3 cases), hemophagocytic lymphohistiocytosis (2 cases) and discoid lupus erythematosus (in two brothers with X-CGD and their mother).
Autoinflammatory complications are frequent in CGD patients and may occure as separate symptom or in combination with infection. Immunosuppressive therapy is selected individually, usually includes the combination of different agents.
22q11 deletion syndrome is one of the most prevalent microdeletion syndromes in humans and characterized by extensive phenotypic variability.
Patients who were diagnosed with 22q11 deletion syndrome, confirmed by fluorescent in situ hybridization (FISH) analysis at Chiang Mai University Hospital, Chiang Mai, Thailand, were enrolled. The data obtained from the history, physical examination, laboratory testing including T-cells, immunoglobulin, calcium, thyroid and parathyroid levels in the blood, cardiac and urological imaging, and intellectual status were evaluated.
We identified 34 patients diagnosed with 22q11 deletion syndrome; 18 (53%) were females. The median age of patients was 18.5 months (IQR; 1.5-35.8). Characteristic facial features were found in 91% of the patients. Moreover, 94% had a congenital heart defect with tetralogy of Fallot in most of the patients (72%), 88% had hypocalcemia, 35% had genitourinary tract abnormalities. Malnutrition was revealed in 83% of patients. Recurrence in the family of the 22q11.2 deletion syndrome was detected in 12% of the cases. Twenty-eight patients (82%) were found to have a low percentage or number of T-cells. Five patients (15%) had low immunoglobulin levels. Intellectual disability (IQ/DQ scores < 70) were found in 20 out of 25 patients who were evaluated (80%), whereas the other five (20%) performed on the level of borderline intellectual function.
Tetralogy of Fallot, hypocalcemia, immunologic defect, and cognitive impairment were common in our 22q11 deletion syndrome study group. We recommend that all affected patients have a multi-system evaluation by a comprehensive care team.
The increasing use of immunoglobulins (Ig) at worldwide level and laboratory manufacturing problems result in high supply tensions on these drugs. Order quotas are set up by the laboratories to ensure a fixed quantity for each establishment.
Issuing clinical guidelines for Ig uses to limit over-consumption of Ig.
The observatory OBSERVIG framework exists since 2012 and meets twice a year. It consists of one referring doctor for each medical speciality.
During this meeting, an assessment of Ig consumption is complete, off label indication are reassess and good use recommendations are discuss.
Capping doses at 150grams/cure/patient for patients has led to important savings (1kg in 2018 corresponding to 36 000€).
Respect of posology at 0,3g/kg in hematology has led to save 2,5kg in 2018 corresponding to 87 500€.
Regularly reassessment to mesure the efficiency of Ig can lead to decrease doses and reduce the cures frequency for stable patients.
Some indications are reevaluated in nephrology where Ig are reserved to treat acute rejection.
Plasma exchange can be the right solution to preserve stock of Ig in some disorders and in some conditions (availability, urgency degree).
All off label indications must be validated by OBSERVIG to justify the use.
The implementation of local recommendations associated with the investment of the medical teams limited the over-consumption of Ig during this rupture. The preserved stock enable to treat vital emergencies, new patients and to provide them an optimal care.
Caregivers have been sensitized on the proper use of these expensive drugs with a limited stock.
The onset of next-generation sequencing (NGS), especially sequencing of the whole genome (WGS) or exome (WES), allows the identification of rare gene mutations underlying inherited disorders of the immune system.
At the department of immunology in Pilsen,1 a boy aged four years with recurrent infections was diagnosed to have severe hypogammaglobulinemia and disturbed specific antibody response. Since his B cell count was normal, the diagnosis of early onset common variable immunodeficiency (CVID) was established, and immunoglobulin substitution was stared. Six months later, he required hydrocortisone substitution for central hypocorticism and congenital malformations of the central nervous system (hydrosyringomyelia, Chiari malformation) were revealed; the latter was resolved by surgical intervention. Within several years, the patient’s B cell count decreased progressively, and he required an increased dosage of immunoglobulin substitution. Later, he developed several autoimmune features, such as thyroiditis, vitiligo and total alopecia along with nail dystrophy and osteoporosis, which resulted in fractures of thoracic vertebrae.
The described complex symptomatology encouraged us to perform WES in Prague research center2,3 that identified a heterozygous mutation c.2557C˃T (NM_001261403.2, p.Arg853*) in NFKB2 gene which was previously described in a single patient with similar symptomatology. WES finding was confirmed by Sanger sequencing.
NGS is a robust modern genetic method allowing us to establish an accurate diagnosis in patients with suspected primary immunodeficiency, but atypical or rare symptomatology. Such precise diagnostics allows individually tailored management of the diseases.
Idiopathic CD4 lymphocytopenia (ICL) is characterized by the absolute CD4 count <300 cells/ml or <20% of total T cells and negativity of HIV infection.
A retrospective analysis of 4 female and 2 male patients with ICL.
The patients were diagnosed aged 16-46 years. One patient was referred because of panniculitis; one suffered from frequent respiratory-tract infections and selective IgA deficiency, another had meningococcal meningitis in his history. In the remaining, the cause of investigation was an incidental observation of lymphocytopenia. During the follow-up, one patient suffered from fevers of unknown origin which disappeared after antibiotic treatment. However, no other manifestations of immunodeficiency were observed.
CD4+ cell numbers were between 33-190 cells/ml and were relatively stable during follow-up.
All patients had a decreased proportion of CD45RA+ cells in CD4+ cells. The proportion of gamma/delta T-lymphocytes in CD3+ cells was increased in 5 patients.
In 5 patients, a decrease in the absolute number of CD8+ cells was observed, NK cells absolute numbers were normal in 5 and increased in 1 patient.
The absolute number of B lymphocytes was decreased in 2 patients, normal in 4. Evaluating B-cell peripheral differentiation markers, variable results were observed.
Except for IgA deficiency in one patient and one transitory decrease in IgG and IgM, other major serum immunoglobulin levels were in the reference ranges. In 3 patients antinuclear antibodies were detected, another had antibodies against cardiolipin and thyroid peroxidase.
Our results show variable laboratory manifestation of ICL; clinical immunodeficiency symptoms are frequently missing.
X-linked agammaglobulinaemia (XLA) is a primary immune deficiency disorder caused by a mutation in the Bruton tyrosine kinase (Btk) gene. A progressive neurodegenerative syndrome of unknown aetiology has been described in patients with XLA on long term immunoglobulin replacement therapy. We present two cousins with XLA caused by the same grandmaternal mutation ((c.1898G>A) in the Btk gene) who developed progressive neurological deterioration in the second decade with prominent extrapyramidal features.
Patient one is a 28yrs male diagnosed with XLA and treated with immunoglobulin replacement from 20 months. He presented with cognitive and behavioural difficulties at 7yrs, subsequent marked cognitive and motor function decline at 16yrs. MRI brain showed a progressive cerebral and cerebellar atrophy. CSF infection screen was negative. He developed progressive dysarthria, bradykinesia, bilateral upper limb rigidity and loss of fine motor movements.
His 21yrs male cousin was diagnosed with XLA through carrier screening and treated with immunoglobulin replacement from 6 months. He presented with a progressive dystonic tremor, dysarthria, cognitive and balance difficulties at 18yrs. MRI brain showed progressive supra-tentorial atrophy and subtle white matter abnormalities. CSF oligoclonal bands and infection screen were negative. He developed increased muscle tone and apraxia of hand movements.
We highlight the familial presentation and ask whether the neurological phenotype could be a direct consequence of the Btk mutation or of another as yet unidentified gene mutation. We are not aware of other such familial cases. Whole genome sequencing may be beneficial to identify genetic predisposition to these rare neurological sequelae.
Pannicke et al. (2013) identified a homozygous mutation in IKBKB encoding IκB kinase 2 (IKK2), resulting in a frameshift leading to a premature stop codon (pGln432Profs*62) in four patients with presenting with SCID. All the IKBKB LOF mutations published until today, resulted in a complete lack of IKK2 protein expression with or without decreased IKK complex expression.
Functional validation of a novel hypomorphic IKBKB mutation
In a boy with recurrent invasive bacterial infection, a private homozygous missense variant in IKBKB (c. 73G>A, p. G25R, CADD-score 29,5; predicted to be damaging in silico) was identified in a whole exome sequencing approach. Patient’s T- and B cells were almost exclusively of naïve phenotype. Hypogammaglobulinemia and polysaccharide antibody deficiency were observed.
The mutation results in normal IKK2 and normal IKK complex expression in different cell types. A significantly decreased IL-6 and IL-8 production after stimulation with LPS and flagellin was observed in patient’s fibroblasts. Moreover, the nuclear translocation of NF-κ p65 after stimulation with LPS was delayed and diminished in patient’s fibroblasts compared to control fibroblasts. Results of ultimate validation results are pending.
Hypomorphic mutations, that decrease but do not abolish the function of a gene product, can result in a milder phenotype or delayed onset of disease. Numerous examples can be found in PID related genes. Further investigation of the functional effects of the described IKBKB mutation will help deciphering the role of IKK2 in the NF-κB pathway.
The Good Syndrome (GS) refers to a combination of thymoma and adult-onset immunodeficiency that consists of low or absent B cells and hypogammaglobulinemia in peripheral blood. The pathogenesis of the immunodeficiency in GS remains elusive. A bone marrow defect is suggested by B and T cell lymphopenia, and the frequent coexistence of eosinopenia. Pure red cell aplasia or neutropenia occasionally develops.
Presentation of 3 GS cases with its clinical features, diagnosis, therapeutic approach and evolution.
Case 1: Female, 43 years-old, diagnosed in 2018 with invasive thymoma with pleural metastasis that later developed oral paraneoplastic pemphigus and myasthenia gravis. The analysis revealed - B lymphopenia and panhypogammaglobulinemia, all associated to recurrent respiratory and urinary infections, anemia that required blood transfusion, severe neutropenia and thrombocytopenia.
During the next year she required several hospitalizations because of respiratory infections and gastrointestinal symptoms, with poor evolution developing sepsis with exitus despite IVIG therapy.
Case 2: Female, 61 years-old, diagnosed with thymoma, with complete resection in 2014. Anemia, severe neutropenia and panhypogammaglobulinemia treated with IVIG. Hospitalized with interstitial lymphoid pneumonitis in 2015 treated with Corticosteroids and Rituximab with a good clinical response. Stable evolution.
Case 3: Male, 69 years-old, diagnosed with GS agammaglobulinemy associated to thymoma (resected) treated with IVIG, associated to chronic diarrhea (Campylobacter yeyuni) and ankylosing spondylitis. Thrombocytopenia and leucopenia with progressive anemia. Also diagnosed with idiopathic cirrhosis Child A with portal hypertension. Stable evolution.
A diversity of the clinical presentation is observed in the GS that requires a multidisciplinary management of these patients.
WHIM syndrome is a rare primary immunodeficiency that is characterized by neutropenia with myelokathexis, hypogammaglobulinema, susceptibility to human papilloma virus infection. It is caused by autosomal dominant gain-of-function mutations in CXC chemokine receptor 4 (CXCR4).
We report a group of 7 patients (6 from unrelated families, one family - P3 is a son of P4) 1-40 years (M – 4y) with CXCR4 mutations. The mutations were detected via NGS targeted panel sequencing and/or Sanger’s sequencing.
All patients manifested with neutropenia, myelokathexis and lymphopenia was observed at the onset of the disease. Four of them had the same mutation (p.R334X). Hypogammaglobulinemia was observed in 6 patients where as P2 showed borderline levels. Severe infections (pneumonia and lung abscess) were observed in 2 patients. Skin warts were observed only in adult patient (P4). 4 patients had variable congenital heart defects, three patients had renal abnormalities. 6 patients were treated with prophylactic antimicrobials, IVIG and subcutaneous injections of G-SCF (3 - 10 μg/kg/d). 2 patients underwent HSCT from a 10/10 (P6) and 9/10 (P3) matched unrelated donor, they are currently 5 years and 60 days post-transplant, respectively, with full donor chimerism.
CXCR4 defects need to be considered in patients with chronic neutropenia and congenital anomalies, especially heart and renal defects, despite lack of severe infections and warts. Based on our experience WHIM can be effectively treated with HSCT, though longer follow-up is needed.
Patients with Rubinstein Taybi Syndrome (RSTS) suffer from recurrent infections. Yet, immunological alterations have not been described in this syndrome. Here we aim to investigate if primary immunodeficiency (PID) is associated with RSTS.
We performed a Pubmed search for “Rubinstein Taybi Syndrome” to identify all published RSTS patients from 2000 onwards. We contacted the corresponding authors of all relevant publications and all referring physicians to obtain complete immunological data and current clinical information. We also contacted colleagues involved in the diagnosis of PID to identify additional patients.
Eighteen RSTS patients were identified (Table 1). For eleven patients, we retrieved data from the published report while for seven patients a 2019 clinical update was provided. Nine patients received a molecular diagnosis, while the remaining cases were clinically diagnosed. The median age at last follow-up was 15 years (range, 2-46 years). All but two patients had recurrent or severe infections (88.9%); five autoimmune disease (27.8%), and four lymphoproliferation (22.2%). One neuroendocrine tumor occurred (5.6%).
Following immunological investigations (Table 2), only three patients showed no abnormalities (16.7%). Humoral and antibody defects were predominant (9/18; 50%) while five patients had combined or severe immunodeficiency (37.8%). Nine patients (50%) were on Ig replacement therapy, seven received antibiotic or antifungal prophylaxis, and one patient received bone marrow transplantation for Omenn’s syndrome.
RSTS can present with a clinical and immunological phenotype of PID, with a high burden of infectious complications. Full immunological work-up is warranted in these patients, who may require specific supportive treatment.
Severe combined immunodeficiency (SCID) is a severe defect in differentiation and function of T cells. The most frequent form of SCID is caused by mutations in the X-linked gene IL2RG. Some patients with X-SCID are often followed by enteropathy and failure to thrive, and rarely present with inflammatory bowel disease (IBD) manifestation in the absence of severe infections. However, detailed reports on pathogenesis about X-SCID with IBD manifestation have not been published.
A 6-month-old boy was referred to our hospital with a 2-month history of intractable diarrhea and recurrent of perianal abscess with fever. No other pathogenic microbes were detected in stools. Colonoscopy revealed multiple longitudinal ulcers from the transverse to the rectal colon, and biopsies demonstrated neutrophil infiltration, proliferative inflammatory granulation tissues, and small granuloma in colon.
Immunological investigation showed hypogammaglobulinemia and mild lymphopenia. DNA sequencing showed a mutation of the IL2RG gene (p.Leu179Argfsx26), which represents T-B+NK- phenotype of SCID in general. However, low number of CD3+ CD4+ T cells had been observed in the peripheral blood and confirmed by identification of maternal T engraftment using microsatellite chimerism. A large number of maternal T cells were infiltrated in colon which was associated with the presence of proliferative inflammatory granulation tissues, and small granuloma.
We proved presence of maternal cells in the intestinal lesions with significant T cell infiltration in spite of a few T cell in the peripheral blood. Therefore, it is likely that these cells are strongly associated with pathogenesis of early-onset IBD in our patient.
Immunodeficiency, centromeric instability and facial anomalies syndrome 2 (ICF2) is a rare autosomal recessive primary immunodeficiency disorder. So far, 27 patients with ICF2 have been reported in the literature. Here we present 3 siblings with ICF2 due to a homozygous ZBTB24 gene mutation (c.1222 T>G), including two twin sisters.
Mutation in ZBTB24 in living patient was detected with whole exome sequencing. Genetic alterations in ZBTB24 were validated by Sanger sequencing. All previously ICF2 patients have been identified through a search in pubmed. Their phenotypes and immunological data have been documented and summarized.
We identified three siblings, including two dizygotic twin sisters with ICF2. One patient had mycobacterial infection and bronchial malformation, which are for the first time associated with ICF2. All patients displayed a gradual reduction in their IgG, B-cell and CD4+ T cell counts, suggesting a progressive course of immunodeficiency in ICF2. Despite their common genetic background, including the same causative mutation in ZBTB24, clinical heterogeneity (recurrent infections Vs. no significant infection record) and evident differences in immunological profiles (e.g. normal IgG levels Vs. severe hypogammaglobulinemia) among these patients suggest the pathogenic relevance of epigenetic modification in this monogenic immunodeficiency disorder.
Considering the high mortality rate of ICF2, previous reports on severe complications, such as opportunistic infections, lymphomas and EBV-induced hemophagocytic lymphohystiosis as well as the here presented evidence on a progressive impairment of the immune system, we suggest early consideration of HSCT in all ICF2 patients.
Pulmonary complications are common in primary immunodeficiency diseases (PID) and contribute to morbidity and mortality in these patients. However, their varied presentation and a general lack of awareness of PID respiratory specialists and primary care physicians make early diagnosis and treatment difficult. The aim of this study was to define the warning signs of PID in patients with respiratory manifestations, the necessary diagnostic tests, and the therapeutic management of both children and adults.
A review of the literature was performed, and 43 PID interdisciplinary specialists were consulted.
This document identifies the pulmonary and extrapulmonary manifestations that should prompt a suspicion of PID, the immunological and respiratory tests that should be included in the diagnostic process according to the level of care, recommendations regarding the use of immunoglobulin replacement therapy according to the specific immunodeficiency, and the minimum recommended immunological and pulmonary monitoring in these patients.
This document is the first to combine scientific evidence with the opinion of a broad panel of experts specialized in the treatment and care of patients with immunodeficiencies. It aims to provide a useful guide for all practitioners who are regularly involved in the management of these patients.
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency with the majority of patients diagnosed in adulthood. So far, monogenic causes as well as risk-associated genes have been identified only in a limited number of patients. Despite tremendous efforts, for the majority of patients the genetic background is still unknown. Several studies indicate a polygenic and complex genetic background of the disease. A combination of germline and somatic mutations may play an essential role in the pathogenesis.
In this study, we have analysed next generation targeted resequencing data of 63 patients diagnosed with CVID to identify the influence of germline and somatic mutations in known PID genes on disease ontogeny and progression.
We could detect a higher frequency of germline mutations in the CTLA-4 gene in patients with CVID compared to the controls, a gene which has been indicated to play a role in disease ontology in previous studies. 6 out of these 10 patients (60 %) had autoimmune manifestations including rheumatoid diseases, thrombocytopenia and inflammatory bowel disease. In addition, we found a significant reduction of global somatic mutation burden as well as potentially pathogenic somatic variants in blood leucocytes from patients with CVID. Leukocyte numbers and age at time of sequencing did not correlate with somatic mutation burden.
Non-infectious complications in CVID, such as autoimmune manifestations are common. We extend previous studies and confirm that germline mutations in CTLA-4 are associated with CVID.
Primary immunodeficiencies are rare genetic diseases of the immune system. The manifestations of primary immunodeficiencies are extremely varied, often hidden under different masks. Despite the creation of alarm signs and improvement of diagnosis there are situations of delaying the diagnosis of primary immunodeficiency.
Aim: to determine the structure of primary immunodeficiencies among the pediatric population in Moldova
Over 25 years at the Institute of Mother and Child were evaluated 51 children with primary immunodeficiency 0-18 years of age by (general blood analysis, serum immunoglobulin determination, lymphocyte immunophenotyping, morphology and immunohistochemistry, molecular genetic methods)
36 patients (70%) were diagnosed postmortem by degrading the specific features of the immune system organs and other organs. Of these 7 patients had DiGeorge syndrome with agenesis or hypoplasia of the thymus; 4 - Louis Bar syndrome, 4 - SCID type Nezelof, 6 - Swiss type SCID and 15 (41.6%) were diagnosed with non-classifiable primary immunodeficiency. Based on the evaluation of the alarm signs, the diagnosis was suspected and confirmed in 15 patients (30%): 3 – Bruton, 1 patient with SCID, 1 - CVID, 1 - hyper IgM and 9 patients with well-defined syndromes (3 - Louis Bar, 3 - WAS, 1 - Bloom, 1 - DiGeorge).
Morphopathological evaluation is important for diagnosis of PID. But the focus should be put on multidisciplinary collaboration to increase the early diagnosis rate of children with immunodeficiency.
Bruton agammaglobulinemia is a hereditary (X-linked) immunodeficiency disorder characterized by the absence of mature B-cells, which leads to severe antibody deficiency and recurrent infections. Clinical manifestations occur as soon as the protective effect of maternal immunoglobulins decreases, approximately at the age of six months. The first sign is frequent respiratory infections, which can have serious progression.
Aim: evaluating the spectrum of infections in Bruton agammaglobulinemia
Were reviewed medical records of 4 patients with Bruton agammaglobulinemia focusing on immunoglobulins, phenotyped peripheral blood lymphocytes and infections.
In all children the first sign of alarm was the frequent early-onset infections. In 2 of the children were present purulent infections with different localizations (meningitis, empyema, sinusitis, osteomyelitis) with progressive severe progression. Recurrent respiratory infections over time have complicated with chronic bronchopulmonary phenomena with bronchial deformities, pulmonary fibrosis, bronchiectasis. The immunological investigation in all patients indicated a reduction of serum immunoglobulin values: IgA - 1.78±0.9 mg/dl; IgM - 1.8±0.67 mg/dl; IgG - 6.75±0.54 mg/dl. Determination of lymphocyte populations in these patients resulted with normal T – 49±13.8% lymphocyte variation and a significant reduction in B cells of 8.8±3.03%.
Lack of antibodies to agammaglobulinemia Bruton leads to a polymorphism of infections with different localization, the respiratory system being predominantly affected.
Patients with PIDD require multi-specialty expertise for optimal outcomes. However, rigorous PIDD training is lacking in many sub-specialties despite a growing need for immunology knowledge in all facets of medicine. PIDD research is also hampered by lack of a cross-disciplinary network across centers. North American institutions united in 2014 to form the North American Immuno-Hematology Clinical Education and Research (NICER) Consortium to address these limitations.
The NICER consortium consists of 15+ institutions and is composed of experts with diverse training including immunology, hematology/oncology, bone marrow transplantation, infectious disease, rheumatology, laboratory medicine and genetics.
To increase PIDD education across specialties, NICER implemented a monthly video case conference presented by rotating institutions. Diverse cases include known molecular defects as well as diagnostic odysseys and information regarding diagnosis and treatment. Partnership with the Clinical Immunology Society (CIS) in 2018 expanded the educational platform of NICER and will improve clinical care with 3 new discussion platforms (listservs): immune cytopenias; malignancy in PIDD; and immune-related adverse events. An annual NICER symposium was initiated in 2018 to highlight PIDD research. A developing research foundation includes a patient registry for cohort development with longitudinal clinical phenotyping across disciplines and a curated PIDD biorepository. Implementation of this infrastructure for clinical trials is projected for the fall of 2019.
The creation and expansion of the NICER consortium has been rapid and relevant in developing educational opportunities for diverse specialists in North America. Current and future work is focused on developing the platform for multi-institutional immuno-hematology research.
The hyper IgE syndrome is a congenital multisystem disorder characterized by eczema and infections. We reported a 27-year-old female with severe eczema, asthma, recurrent cellulitis, gingivitis, mastitis, and pneumonia since childhood. She also had bronchiectasis, pneumatocele, retained primary teeth, spontaneous right rib fracture and brain ischemia. Her 4-year-old son had recurrent pneumonia, cellulitis, severe eczema and chronic mucocutaneous candidiasis. The most common causal pathogen of these episodes was Staphylococcus aureus.
We collected the blood from the mother and son. Six healthy adults and two healthy children were enrolled for comparison. The PBMCs were sent for functional analyses and serum cytokines were measured with ELISA.
Genomic DNA was extracted from the blood cells, and the STAT3 gene was sequenced.
The patients had marked elevated serum total immunoglobulin E (20378.67 IU/mL and 2728 IU/mL respectively, reference range: 1.31 -165.3 IU/mL), persisted eosinophilia up to 8494 cells/μL, normal polymorphonuclear granulocyte (PMN) bacterial killing, chemotaxis and phagocytosis functions, normal complement levels (C3, C4, CH50), and normal IgG, IgA, IgM levels. Cytokine levels of CXCL1, CXCL10, sCD40L, IL-12p40, IL-9, and TNF-α were elevated.
Their STAT3 gene sequencing showed the same point mutation in exon 20, encoding the SH2 domain. This heterozygous missense mutation of A1843G led to a K615E substitution.
The patients were diagnosed as autosomal dominant hyper IgE syndrome with National Institutes of Health score of 70 and 56, respectively. This A1843G was a new mutation associated with hyper IgE syndrome.
Autosomal dominant (AD) signal transducer and activator of transcription 1 (STAT1) gain-of-function (GOF) mutations result in a primary immunodeficiency (PID) characterized by chronic mucocutaneous candidiasis (CMC), recidivating respiratory infections, autoimmunity, and vascular anomalies. While CMC is the most common symptom, additional phenotypes such as JC virus induced progressive multifocal leukoencephalopathy, IPEX-like syndromes with CMC, and a combined immunodeficiency (CID) without CMC have been associated with STAT1 GOF mutations, but remain unexplained from a pathophysiological point-of-view. We hypothesize that differences in phenotypes could be linked to varying molecular mechanisms associated with different STAT1 GOF mutation. Therefore, we studied the molecular dynamics of four STAT1 GOF mutations (R274W, R321S, N574I and T419R) situated in three distinct domains of the protein.
We evaluated phosphorylation level, efficiency in activating the transcription of interferon stimulated genes (ISGs) and nuclear accumulation rate of the different GOF mutants in different cell lines. Next, we used Raster Imaging Correlation Spectroscopy (RICS) to study the cellular dynamic behavior of the different mutants.
We observed distinct routes towards a STAT1 GOF phenotype: an increased nuclear accumulation rate (R274W), increased affinity for DNA (T419R), and a reduced nuclear diffusion speed (R321S and N574I) upon stimulation with IFN gamma.
Our results suggest that STAT1 GOF is the resultant of various molecular mechanisms. We speculate that this might contribute to the spectrum of clinical phenotypes and/or responsiveness for targeted therapy.
EBV-lymphoproliferative diseases (EBV-LPD) are either non-malignant or malignant disorders but overlap may exist between both entities.
We investigated 2 sisters from a consanguineous family. P2.1 presented a combined immune deficiency with recurrent lower respiratory tract infections, epidermodysplasia verruciformis and high chronic EBV viremia (>5 log). P2.2 developed an EBV-LPD at the age of 10 that was considered as an isolated Burkitt leukemia without c-myc rearrangement.
Targeted-sequencing in P2.1 then exome sequencing was performed in both, floowed by T-cell assays.
P2.1 was found to be carrier of a novel hypomorphic homozygous private variation (c.252C>G; p.84C>W) associated with a decreased ZAP70 expression and defects in TCR signaling and activation (total tyrosine phosphorylation, calcium flux, proliferation, degranulation, AICD). Unexpectedly, P2.2 was not carrier of the ZAP70 mutation and did not present any TCR functional defects.
Hence, both patients underwent exome sequencing which revealed a homozygous FAAP24 variation (c.635C>T; p.212T>M) segregating with the disease. The exact same mutation has been previously reported in 2 patients who died from EBV-LPD. Thus, we hypothesized that this mutation was involved in the EBV-LPD of P2.2. FAAP24 is involved in DNA damage response by recruiting Fanconi proteins and regulating cell cycle. Experiments are ongoing to assess these pathways and to test the stimulation between EBV-infected B cells and EBV-specific T cells.
This study highlights the genetic complexity underlying immunological phenotypes within a single family. Additional studies are warranted to characterize the interactions between the ZAP70 and FAAP24 mutations in P2.1 and to understand the function of FAAP24 in EBV immunity.
Hereditary angioedema (HAE) was almost unheard of in Hong Kong prior to the establishment of its first public Clinical Immunology service in 2018. Since then, Queen Mary Hospital established a dedicated Immunology Clinic and the first HAE registry in the region. The aim was to study the prevalence as well as the clinical features of these previously undiagnosed HAE patients in Hong Kong.
From 2018-2019, all referrals for angioedema and suspected HAE were screened and reviewed. Referrals were encouraged by conducting a series of educational lectures as well as a dedicated Immunology chapter in the territory-wide handbook accessible to all public-sector doctors. All confirmed HAE patients consented to participate in the Hong Kong HAE registry and their clinical features were reviewed for analysis.
Between July 2018 to July 2019, 81 referrals were received for workup of angioedema and/or suspected immunodeficiency. Eight families with HAE were identified. Seven families carried unique mutations for HAE I, and one family carried a mutation for HAE II. After family screening, 19 individuals were confirmed to have HAE, with a further 91 potentially affected family members pending screening. More than 20% of patients had a history of laryngeal attacks, and 64% of patients had been hospitalized (at least once) for acute angioedema attacks. All confirmed HAE patients were offered C1 inhibitor replacement in a structured protocol.
We describe the clinical characteristics of the first HAE registry in Hong Kong and our region, which also enabled provision of much needed C1 inhibitor replacement for these patients.
PI is a lifetime disease, so the patient is in frequent contact not only with physicians but also with nurses. An immunology nurse is a first contact person for every PID patient so it is very important to build and maintain relation between them based on mutual trust and honesty. Nurses have to answer many questions regarding life management or treatment options. They also must be able to react in crisis situations so it is important to equip them in a necessary psychological knowledge.
In 2019 Polish immunology nurses took part in one-day trainings on communication and building long-lasting relations with PID patients. It consisted of the following modules:
- Preferences of PID patients regarding treatment
- Effective communication with the patient - how to build an understanding?
- Workshop – patient-nurse conversation role-plays
After the course nurses filled out a survey regarding the discussed matters.
62,5% of participants stated that they definitely would like to continue such trainings in the area of patient-nurse relations. 37,5% declared “rather yes”.
Participants also listed such benefits:
- Psychological tips on coping with patients’ stress
- Opportunity to comment case studies
- Practical workshops
- Exchanges of experiences
It is important to create an opportunity for the nurses to participate in such workshops to improve their soft skills. As a result they will feel better, more self-confident and will increase their effectiveness. It is crucial as patients rely on them in many fields and spend much more time with them than the physicians do.
Therapeutic Patient Education (TPE) is of increasing importance in patients' management program by providing them, in a comprehensive manner, the knowledge relevant to their disease. PID is a particularly challenging field for TPE application. Indeed not only immunology is a discipline endowed with many levels of complexity but, in addition, PID usually manifest early in life, with several clinical faces.
The PID4KIDS program (Primary Immune Deficiencies for Kids) is a TPE program conducted by both the Immunology care unit at the Children Hospital, and the BSc students enrolled in immunology program at the University of Toulouse.
The program involves several steps. First, the immunology professor invited his students to form team-projects with the objective to assemble immunology resources dedicated to children. Second, the students proposed a project, which they developed upon validation over a 3-months period. The project development was assisted scientifically by PhD students and technically by a civic service volunteer. Third, the resources were transferred to the care unit with the aim to be proposed to patients in TPE sessions. Two videos, one book, fact sheets and 5 board games were produced by 28 students split in 9 team-projects. A dialog between the staff of the care unit, the professor and the student will be engaged to step-by step improve the content of the provided resources at the benefits of the patients.
We believe these benefits will extend in the next few years to the PID patients which could be enrolled in the coming TPE sessions.
Malignancy is still a relevant barrier to long term survival after heart transplantation. Immune monitoring of basic components of the immune response could be a useful tool to identify the risk for development of malignancy. We aimed to identify immunological biomarkers that could be associated with risk of malignancy.
In a prospective follow-up study 265 patients were evaluated in a single center. Mean age was 66,48 years (women 13,04%, men 86,96%). During a long-term follow-up, 69 patients developed at least one new malignancy after heart transplantation. Mean time from transplantation to diagnosis of post transplant malignancy was 4,71 years. A total of 122 malignancies were diagnosed: epithelial (35,2%), mucose (24,6%), metastasis (8,2%). Immunological biomarkers were evaluated at the time of inclusion in waiting list and at 7 and 30 days after heart tranplantation.
One-week after transplantation lower B-cell percentages (<3,13%) and lower B-cell absolute counts (<73,5 cells/uL) were risk factors for development of malignancy. Seven days after-transplantation, patients with IgG hypogammaglobulinemia (IgG<477 mg/dL, p=0,019), absolute NK-cell counts (<72,5/uL, p=0,004) and absolute T CD3+ counts (<208,50/uL) were at higher risk of having metastasis after diagnosis of malignancy during follow-up. Clinical risk factors of malignancy were age> 66 years; smoke; ischemia, chronic inflammatory conditions and infections. Low B-cell counts at 7 days (LB <73,5 cell/uL, OR 6.19, 95% CI 2,25-17,07, p<0,001) were significantly associated with malignancy risk after adjustment by clinical variables.
A profile of distinct immunological abnormalities is associated with a high risk for developing malignancy and metastasis after heart transplantation.