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Hanitsch LG, Wittke K, Stittrich AB, Volk HD, Scheibenbogen C. Interstitial Lung Disease Frequently Precedes CVID Diagnosis. J Clin Immunol 2019; 39:849-851. [PMID: 31637570 DOI: 10.1007/s10875-019-00708-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/11/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Leif G Hanitsch
- Outpatient Clinic for Immunodeficiencies, Institute for Medical Immunology, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Kirsten Wittke
- Outpatient Clinic for Immunodeficiencies, Institute for Medical Immunology, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anna Barbara Stittrich
- Outpatient Clinic for Immunodeficiencies, Institute for Medical Immunology, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Hans Dieter Volk
- Outpatient Clinic for Immunodeficiencies, Institute for Medical Immunology, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health (BIH), Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin and Max Delbrück Center, Berlin, Germany
| | - Carmen Scheibenbogen
- Outpatient Clinic for Immunodeficiencies, Institute for Medical Immunology, Charité-Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health (BIH), Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin and Max Delbrück Center, Berlin, Germany
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Abstract
The most common primary immune deficiencies are those of the humoral immune system, and most of these present in childhood. The severity of these disorders ranges from transient deficiencies to deficiencies that are associated with a complete loss of ability to make adequate or functional antibodies, and have infectious as well as noninfectious complications. This article reviews, in a case-based discussion, the most common of the humoral immune deficiencies; their presentations, diagnoses, treatments; and, when known, the genetic defects.
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53
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Kellner ES, Fuleihan R, Cunningham-Rundles C, Wechsler JB. Cellular Defects in CVID Patients with Chronic Lung Disease in the USIDNET Registry. J Clin Immunol 2019; 39:569-576. [PMID: 31250334 PMCID: PMC6903687 DOI: 10.1007/s10875-019-00657-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 06/10/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Chronic lung disease is the most common cause of morbidity and mortality in patients with common variable immunodeficiency (CVID). While biomarkers exist to predict non-infectious complications, the unique features that define CVID patients with chronic lung disease are not well understood. METHODS We analyzed data from CVID patients from the retrospective USIDNET (United States Immunodeficiency Network) patient database. Patients were categorized into 3 phenotypes for comparison: (1) CVID without chronic lung disease, (2) CVID with bronchiectasis only, and (3) CVID with interstitial lung disease (ILD) with or without bronchiectasis. Among these groups, differences were assessed in demographics, comorbidities, infections, treatments, and peripheral blood immune measures. We analyzed 1518 CVID patients which included 1233 (81.2%) without chronic lung disease, 147 (9.7%) with bronchiectasis only, and 138 (9.1%) with interstitial lung disease. RESULTS Patients with ILD had lower CD3+ cell counts (P = .001), CD4+ cell counts (P < .05), and CD8+ cell counts (P < .001) compared with patients without lung disease. Additionally, there was significantly more CVID patients with ILD with pneumonia (P < .001), herpes viruses (P = .01) and fungal infections (P < .001) compared with patients with CVID without chronic lung disease. CONCLUSION This analysis suggests that patients with chronic lung disease may be more likely to have lower peripheral T cell counts and complications of those defects compared with CVID patients without chronic lung disease.
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Affiliation(s)
- Erinn S Kellner
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Ramsay Fuleihan
- Division of Allergy-Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charlotte Cunningham-Rundles
- Division of Allergy and Immunology, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Joshua B Wechsler
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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54
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Cinetto F, Scarpa R, Pulvirenti F, Quinti I, Agostini C, Milito C. Appropriate lung management in patients with primary antibody deficiencies. Expert Rev Respir Med 2019; 13:823-838. [PMID: 31361157 DOI: 10.1080/17476348.2019.1641085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Human primary immunodeficiency diseases (PIDs) include a broad spectrum of more than 350 disorders, involving different branches of the immune system and classified as 'rare diseases.' Predominantly antibody deficiencies (PADs) represent more than half of the PIDs diagnosed in Europe and are often diagnosed in the adulthood. Areas covered: Although PAD could first present with autoimmune or neoplastic features, respiratory infections are frequent and respiratory disease represents a relevant cause of morbidity and mortality. Pulmonary complications may be classified as infection-related (acute and chronic), immune-mediated, and neoplastic. Expert opinion: At present, no consensus guidelines are available on how to monitor and manage lung complications in PAD patients. In this review, we will discuss the available diagnostic, prognostic and therapeutic instruments and we will suggest an appropriate and evidence-based approach to lung diseases in primary antibody deficiencies. We will also highlight the possible role of promising new tools and strategies in the management of pulmonary complications. However, future studies are needed to reduce of diagnostic delay of PAD and to better understand lung diseases mechanisms, with the final aim to ameliorate therapeutic options that will have a strong impact on Quality of Life and long-term prognosis of PAD patients.
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Affiliation(s)
- Francesco Cinetto
- Department of Medicine - DIMED, University of Padova , Padova , Italy.,Internal Medicine I, Ca' Foncello Hospital , Treviso , Italy
| | - Riccardo Scarpa
- Department of Medicine - DIMED, University of Padova , Padova , Italy.,Internal Medicine I, Ca' Foncello Hospital , Treviso , Italy
| | - Federica Pulvirenti
- Department of Molecular Medicine, "Sapienza" University of Roma , Roma , Italy
| | - Isabella Quinti
- Department of Molecular Medicine, "Sapienza" University of Roma , Roma , Italy
| | - Carlo Agostini
- Department of Medicine - DIMED, University of Padova , Padova , Italy.,Internal Medicine I, Ca' Foncello Hospital , Treviso , Italy
| | - Cinzia Milito
- Department of Molecular Medicine, "Sapienza" University of Roma , Roma , Italy
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55
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Agarwal S, Cunningham-Rundles C. Autoimmunity in common variable immunodeficiency. Ann Allergy Asthma Immunol 2019; 123:454-460. [PMID: 31349011 DOI: 10.1016/j.anai.2019.07.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Common variable immunodeficiency (CVID) is a primary immunodeficiency that is clinically heterogeneous, characterized by both infectious and noninfectious complications. Although the hallmark of disease presentation is commonly a history of recurrent sinopulmonary infections, autoimmunity and noninfectious inflammatory conditions are increasingly associated with CVID. DATA SOURCES A comprehensive literature search using PubMed of basic science and clinical articles was performed. STUDY SELECTIONS Articles discussing the association of autoimmunity with primary immunodeficiency, specifically CVID, were selected. RESULTS The most common autoimmune conditions are cytopenias, including immune thrombocytopenia purpura and hemolytic anemia, but organ-specific autoimmune/inflammatory complications involving the gastrointestinal, skin, joints, connective tissue, and respiratory tract. In most cases, immunoglobulin replacement therapy does not ameliorate or treat these inflammatory complications, and additional immunomodulatory treatments are needed. CONCLUSION Mechanisms producing these conditions are poorly understood but include cytokine and cellular inflammatory pathways, and loss of tolerance to self-antigens through the multiple signaling molecules and pathways common to tolerance and immune deficiency.
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Affiliation(s)
- Shradha Agarwal
- Icahn School of Medicine at Mount Sinai, Division of Allergy and Clinical Immunology, Department of Medicine, New York, New York.
| | - Charlotte Cunningham-Rundles
- Icahn School of Medicine at Mount Sinai, Division of Allergy and Clinical Immunology, Department of Medicine, New York, New York
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56
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Patel S, Anzilotti C, Lucas M, Moore N, Chapel H. Interstitial lung disease in patients with common variable immunodeficiency disorders: several different pathologies? Clin Exp Immunol 2019; 198:212-223. [PMID: 31216049 DOI: 10.1111/cei.13343] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 12/30/2022] Open
Abstract
Various reports of disease-related lung pathologies in common variable immunodeficiency disorder (CVID) patients have been published, with differing histological and high-resolution computed tomography (HRCT) findings. Data were extracted from the validated Oxford Primary Immune Deficiencies Database (PID) database (1986-2016) on adult, sporadic CVID patients with suspected interstitial lung disease (ILD). Histology of lung biopsies was studied in relation to length of follow-up, clinical outcomes, HRCT findings and chest symptoms, to look for evidence for different pathological processes. Twenty-nine CVID patients with lung histology and/or radiological evidence of ILD were followed. After exclusions, lung biopsies from 16 patients were reanalysed for ILD. There were no well-formed granulomata, even though 10 patients had systemic, biopsy-proven granulomata in other organs. Lymphocytic infiltration without recognizable histological pattern was the most common finding, usually with another feature. On immunochemistry (n = 5), lymphocytic infiltration was due to T cells (CD4 or CD8). Only one patient showed B cell follicles with germinal centres. Interstitial inflammation was common; only four of 11 such biopsies also showed interstitial fibrosis. Outcomes were variable and not related to histology, suggesting possible different pathologies. The frequent nodules on HRCT were not correlated with histology, as there were no well-formed granulomata. Five patients were asymptomatic, so it is essential for all patients to undergo HRCT, and to biopsy if abnormal HRCT findings are seen. Internationally standardized pathology and immunochemical data are needed for longitudinal studies to determine the precise pathologies and prognoses in this severe complication of CVIDs, so that appropriate therapies may be found.
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Affiliation(s)
- S Patel
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Clinical Immunology, Oxford University Hospitals, John Radcliffe Site, Oxford, UK
| | - C Anzilotti
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Clinical Immunology, Oxford University Hospitals, John Radcliffe Site, Oxford, UK
| | - M Lucas
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - N Moore
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H Chapel
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Clinical Immunology, Oxford University Hospitals, John Radcliffe Site, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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57
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Weinberger T, Fuleihan R, Cunningham-Rundles C, Maglione PJ. Factors Beyond Lack of Antibody Govern Pulmonary Complications in Primary Antibody Deficiency. J Clin Immunol 2019; 39:440-447. [PMID: 31089938 DOI: 10.1007/s10875-019-00640-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/01/2019] [Indexed: 01/12/2023]
Abstract
PURPOSE Pulmonary complications occur frequently in primary antibody deficiency (PAD). While the impact of antibody deficiency may appear implicit for certain respiratory infections, immunoglobulin replacement therapy does not completely ameliorate pulmonary complications in PAD. Thus, there may be antibody-independent factors influencing susceptibility to respiratory disease in PAD, but these remain incompletely defined. METHODS We harnessed the multicenter US Immunodeficiency Network primary immunodeficiency registry to compare prevalence of asthma, bronchiectasis, interstitial lung disease (ILD), and respiratory infections between two forms of PAD: common variable immunodeficiency (CVID) and x-linked agammaglobulinemia (XLA). We also defined the clinical and immunological characteristics associated with ILD and asthma in CVID. RESULTS Asthma, bronchiectasis, ILD, pneumonia, and upper respiratory infections were more prevalent in CVID than XLA. ILD was associated with autoimmunity, bronchiectasis, and pneumonia as well as fewer B and T cells in CVID. Asthma was the most common chronic pulmonary complication and associated with lower IgA and IgM in CVID. Age of symptom onset or CVID diagnosis was unrelated with ILD or asthma. CONCLUSION Despite having less severe immunoglobulin deficiency than XLA, respiratory infections, ILD, and asthma were more common in CVID. Among CVID patients, ILD was associated with autoimmunity and reduced lymphocytes and asthma with lower immunoglobulins. Though our results are tempered by registry limitations, they provide evidence that factors beyond lack of antibody promote pulmonary complications in PAD. Efforts to understand how genetic etiology, nature of concurrent T cell deficiency, and propensity for autoimmunity shape pulmonary disease may improve treatment of PAD.
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Affiliation(s)
- Tamar Weinberger
- Department of Medicine, Center for Allergy, Asthma, and Immune Disorders, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ramsay Fuleihan
- Department of Pediatrics, Division of Allergy and Immunology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charlotte Cunningham-Rundles
- Department of Medicine, Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul J Maglione
- Department of Medicine, Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Department of Medicine, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, School of Medicine, Boston University, Boston, MA, USA. .,Pulmonary Center, School of Medicine, Boston University, 72 East Concord Street, R304, Boston, MA, 02118, USA.
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58
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Pecoraro A, Crescenzi L, Galdiero MR, Marone G, Rivellese F, Rossi FW, de Paulis A, Genovese A, Spadaro G. Immunosuppressive therapy with rituximab in common variable immunodeficiency. Clin Mol Allergy 2019; 17:9. [PMID: 31080365 PMCID: PMC6501382 DOI: 10.1186/s12948-019-0113-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 12/23/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequent symptomatic primary antibody deficiency in adulthood and is characterized by the marked reduction of IgG and IgA serum levels. Thanks to the successful use of polyvalent immunoglobulin replacement therapy to treat and prevent recurrent infections, non-infectious complications, including autoimmunity, polyclonal lymphoproliferation and malignancies, have progressively become the major cause of morbidity and mortality in CVID patients. The management of these complications is particularly challenging, often requiring multiple lines of immunosuppressive treatments. Over the last 5–10 years, the anti-CD20 monoclonal antibody (i.e., rituximab) has been increasingly used for the treatment of both autoimmune and non-malignant lymphoproliferative manifestations associated with CVID. This review illustrates the evidence on the use of rituximab in CVID. For this purpose, first we discuss the mechanisms proposed for the rituximab mediated B-cell depletion; then, we analyze the literature data regarding the CVID-related complications for which rituximab has been used, focusing on autoimmune cytopenias, granulomatous lymphocytic interstitial lung disease (GLILD) and non-malignant lymphoproliferative syndromes. The cumulative data suggest that in the vast majority of the studies, rituximab has proven to be an effective and relatively safe therapeutic option. However, there are currently no data on the long-term efficacy and side effects of rituximab and other second-line therapeutic options. Further randomized controlled trials are needed to optimize the management strategies of non-infectious complications of CVID.
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Affiliation(s)
- Antonio Pecoraro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Ludovica Crescenzi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Maria Rosaria Galdiero
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giancarlo Marone
- 2Department of Public Health, University of Naples Federico II, Naples, Italy.,3Monaldi Hospital Pharmacy, Naples, Italy
| | - Felice Rivellese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy.,4Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Francesca Wanda Rossi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Amato de Paulis
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Arturo Genovese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giuseppe Spadaro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
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59
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Tillman R, Guillerman RP, Trojan T, Silva-Carmona M, Chinn IK. Treatment-Responsive Granulomatous-Lymphocytic Interstitial Lung Disease in a Pediatric Case of Common Variable Immunodeficiency. Front Pediatr 2019; 7:105. [PMID: 30984724 PMCID: PMC6449420 DOI: 10.3389/fped.2019.00105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/05/2019] [Indexed: 12/17/2022] Open
Abstract
Granulomatous-Lymphocytic Interstitial Lung disease (GLILD) is a granulomatous and lymphoproliferative condition occurring in ~25% of Common Variable Immunodeficiency (CVID) patients with the highest prevalence in the late teen to young adult years. GLILD was first described in adults and carries a poor prognosis with survival estimated to be reduced by half. Here we report a pediatric case of CVID-associated GLILD that presented with rapid deterioration over 3 months and responded to adult-based treatment with dual chemotherapeutic agents (rituximab and azathioprine), resulting in complete resolution of clinical findings and near complete resolution of radiologic findings. This case highlights the opportunity to achieve a favorable outcome in GLILD following appropriate diagnosis and therapy.
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Affiliation(s)
- Robert Tillman
- Pediatric Pulmonary, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - R Paul Guillerman
- Pediatric Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Timothy Trojan
- Allergy Immunology, Allergy Partners of Oklahoma, Endid, OK, United States
| | - Manuel Silva-Carmona
- Pediatric Pulmonary, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States.,Pediatric Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Ivan K Chinn
- Pediatric Allergy and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
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60
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Tsai S, McOlash L, Jia S, Zhang J, Simpson P, Kaldunski ML, Aldakkak M, Grewal J, Palen K, Dwinell MB, Johnson BD, Mackinnon A, Hessner MJ, Gershan JA. A Serum-Induced Transcriptome and Serum Cytokine Signature Obtained at Diagnosis Correlates with the Development of Early Pancreatic Ductal Adenocarcinoma Metastasis. Cancer Epidemiol Biomarkers Prev 2018; 28:680-689. [PMID: 30530849 DOI: 10.1158/1055-9965.epi-18-0813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/11/2018] [Accepted: 11/26/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Despite the accessibility of blood, identification of systemic biomarkers associated with cancer progression has been especially challenging. The aim of this study was to determine a difference in baseline serum immune signatures in patients that experienced early pancreatic ductal adenocarcinoma (PDAC) metastasis compared with patients that did not. We hypothesized that immune mediators would differ in the baseline serum of these patient cohorts. To test this hypothesis, novel approaches of systemic immune analysis were performed. METHODS A serum-induced transcriptional assay was used to identify transcriptome signatures. To enable an understanding of the transcriptome data in a global sense, a transcriptome index was calculated for each patient taking into consideration the relationship of up- and downregulated transcripts. For each patient, serum cytokine concentrations were also analyzed globally as a cytokine index (CI). RESULTS A transcriptome signature of innate type I IFN inflammation was identified in patients that experienced early metastatic progression. Patients without early metastatic progression had a baseline transcriptome signature of TGFβ/IL10-regulated acute inflammation. The transcriptome index was greater in patients with early metastasis. There was a significant difference in the CI in patients with and without early metastatic progression. CONCLUSIONS The association of serum-induced transcriptional signatures with PDAC metastasis is a novel finding. Global assessment of serum cytokine concentrations as a CI is a novel approach to assess systemic cancer immunity. IMPACT These systemic indices can be assessed in combination with tumor markers to further define subsets of PDAC that will provide insight into effective treatment, progression, and outcome.
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Affiliation(s)
- Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura McOlash
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Shuang Jia
- Department of Pediatrics, Division of Endocrinology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jian Zhang
- Department of Pediatrics, Division of Quantitative Health Services, Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Services, Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary L Kaldunski
- Department of Pediatrics, Division of Endocrinology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mohammed Aldakkak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jenny Grewal
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Katie Palen
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael B Dwinell
- Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bryon D Johnson
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Martin J Hessner
- Department of Pediatrics, Division of Endocrinology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jill A Gershan
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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61
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Eren Akarcan S, Edeer Karaca N, Aksu G, Aykut A, Yilmaz Karapinar D, Cetin F, Aydinok Y, Azarsiz E, Gambineri E, Cogulu O, Ulusoy Severcan E, Alper H, Kutukculer N. Two male siblings with a novel LRBA mutation presenting with different findings of IPEX syndrome. JMM Case Rep 2018; 5:e005167. [PMID: 30479781 PMCID: PMC6249428 DOI: 10.1099/jmmcr.0.005167] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/06/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction LPS-responsive beige-like anchor (LRBA) protein deficiency is a disease of immune dysregulation with autoimmunity affecting various systems. Case Presentation Two male siblings with a novel LRBA mutation had different primary findings at admission: the younger sibling had chronic early-onset diarrhoea and the elder one had autoimmune haemolytic anaemia. During long-term follow-up for IPEX phenotype, both developed hypogammaglobulinaemia, enteropathy and lung involvement. The patients partially responded to immunosuppressive therapies. A homozygous c.2496C>A, p.Cys832Ter (p.C832*) mutation in the LRBA gene causing a premature stop codon was detected. After molecular diagnosis, abatacept, as a target-specific molecule, was used with promising results. Conclusion LRBA deficiency is a recently defined defect, with variable presentations in different patients; a single, definitive treatment option is thus not yet available.
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Affiliation(s)
- Sanem Eren Akarcan
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Neslihan Edeer Karaca
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Guzide Aksu
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ayca Aykut
- Department of Medical Genetics, Ege University Faculty of Medicine, Izmir, Turkey
| | | | - Funda Cetin
- Department of Pediatric Gastroenterology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Yesim Aydinok
- Department of Pediatric Hematology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Elif Azarsiz
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Eleonora Gambineri
- Department of Hematology-Oncology: Bone Marrow Transplant (BMT) Unit, University of Florence, Department of ''NEUROFARBA'': Section of Child's Health, ''Anna Meyer'' Children's Hospital, Florence, Italy
| | - Ozgur Cogulu
- Department of Medical Genetics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ezgi Ulusoy Severcan
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Hudaver Alper
- Department of Pediatric Radiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Necil Kutukculer
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
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62
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Cinetto F, Scarpa R, Rattazzi M, Agostini C. The broad spectrum of lung diseases in primary antibody deficiencies. Eur Respir Rev 2018; 27:27/149/180019. [PMID: 30158276 PMCID: PMC9488739 DOI: 10.1183/16000617.0019-2018] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/13/2018] [Indexed: 12/17/2022] Open
Abstract
Human primary immunodeficiency diseases (PIDs) represent a heterogeneous group of more than 350 disorders. They are rare diseases, but their global incidence is more relevant than generally thought. The underlying defect may involve different branches of the innate and/or adaptive immune response. Thus, the clinical picture may range from severe phenotypes characterised by a broad spectrum of infections to milder infectious phenotypes due to more selective (and frequent) immune defects. Moreover, infections may not be the main clinical features in some PIDs that might present with autoimmunity, auto-inflammation and/or cancer. Primary antibody deficiencies (PADs) represent a small percentage of the known PIDs but they are the most frequently diagnosed, particularly in adulthood. Common variable immunodeficiency (CVID) is the most prevalent symptomatic PAD. PAD patients share a significant susceptibility to respiratory diseases that represent a relevant cause of morbidity and mortality. Pulmonary complications include acute and chronic infection-related diseases, such as pneumonia and bronchiectasis. They also include immune-mediated interstitial lung diseases, such as granulomatous-lymphocytic interstitial lung disease (GLILD) and cancer. Herein we will discuss the main pulmonary manifestations of PADs, the associated functional and imaging findings, and the relevant role of pulmonologists and chest radiologists in diagnosis and surveillance. The spectrum of lung complications in primary antibody deficiency ranges from asthma or COPD to extremely rare and specific ILDs. Early diagnosis of the underlying immune defect might significantly improve patients' lung disease, QoL and long-term prognosis.http://ow.ly/5cP230kZvOB
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Affiliation(s)
- Francesco Cinetto
- Dept of Medicine - DIMED, University of Padova, Padova, Italy.,Medicina Interna I, Ca' Foncello Hospital, Treviso, Italy
| | - Riccardo Scarpa
- Dept of Medicine - DIMED, University of Padova, Padova, Italy.,Medicina Interna I, Ca' Foncello Hospital, Treviso, Italy
| | - Marcello Rattazzi
- Dept of Medicine - DIMED, University of Padova, Padova, Italy.,Medicina Interna I, Ca' Foncello Hospital, Treviso, Italy
| | - Carlo Agostini
- Dept of Medicine - DIMED, University of Padova, Padova, Italy.,Medicina Interna I, Ca' Foncello Hospital, Treviso, Italy
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63
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Baumann U, Routes JM, Soler-Palacín P, Jolles S. The Lung in Primary Immunodeficiencies: New Concepts in Infection and Inflammation. Front Immunol 2018; 9:1837. [PMID: 30147696 PMCID: PMC6096054 DOI: 10.3389/fimmu.2018.01837] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/25/2018] [Indexed: 12/12/2022] Open
Abstract
Immunoglobulin replacement therapy (IGRT) has contributed critically to the management of primary antibody deficiencies (PAD) and the decrease in pneumonia rate. However, despite adequate IGRT and improved prognosis, patients with PAD continue to experience recurrent respiratory tract infections, leading to bronchiectasis and continuing decline in lung function with a severe impact on their quality of life. Moreover, non-infectious inflammatory and interstitial lung complications, such as granulomatous-lymphocytic interstitial lung disease, contribute substantially to the overall morbidity of PAD. These conditions develop much more often than appreciated and represent a major therapeutic challenge. Therefore, a regular assessment of the structural and functional condition of the lung and the upper airways with appropriate treatment is required to minimize the deterioration of lung function. This work summarizes the knowledge on lung complications in PAD and discusses the currently available diagnostic tools and treatment options.
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Affiliation(s)
- Ulrich Baumann
- Department of Paediatric Pulmonology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - John M Routes
- Division of Asthma, Allergy and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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64
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Lee HE, Churg A, Ryu JH, Bilawich AM, Larsen BT, Tazelaar HD, Yi ES. Histopathologic findings in lung biopsies from patients with primary biliary cholangitis. Hum Pathol 2018; 82:177-186. [PMID: 30067952 DOI: 10.1016/j.humpath.2018.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/05/2018] [Accepted: 07/19/2018] [Indexed: 11/26/2022]
Abstract
Primary biliary cholangitis (PBC) is a progressive autoimmune disease of the liver causing destruction of intrahepatic bile ducts, associated with lymphocytic and granulomatous inflammation. PBC has been associated with many extrahepatic manifestations including interstitial lung disease. However, comprehensive pulmonary histopathology in PBC has not been well documented. Sixteen PBC patients who underwent lung biopsies were identified from surgical pathology files in three institutions. Histopathologic review was performed. Patient age ranged 41 to 79 years (median 55 years) and 15 patients (94%) were women. Specimens consisted of lobectomy (n = 1), surgical biopsies (n = 12), transthoracic needle biopsy (n = 1) and transbronchial biopsy (n = 2). Fifteen of 16 (94%) cases showed lymphocytic inflammation, mainly localized to peribronchiolar stroma and alveolar septa. Thirteen (81%) cases revealed non-necrotizing granulomas, most of which were poorly formed, reminiscent of those seen in liver biopsies from PBC patients. Six cases also showed eosinophilic infiltrates. Organizing pneumonia was seen in 7 cases. Four cases showed diffuse interstitial fibrosis with nonspecific interstitial pneumonia and usual interstitial pneumonia patterns. One patient underwent lobectomy for a mass lesion and was diagnosed with light chain deposition disease with underlying κ-restricted extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. In summary, PBC-associated histopathologic changes in the lung include lymphocytic inflammation predominantly around small airways and non-necrotizing granulomas in multiple compartments of lung tissue, which parallel PBC-associated histopathology in liver biopsies, often associated with other common patterns of diffuse lung disease.
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Affiliation(s)
- Hee Eun Lee
- Division of Anatomic Pathology, Mayo Clinic, Rochester, 55905 MN
| | - Andrew Churg
- Department of Pathology, University of British Columbia, Canada, V6T 2B5
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, 55905 MN
| | | | - Brandon T Larsen
- Division of Anatomic Pathology, Mayo Clinic, Scottsdale, 85259 AZ
| | - Henry D Tazelaar
- Division of Anatomic Pathology, Mayo Clinic, Scottsdale, 85259 AZ
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, 55905 MN.
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Deyà-Martínez A, Esteve-Solé A, Vélez-Tirado N, Celis V, Costa J, Cols M, Jou C, Vlagea A, Plaza-Martin AM, Juan M, Alsina L. Sirolimus as an alternative treatment in patients with granulomatous-lymphocytic lung disease and humoral immunodeficiency with impaired regulatory T cells. Pediatr Allergy Immunol 2018. [PMID: 29532571 DOI: 10.1111/pai.12890] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND One of the most frequent non-infectious complications of humoral immunodeficiencies with a CVID-like pattern is a particular form of inflammatory lung disease which is called granulomatous-lymphocytic interstitial lung disease (GLILD). Its development worsens patient prognosis, with a significant decrease in survival. Currently, there are no unified guidelines regarding its management, and different combinations of immunosuppressants have been used with variable success. METHODS Clinical and radiological data were collected from patient's medical charts. Flow cytometry was performed to characterize the immunological features with special focus in regulatory T cells (Tregs). RESULTS A 16-year-old girl with Kabuki syndrome and a 12-year-old boy, both with a CVID-like humoral immunodeficiency on immunoglobulin replacement treatment, developed during follow-up an inflammatory complication radiologically, clinically, and histologically compatible with GLILD. They required treatment, and sirolimus was started, with very good response and no serious side effects. CONCLUSIONS These 2 cases provide insight into the underlying local and systemic immune anomalies involved in the development of GLILD, including the possible role of Tregs. Combined chemotherapy is commonly used as treatment for GLILD when steroids fail, but there have been some reports of successful monotherapy. As far as we know, these are the first 2 GLILD patients treated successfully with sirolimus, suggesting the advisability of further study of mTOR inhibitors as a more targeted treatment for GLILD, if impairment in Tregs is demonstrated.
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Affiliation(s)
- Angela Deyà-Martínez
- Allergy and Clinical Immunology Department, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain.,Functional Unit of Clinical Immunology, Hospital Sant Joan de Déu-Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Ana Esteve-Solé
- Allergy and Clinical Immunology Department, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain.,Functional Unit of Clinical Immunology, Hospital Sant Joan de Déu-Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | | | - Veronica Celis
- Department of Pediatric oncology, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Jordi Costa
- Department of Pediatric Pneumology, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Maria Cols
- Department of Pediatric Pneumology, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Cristina Jou
- Department of Pathology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Alexandru Vlagea
- Functional Unit of Clinical Immunology, Hospital Sant Joan de Déu-Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.,Immunology Department, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Ana María Plaza-Martin
- Allergy and Clinical Immunology Department, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain.,Functional Unit of Clinical Immunology, Hospital Sant Joan de Déu-Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Manel Juan
- Functional Unit of Clinical Immunology, Hospital Sant Joan de Déu-Hospital Clinic, Universitat de Barcelona, Barcelona, Spain.,Immunology Department, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Laia Alsina
- Allergy and Clinical Immunology Department, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain.,Functional Unit of Clinical Immunology, Hospital Sant Joan de Déu-Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
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Vieira A, Vale A, Melo N, Caetano Mota P, Jesus J, Cunha R, Guimarães S, Souto Moura C, Morais A. Organizing pneumonia revisited: insights and uncertainties from a series of 67 patients. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2018; 35:129-138. [PMID: 32476892 PMCID: PMC7170093 DOI: 10.36141/svdld.v35i2.6860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/08/2018] [Indexed: 12/23/2022]
Abstract
Background: Organizing pneumonia (OP) is classified as an acute/subacute pneumonia according to the American Thoracic Society/European Respiratory Society statement (2013 update). Although its clinical presentation, radiologic and histologic features are well established, data on the relevance of potential causes, corticosteroid doses and length, or management of relapses are based on heterogeneous series of patients. Objectives: The aims of this study were to describe clinical presentation, diagnosis and treatment of OP, explore potential causes, discuss strategies for managing relapses, and analyze prognostic factors. We also discuss our findings in relation to relevant data in the literature. Methods: We performed a cross-sectional study of all patients diagnosed with OP at a tertiary referral center in northern Portugal between 2008 and 2015. Results: Sixty-seven patients were diagnosed with OP over the 7-year study period. Dyspnea and cough were the most common presenting symptoms and approximately 30% of patients were hospitalized at the time of diagnosis. Approximately half of the patients were receiving drugs described as potential causes of OP. Microorganisms were isolated in approximately one-third of patients. Other potential causes identified were hematologic disorders, neoplasms, connective tissue diseases, myelodysplastic syndromes, immunodeficiencies, radiotherapy, and bird exposure. Cryptogenic OP was diagnosed in just 16 patients (23.8%). Corticosteroids were the most common treatment and 11 patients (16.4%) experienced relapse. Conclusions: The findings for this series of patients confirm the extreme variability of the contexts in which OP can occur and suggest that rather than a distinct, homogeneous clinicopathologic entity, OP is a non-specific reaction whose outcomes are dependent on the cause. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 129-138).
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Affiliation(s)
- A.L. Vieira
- Pulmonology Department, Hospital de Braga, Braga, Portugal
| | - A. Vale
- Pulmonology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - N. Melo
- Pulmonology Department and Diffuse Lung Diseases Study Group, Centro Hospitalar de São João, Porto, Portugal
| | - P. Caetano Mota
- Pulmonology Department and Diffuse Lung Diseases Study Group, Centro Hospitalar de São João, Porto, Portugal
- Faculdade de Medicina do Porto, Universidade do Porto, Porto, Portugal
| | - J.M. Jesus
- Radiology Department, Centro Hospitalar de São João, Porto, Portugal
| | - R. Cunha
- Radiology Department, Centro Hospitalar de São João, Porto, Portugal
| | - S. Guimarães
- Pathology Department, Centro Hospitalar de São João, Porto, Portugal
| | - C. Souto Moura
- Pathology Department, Centro Hospitalar de São João, Porto, Portugal
| | - A. Morais
- Pulmonology Department and Diffuse Lung Diseases Study Group, Centro Hospitalar de São João, Porto, Portugal
- Pathology Department, Centro Hospitalar de São João, Porto, Portugal
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67
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Sood AK, Funkhouser W, Handly B, Weston B, Wu EY. Granulomatous-Lymphocytic Interstitial Lung Disease in 22q11.2 Deletion Syndrome: a Case Report and Literature Review. Curr Allergy Asthma Rep 2018; 18:14. [PMID: 29470661 PMCID: PMC5935501 DOI: 10.1007/s11882-018-0769-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Granulomatous-lymphocytic interstitial lung disease (GLILD) has classically been associated with common variable immune deficiency (CVID), but is increasingly being reported in other immunodeficiencies. We describe the second reported case of GLILD in a patient with 22q11.2 deletion syndrome (22q11.2DS) and review the recent literature surrounding GLILD. RECENT FINDINGS GLILD is characterized by granulomata and lymphoproliferation. Consensus statements and retrospective and case-control studies have better elucidated the clinicopathological and radiographic manifestations of GLILD, allowing for its differentiation from similar conditions like sarcoidosis. Gaps of knowledge remain, however, particularly regarding optimal management strategies. Combination therapies targeting T and B cell populations have recently shown favorable results. GLILD is associated with poorer outcomes in CVID. Its recognition as a rare complication of 22q11.2DS and other immunodeficiencies therefore has important therapeutic and prognostic implications. Additional research is needed to better understand the natural history and pathogenesis of GLILD and to develop evidence-based practice guidelines.
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Affiliation(s)
- Amika K Sood
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, University of North Carolina, Chapel Hill, NC, USA.
- Center for Environmental Medicine, Asthma and Lung Biology, University of North Carolina at Chapel Hill, 104 Mason Farm Road, CB #7310, Chapel Hill, NC, 27599-7310, USA.
| | - William Funkhouser
- Deparment of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Brian Handly
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Brent Weston
- Department of Pediatrics, Division of Hematology-Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - Eveline Y Wu
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, University of North Carolina, Chapel Hill, NC, USA
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68
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Narahari NK, Gongati PK, Uppin SG, Kapoor A, Kakarla B, Tella RD. A 66-Year-Old Man With Mediastinal Mass and Dyspnea. Chest 2017; 150:e109-e115. [PMID: 27719827 DOI: 10.1016/j.chest.2016.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 06/10/2016] [Accepted: 07/03/2016] [Indexed: 12/13/2022] Open
Abstract
A 66-year-old man presented with dry cough and shortness of breath on exertion of 6 months' duration. There were no complaints of fever and hemoptysis. His history was significant for recurrent episodes of respiratory tract infections over the previous 4 years. He had also had episodes of recurrent otitis media and pus discharge from the left ear for 3 years, with progressive loss of hearing. There was no history of recurrent skin infections or diarrhea. He was treated symptomatically with antibiotics by local general practitioners. He was a nonsmoker and did not drink alcohol, and there was no history of environmental or occupational exposure. He had been known to have diabetes for 10 years. He had negative results for the presence of HIV and hepatitis B surface antigen.
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Affiliation(s)
- Narendra Kumar Narahari
- Department of Respiratory Medicine, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India.
| | - Paramjyothi K Gongati
- Department of Respiratory Medicine, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Shantveer G Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Anu Kapoor
- Department of Radiology and Imaging, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Bhaskar Kakarla
- Department of Respiratory Medicine, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Ramakrishna Dev Tella
- Department of Cardiothoracic Surgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
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Humoral primary immunodeficiency diseases: clinical overview and chest high-resolution computed tomography (HRCT) features in the adult population. Clin Radiol 2017; 72:534-542. [PMID: 28433201 DOI: 10.1016/j.crad.2017.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/10/2017] [Accepted: 03/21/2017] [Indexed: 12/27/2022]
Abstract
Humoral primary immunodeficiency diseases (hPIDs) are a heterogeneous group of hereditary disorders resulting in abnormal susceptibility to infections of the sinopulmonary tract. Some of these conditions (e.g., common variable immunodeficiency disorders [CVID]) imply a number of non-infectious thoracic complications such as non-infectious airway disorders, diffuse lung parenchymal diseases, and neoplasms. Chest high-resolution computed tomography (HRCT) is a key imaging tool to characterise and quantify the extent of underlying thoracic involvement, as well as to direct and monitor treatment. The aims of this review are to provide a brief clinical overview of hPIDs and describe the related chest HRCT imaging features in the adult population, with a special focus on CVID and its complications.
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70
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British Lung Foundation/United Kingdom Primary Immunodeficiency Network Consensus Statement on the Definition, Diagnosis, and Management of Granulomatous-Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:938-945. [PMID: 28351785 DOI: 10.1016/j.jaip.2017.01.021] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/10/2017] [Accepted: 01/24/2017] [Indexed: 12/29/2022]
Abstract
A proportion of people living with common variable immunodeficiency disorders develop granulomatous-lymphocytic interstitial lung disease (GLILD). We aimed to develop a consensus statement on the definition, diagnosis, and management of GLILD. All UK specialist centers were contacted and relevant physicians were invited to take part in a 3-round online Delphi process. Responses were graded as Strongly Agree, Tend to Agree, Neither Agree nor Disagree, Tend to Disagree, and Strongly Disagree, scored +1, +0.5, 0, -0.5, and -1, respectively. Agreement was defined as greater than or equal to 80% consensus. Scores are reported as mean ± SD. There was 100% agreement (score, 0.92 ± 0.19) for the following definition: "GLILD is a distinct clinico-radio-pathological ILD occurring in patients with [common variable immunodeficiency disorders], associated with a lymphocytic infiltrate and/or granuloma in the lung, and in whom other conditions have been considered and where possible excluded." There was consensus that the workup of suspected GLILD requires chest computed tomography (CT) (0.98 ± 0.01), lung function tests (eg, gas transfer, 0.94 ± 0.17), bronchoscopy to exclude infection (0.63 ± 0.50), and lung biopsy (0.58 ± 0.40). There was no consensus on whether expectant management following optimization of immunoglobulin therapy was acceptable: 67% agreed, 25% disagreed, score 0.38 ± 0.59; 90% agreed that when treatment was required, first-line treatment should be with corticosteroids alone (score, 0.55 ± 0.51).
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Abstract
Although primary immunodeficiencies typically present with recurrent, chronic, or severe infections, autoimmune manifestations frequently accompany these disorders and may be the initial clinical manifestations. The presence of 2 or more autoimmune disorders, unusual severe atopic disease, or a combination of these disorders should lead a clinician to consider primary immunodeficiency disorders.
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Affiliation(s)
- John M Routes
- Department of Pediatrics, Children's Research Institute, Medical College of Wisconsin, Children's Clinics Building, Suite B440, 9000 West Wisconsin Avenue, Milwaukee, WI 53226-4874, USA.
| | - James W Verbsky
- Department of Pediatrics, Children's Corporate Center, Children's Research Institute, Medical College of Wisconsin, Suite C465, 9000 West Wisconsin Avenue, Milwaukee, WI 53226-4874, USA
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72
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Schussler E, Beasley MB, Maglione PJ. Lung Disease in Primary Antibody Deficiencies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2016; 4:1039-1052. [PMID: 27836055 PMCID: PMC5129846 DOI: 10.1016/j.jaip.2016.08.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/03/2016] [Accepted: 08/22/2016] [Indexed: 01/08/2023]
Abstract
Primary antibody deficiencies (PADs) are the most common form of primary immunodeficiency and predispose to severe and recurrent pulmonary infections, which can result in chronic lung disease including bronchiectasis. Chronic lung disease is among the most common complications of PAD and a significant source of morbidity and mortality for these patients. However, the development of lung disease in PAD may not be solely the result of recurrent bacterial infection or a consequence of bronchiectasis. Recent characterization of monogenic immune dysregulation disorders and more extensive study of common variable immunodeficiency have demonstrated that interstitial lung disease (ILD) in PAD can result from generalized immune dysregulation and frequently occurs in the absence of pneumonia history or bronchiectasis. This distinction between bronchiectasis and ILD has important consequences in the evaluation and management of lung disease in PAD. For example, treatment of ILD in PAD typically uses immunomodulatory approaches in addition to immunoglobulin replacement and antibiotic prophylaxis, which are the stalwarts of bronchiectasis management in these patients. Although all antibody-deficient patients are at risk of developing bronchiectasis, ILD occurs in some forms of PAD much more commonly than in others, suggesting that distinct but poorly understood immunological factors underlie the development of this complication. Importantly, ILD can have earlier onset and may worsen survival more than bronchiectasis. Further efforts to understand the pathogenesis of lung disease in PAD will provide vital information for the most effective methods of diagnosis, surveillance, and treatment of these patients.
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Affiliation(s)
- Edith Schussler
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mary B Beasley
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paul J Maglione
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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73
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Maglione PJ. Autoimmune and Lymphoproliferative Complications of Common Variable Immunodeficiency. Curr Allergy Asthma Rep 2016; 16:19. [PMID: 26857017 DOI: 10.1007/s11882-016-0597-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Common variable immunodeficiency (CVID) is frequently complicated by the development of autoimmune and lymphoproliferative diseases. With widespread use of immunoglobulin replacement therapy, autoimmune and lymphoproliferative complications have replaced infection as the major cause of morbidity and mortality in CVID patients. Certain CVID complications, such as bronchiectasis, are likely to be the result of immunodeficiency and are associated with infection susceptibility. However, other complications may result from immune dysregulation rather than immunocompromise. CVID patients develop autoimmunity, lymphoproliferation, and granulomas in association with distinct immunological abnormalities. Mutations in transmembrane activator and CAML interactor, reduction of isotype-switched memory B cells, expansion of CD21 low B cells, heightened interferon signature expression, and retained B cell function are all associated with both autoimmunity and lymphoproliferation in CVID. Further research aimed to better understand that the pathological mechanisms of these shared forms of immune dysregulation may inspire therapies beneficial for multiple CVID complications.
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Affiliation(s)
- Paul J Maglione
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1089, New York, NY, 10029, USA.
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Tashtoush B, Memarpour R, Ramirez J, Bejarano P, Mehta J. Granulomatous-lymphocytic interstitial lung disease as the first manifestation of common variable immunodeficiency. CLINICAL RESPIRATORY JOURNAL 2016; 12:337-343. [PMID: 27243233 DOI: 10.1111/crj.12511] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/18/2016] [Accepted: 05/29/2016] [Indexed: 12/15/2022]
Abstract
Common variable immunodeficiency (CVID) is one of the most common primary immunodeficiencies, which is characterized by reduced serum immunoglobulin levels and B-lymphocyte dysfunction. There are many clinical manifestations of this disease, the most common of which are recurrent respiratory tract infections. Among the most recently recognized autoimmune manifestation of CVID is a disease described as granulomatous-lymphocytic interstitial lung disease (GLILD), where CVID coexists with a small airway lymphoproliferative disorder, mimicking follicular bronchiolitis, or lymphocytic interstitial pneumonitis (LIP) on histology specimens. We herein describe the clinical and radiological features of GLILD in a 55-year-old woman where the diagnosis of CVID was actively pursued and eventually confirmed after her lung biopsy showed characteristic features of GLILD. The patient had dramatic response to treatment with IVIG and corticosteroids for 3 months followed by Mycophenolate mofetil for maintenance therapy.
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Affiliation(s)
- Basheer Tashtoush
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Roya Memarpour
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Jose Ramirez
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Pablo Bejarano
- Department of Pathology, Cleveland Clinic Florida, Weston, Florida
| | - Jinesh Mehta
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
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