251
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Schaballie H, Wuyts G, Dillaerts D, Frans G, Moens L, Proesmans M, Vermeulen F, De Boeck K, Meyts I, Bossuyt X. Effect of previous vaccination with pneumococcal conjugate vaccine on pneumococcal polysaccharide vaccine antibody responses. Clin Exp Immunol 2016; 185:180-9. [PMID: 26939935 DOI: 10.1111/cei.12784] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2016] [Indexed: 11/30/2022] Open
Abstract
During the past 10 years, pneumococcal conjugate vaccine (PCV) has become part of the standard childhood vaccination programme. This may impact upon the diagnosis of polysaccharide antibody deficiency by measurement of anti-polysaccharide immunoglobulin (Ig)G after immunization with unconjugated pneumococcal polysaccharide vaccine (PPV). Indeed, contrary to PPV, PCV induces a T-dependent, more pronounced memory response. The antibody response to PPV was studied retrospectively in patients referred for suspected humoral immunodeficiency. The study population was divided into four subgroups based on age (2-5 years versus ≥ 10 years) and time tested (1998-2005 versus 2010-12). Only 2-5-year-old children tested in 2010-12 had been vaccinated with PCV prior to PPV. The PCV primed group showed higher antibody responses for PCV-PPV shared serotypes 4 and 18C than the unprimed groups. To a lesser extent, this was also found for non-PCV serotype 9N, but not for non-PCV serotypes 19A and 8. Furthermore, PCV-priming elicited a higher IgG2 response. In conclusion, previous PCV vaccination affects antibody response to PPV for shared serotypes, but can also influence antibody response to some non-PCV serotypes (9N). With increasing number of serotypes included in PCV, the diagnostic assessment for polysaccharide antibody deficiency requires careful selection of serotypes that are not influenced by prior PCV (e.g. serotype 8). Further research is needed to identify more serotypes that are not influenced.
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Affiliation(s)
- H Schaballie
- Department of Pediatrics, University Hospitals Leuven.,Department of Microbiology and Immunology, KU Leuven - University of Leuven
| | - G Wuyts
- Department of Microbiology and Immunology, KU Leuven - University of Leuven
| | - D Dillaerts
- Department of Microbiology and Immunology, KU Leuven - University of Leuven
| | - G Frans
- Department of Microbiology and Immunology, KU Leuven - University of Leuven.,Department of Laboratory Medicine, University Hospitals Leuven, Belgium
| | - L Moens
- Department of Microbiology and Immunology, KU Leuven - University of Leuven
| | - M Proesmans
- Department of Pediatrics, University Hospitals Leuven
| | - F Vermeulen
- Department of Pediatrics, University Hospitals Leuven
| | - K De Boeck
- Department of Pediatrics, University Hospitals Leuven
| | - I Meyts
- Department of Pediatrics, University Hospitals Leuven.,Department of Microbiology and Immunology, KU Leuven - University of Leuven
| | - X Bossuyt
- Department of Microbiology and Immunology, KU Leuven - University of Leuven.,Department of Laboratory Medicine, University Hospitals Leuven, Belgium
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252
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Selective Subnormal IgG1 in 54 Adult Index Patients with Frequent or Severe Bacterial Respiratory Tract Infections. J Immunol Res 2016; 2016:1405950. [PMID: 27123464 PMCID: PMC4830719 DOI: 10.1155/2016/1405950] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/15/2016] [Accepted: 01/27/2016] [Indexed: 01/04/2023] Open
Abstract
We characterized 54 adult index patients with reports of frequent or severe bacterial respiratory tract infections at diagnosis of selective subnormal IgG1. Mean age was 50 ± 13 (SD) y; 87.0% were women. Associated disorders included the following: autoimmune conditions 50.0%; hypothyroidism 24.1%; atopy 38.9%; and other allergy 31.5%. In 35.5%, proportions of protective S. pneumoniae serotype-specific IgG levels did not increase after polyvalent pneumococcal polysaccharide vaccination (PPPV). Blood lymphocyte subset levels were within reference limits in most patients. Regressions on IgG1 and IgG3 revealed no significant association with age, sex, autoimmune conditions, hypothyroidism, atopy, other allergy, corticosteroid therapy, or lymphocyte subsets. Regression on IgG2 revealed significant associations with PPPV response (negative) and CD19+ lymphocytes (positive). Regression on IgG4 revealed significant positive associations with episodic corticosteroid use and IgA. Regression on IgA revealed positive associations with IgG2 and IgG4. Regression on IgM revealed negative associations with CD56+/CD16+ lymphocytes. Regressions on categories of infection revealed a negative association of urinary tract infections and IgG1. HLA-A⁎03, HLA-B⁎55 and HLA-A⁎24, HLA-B⁎35 haplotype frequencies were greater in 38 patients than 751 controls. We conclude that nonprotective S. pneumoniae IgG levels and atopy contribute to increased susceptibility to respiratory tract infections in patients with selective subnormal IgG1.
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253
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Orange JS, Seeborg FO, Boyle M, Scalchunes C, Hernandez-Trujillo V. Family Physician Perspectives on Primary Immunodeficiency Diseases. Front Med (Lausanne) 2016; 3:12. [PMID: 27066486 PMCID: PMC4811961 DOI: 10.3389/fmed.2016.00012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/14/2016] [Indexed: 12/24/2022] Open
Abstract
Primary immunodeficiency diseases (PIDs) include over 250 diverse disorders. The current study assessed management of PID by family practice physicians. The American Academy of Allergy, Asthma, and Immunology Primary Immunodeficiency Committee and the Immune Deficiency Foundation conducted an incentivized mail survey of family practice physician members of the American Medical Association and the American Osteopathic Association in direct patient care. Responses were compared with subspecialist immunologist responses from a similar survey. Surveys were returned by 528 (of 4500 surveys mailed) family practice physicians, of whom 44% reported following ≥1 patient with PID. Selective immunoglobulin A deficiency (21%) and chronic granulomatous disease (11%) were most common and were followed by significantly more subspecialist immunologists (P < 0.05). Use of intravenously administered immunoglobulin and live viral vaccinations across PID was significantly different (P < 0.05). Few family practice physicians were aware of professional guidelines for diagnosis and management of PID (4 vs. 79% of subspecialist immunologists, P < 0.05). Family practice physicians will likely encounter patients with PID diagnoses during their career. Differences in how family practice physicians and subspecialist immunologists manage patients with PID underscore areas where improved educational and training initiatives may benefit patient care.
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Affiliation(s)
- Jordan S. Orange
- Section of Immunology, Allergy and Rheumatology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Filiz O. Seeborg
- Section of Immunology, Allergy and Rheumatology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Vivian Hernandez-Trujillo
- Department of Pediatrics, Division of Allergy and Immunology, Miami Children’s Hospital, Miami, FL, USA
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254
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Rákóczi É, Perge B, Végh E, Csomor P, Pusztai A, Szamosi S, Bodnár N, Szántó S, Szücs G, Szekanecz Z. Evaluation of the immunogenicity of the 13-valent conjugated pneumococcal vaccine in rheumatoid arthritis patients treated with etanercept. Joint Bone Spine 2016; 83:675-679. [PMID: 26995488 DOI: 10.1016/j.jbspin.2015.10.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 10/19/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To prospectively evaluate the immunogenicity of a 13-valent conjugated pneumococcal vaccine (PCV13) in rheumatoid arthritis (RA) patients undergoing etanercept therapy. METHODS Twenty-two RA patients treated with etanercept (ETA) in combination with methotrexate (MTX) (n=15) or monotherapy (n=7) for at least one year were included. Altogether 24 osteoarthritis patients not receiving biological or MTX therapy, treating only NSAIDs or analgesics served as controls. All subjects were vaccinated with a single dose (0.5ml) of the PCV13. Pneumococcal antibody levels at baseline, 4 and 8weeks were assessed by a VaccZyme™ Anti-PCP IgG Enzyme Immunoassay Kit. Based on recommendations of the American Academy of Allergy, Asthma & Immunology, an at least two-fold increase in antibody level, as the protective antibody response (pAR) was an indicator of responsiveness (i.e., ratio of postvaccination and prevaccination antibody levels). The antibody levels and their ratios were analysed in a variety of different ways, vaccine safety parameters (fever, infections, changes in regular antirheumatic treatments) were assessed at baseline, 4 and 8weeks after vaccination. RESULTS Four weeks after vaccination, the anti-pneumococcal antibody levels significantly increased in both groups. At week 8, antibody levels somewhat decreased in both groups, however, still remained significantly higher compared to baseline. Compared with postvaccination levels at 4 and 8weeks between two groups, the mean protective antibody levels were higher in control group (1st month P=0.016; 2nd month: P=0.039). Possible predictors of pAR were analysed by logistic regression model. In RA, increases of antibody levels at week 8 compared to baseline exerted a negative correlation with age, (Spearman's R=-0,431; P=0.045). There were no clinically significant side effects or reaction after administration of vaccine observed in any of these patients after the 2-month follow-up period, all patients medical condition were stable. CONCLUSIONS In RA patients treated with ETA, vaccination with PCV13 is effective and safe, resulting in pAR one and two months after vaccination. Higher age at vaccination was identified as predictors of impaired pAR. The efficacy of vaccination may be more pronounced in younger RA patients. The vaccine is safe in RA patients on ETA.
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Affiliation(s)
- Éva Rákóczi
- Institute of Clinical Pharmacology, Infectious Diseases and Allergology, Kenézy Gyula Hospital, 2-6, Bartók B street, 4034 Debrecen, Hungary
| | - Bianka Perge
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Edit Végh
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Péter Csomor
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Anita Pusztai
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Szilvia Szamosi
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Nóra Bodnár
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Sándor Szántó
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Gabriella Szücs
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary
| | - Zoltán Szekanecz
- Department of Rheumatology, Medical and Health Sciences Center, Faculty of Medicine, University of Debrecen, 98, Nagyerdei street, 4032 Debrecen, Hungary.
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255
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Rezende RPV, Ribeiro FM, Albuquerque EMN, Gayer CR, Andrade LEC, Klumb EM. Immunogenicity of pneumococcal polysaccharide vaccine in adult systemic lupus erythematosus patients undergoing immunosuppressive treatment. Lupus 2016; 25:1254-9. [PMID: 26923283 DOI: 10.1177/0961203316636472] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the immunogenicity of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in adult systemic lupus erythematosus patients undergoing (IS group) and not undergoing (non-IS group) immunosuppressive treatment. METHODS In this prospective open-label study from February 2013 to April 2014, 54 patients had blood samples collected immediately before PPSV23 immunization and 4-6 weeks thereafter for the ELISA measurement of IgG antibody levels against seven pneumococcal serotypes. Positive vaccine response for each serotype was defined as a four-fold or greater antibody response over baseline levels or as a post-vaccine anti-pneumococcal IgG level ≥1.3 µg/ml when baseline values were <1.3 µg/ml. Patients should have responded appropriately to ≥70% of the tested serotypes. We also calculated the mean ratio of post- to pre-vaccination anti-pneumococcal IgG levels. RESULTS Twenty-eight patients were classified into the IS group and 26 into non-IS group. The median dose of prednisone at baseline was ≤5 mg/day in both groups. Serotype-specific vaccine response rates were not significantly different between the groups. Less than 40% of patients responded adequately by both vaccine response criteria, being numerically lower among IS patients. The mean ratio of increase in anti-pneumococcal levels was 6.4 versus 4.7 (p = 0.001) in non-IS and IS groups, respectively. CONCLUSION The vaccine was poorly immunogenic, especially among adult systemic lupus erythematosus patients under immunosuppressive therapy.
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Affiliation(s)
- R P V Rezende
- Department of Rheumatology, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - F M Ribeiro
- Department of Rheumatology, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - E M N Albuquerque
- Department of Rheumatology, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - C R Gayer
- Department of Biochemistry, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - E M Klumb
- Department of Rheumatology, Rio de Janeiro State University, Rio de Janeiro, Brazil
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256
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Parker AR, Allen S, Harding S. Concentration of anti-pneumococcal capsular polysaccharide IgM, IgG and IgA specific antibodies in adult blood donors. Pract Lab Med 2016; 5:1-5. [PMID: 28856197 PMCID: PMC5574502 DOI: 10.1016/j.plabm.2016.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/16/2016] [Accepted: 02/23/2016] [Indexed: 12/02/2022] Open
Abstract
Objectives Anti-pneumococcal capsular polysaccharide (PCP) IgM, IgG and IgA ELISAs have been developed to aid assessment of the adaptive immune system. The relationship between the concentrations of PCP IgM, IgG, and IgA was investigated. Design and methods The concentrations of PCP IgM, IgG, and IgA were measured in sera obtained from 231 adult blood donors. Results Concentrations of each isotype were not normally distributed. The median concentration for PCP IgM was 54 U/mL (range 37–75 U/mL), IgG 40 mg/L (range 26–79 mg/L) and IgA 21 U/mL (range 13–44 U/mL). The median PCP IgM titres decreased with age and were significantly lower in patients aged 81–90 years compared to those aged 18–80 years. By contrast, there was a significantly higher median serum PCP IgG titre in the 61–90 years group compared to those aged 18–60 years and a significantly higher median serum PCP IgA titre in the 51–90 years group compared to those aged 18–50 years. The correlation between PCP IgG and IgA was more significant than between IgM and IgA and between IgM and IgG. Correlation of PCP IgA and IgM concentrations identified four phenotypes: high PCP IgM and IgA; high PCP IgM only; high PCP IgA only; and low PCP IgM and IgA. A significant number of individuals with a PCP IgG concentration >50 mg/L had low PCP IgA and IgM concentrations. Conclusion The additional measurement of PCP IgA and PCP IgM, alongside PCP IgG, in individuals investigated for a compromised immune system may provide a more detailed antibody profile.
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257
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Lachance S, Christofides A, Lee J, Sehn L, Ritchie B, Shustik C, Stewart D, Toze C, Haddad E, Vinh D. A Canadian perspective on the use of immunoglobulin therapy to reduce infectious complications in chronic lymphocytic leukemia. Curr Oncol 2016; 23:42-51. [PMID: 26966403 PMCID: PMC4754059 DOI: 10.3747/co.23.2810] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Infections are a major cause of morbidity and mortality in patients with chronic lymphocytic leukemia (cll), who typically have increased susceptibility because of hypogammaglobulinemia (hgg) related to their disease and its treatment. Immunoglobulin replacement therapy (igrt) has been shown to reduce the frequency of bacterial infections and associated hospitalizations in patients with hgg or a history of infection, or both. However, use of igrt in cll is contentious. Studies examining such treatment were conducted largely before the use of newer chemoimmunotherapies, which can extend lifespan, but do not correct the hgg inherent to the disease. Thus, the utility of igrt has to be re-evaluated in the current setting. Here, we discuss the evidence for the use of igrt in cll and provide a practical approach to its use in the prevention and management of infections.
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Affiliation(s)
| | | | - J.K. Lee
- Canadian Society of Allergy and Clinical Immunology, Toronto, ON
| | | | | | - C. Shustik
- McGill University Health Centre, Montreal, QC
| | | | - C.L. Toze
- Leukemia/Bone Marrow Transplant Program of BC, Vancouver General Hospital, BC Cancer Agency, and University of British Columbia, Vancouver, BC
| | - E. Haddad
- chu Sainte-Justine, Departments of Pediatrics and of Microbiology, Immunology, and Infectiology, Université de Montréal, Montreal, QC
| | - D.C. Vinh
- McGill University Health Centre, Montreal, QC
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258
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Lee HY, Yoon SW, Kim Y, Cho HJ, Lee JY, Gu KM, Park TY, Choi JC, Shin JW, Kim JY, Park IW, Choi BW, Jung JW. Intravenous immunoglobulin therapy in a selective IgG3 deficient patient with recurrent respiratory infections and asthma attacks. ALLERGY ASTHMA & RESPIRATORY DISEASE 2016. [DOI: 10.4168/aard.2016.4.3.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Hong Yeul Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sang Won Yoon
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hwan Jun Cho
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Joo Young Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kang Mo Gu
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Tae Yun Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jae Chol Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jong Wook Shin
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jae Yeol Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - In Won Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Byoung Whui Choi
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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259
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Bonilla FA, Barlan I, Chapel H, Costa-Carvalho BT, Cunningham-Rundles C, de la Morena MT, Espinosa-Rosales FJ, Hammarström L, Nonoyama S, Quinti I, Routes JM, Tang MLK, Warnatz K. International Consensus Document (ICON): Common Variable Immunodeficiency Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 4:38-59. [PMID: 26563668 DOI: 10.1016/j.jaip.2015.07.025] [Citation(s) in RCA: 515] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 06/24/2015] [Accepted: 07/24/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | - Isil Barlan
- Marmara University Pendik Education and Research Hospital, Istanbul, Turkey
| | - Helen Chapel
- John Radcliffe Hospital and University of Oxford, Oxford, United Kingdom
| | | | | | - M Teresa de la Morena
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - John M Routes
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis
| | - Mimi L K Tang
- Royal Children's Hospital and Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
| | - Klaus Warnatz
- University Medical Center Freiburg, Freiburg, Germany
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260
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Iroh Tam PY, McAllister SC. Vaccine Responses and Immunologic Characteristics of Pediatric Patients With DiGeorge Syndrome. Clin Pediatr (Phila) 2015; 54:1290-2. [PMID: 25573949 DOI: 10.1177/0009922814565885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Pui-Ying Iroh Tam
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Shane C McAllister
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
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261
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262
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Knutsen AP, Leiva LE, Caruthers C, Rodrigues J, Sorensen RU. Streptococcus pneumoniae antibody titres in patients with primary antibody deficiency receiving intravenous immunoglobulin (IVIG) compared to subcutaneous immunoglobulin (SCIG). Clin Exp Immunol 2015; 182:51-6. [PMID: 26230522 PMCID: PMC4578508 DOI: 10.1111/cei.12665] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 05/29/2015] [Accepted: 06/07/2015] [Indexed: 11/28/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) and subcutaneous immunoglobulin (SCIG) are effective in the treatment of patients with primary antibody deficiency disorders (PAD). The purpose of this study was to evaluate Streptococcus pneumoniae (Spn) antibody titres to 14 serotypes in patients receiving IVIG compared to SCIG and to correlate Spn antibody levels to clinical outcome. The doses of immunoglobulin (Ig)G/kg/month were similar in both IVIG and SCIG groups. In 11 patients treated with IVIG, Spn antibody titres were ≥ 1·3 μg/ml to 99·4 ± 2·1% of the 14 serotypes at peak IVIG but decreased to 66·9 ± 19·8% at trough IVIG. Loss of Spn titres ≥ 1·3 μg/ml was most frequent for Spn serotypes 1, 4, 9V and 23. This correlated with lower Spn antibody titres to these serotypes at peak IVIG compared to the other serotypes. In 13 patients treated with SCIG, Spn antibody titres were protective to 58·2 ± 23·3% of the serotypes 3-5 days after infusion, similar to trough IVIG. Similarly, the Spn serotypes with the least protective percentages were the same as the ones observed in trough IVIG. There were no annualized serious bacterial infections (aSBI) in either group. However, there were significantly decreased annualized other infections (aOI) in the SCIG group compared to the IVIG-treated group, 0·8 ± 0·7 versus 2·2 ± 1·2 infections/patient/year (P = 0·004). Breakthrough aOI did not correlate with protective or higher serum Spn antibody titres.
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Affiliation(s)
- A P Knutsen
- Department of Pediatrics, Division Allergy & Immunology, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, Saint Louis UniversitySt Louis, MO
| | - L E Leiva
- Department of Pediatrics, Allergy/Immunology Division, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, Louisiana State University Health Sciences CenterNew Orleans, LA, USA
| | - C Caruthers
- Department of Pediatrics, Division Allergy & Immunology, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, Saint Louis UniversitySt Louis, MO
| | - J Rodrigues
- Department of Pediatrics, Division Allergy & Immunology, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, Saint Louis UniversitySt Louis, MO
| | - R U Sorensen
- Department of Pediatrics, Allergy/Immunology Division, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, Louisiana State University Health Sciences CenterNew Orleans, LA, USA
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263
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Janssen WJM, Nierkens S, Sanders EA, Boes M, van Montfrans JM. Antigen-specific IgA titres after 23-valent pneumococcal vaccine indicate transient antibody deficiency disease in children. Vaccine 2015; 33:6320-6. [PMID: 26413880 DOI: 10.1016/j.vaccine.2015.09.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 09/01/2015] [Accepted: 09/15/2015] [Indexed: 02/01/2023]
Abstract
Paediatric patients with antibody deficiency may either be delayed in development of humoral immunity or may be persistently deficient in antibody production. To differentiate between these entities, we examined the 23-valent pneumococcal polysaccharide (PnPS) vaccine-induced IgM-, IgG- and IgA antibody responses in a cohort of 66 children with recurrent respiratory tract infections. Individual serum titres against 11 pneumococcal serotypes were measured by Luminex. The cohort contained 33 antibody deficiency patients, 17 transient antibody deficiency patients and 16 patients without antibody deficiency diagnosis (control group). Transient antibody deficiency patients produced consistently higher levels of PnPS-specific IgA responses than antibody deficiency patients. Decreased IgA responses to serotypes 1, 5, 7F and 18C were most discriminative to stratify transient antibody deficiency patients from antibody deficiency patients with persistent disease. We conclude that measuring PnPS-specific IgA responses may predict the disease course in young children diagnosed with antibody deficiency and suggest confirmation of these data in a prospective setting.
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Affiliation(s)
- Willemijn J M Janssen
- Department of Pediatric Immunology and Infectious Diseases/Laboratory of Translational Immunology, Wilhelmina Children's Hospital, University Medical Center, Lundlaan 6, 3508 AB Utrecht, The Netherlands
| | - Stefan Nierkens
- Department of Medical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Elisabeth A Sanders
- Department of Pediatric Immunology and Infectious Diseases/Laboratory of Translational Immunology, Wilhelmina Children's Hospital, University Medical Center, Lundlaan 6, 3508 AB Utrecht, The Netherlands; Department of Medical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marianne Boes
- Department of Pediatric Immunology and Infectious Diseases/Laboratory of Translational Immunology, Wilhelmina Children's Hospital, University Medical Center, Lundlaan 6, 3508 AB Utrecht, The Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases/Laboratory of Translational Immunology, Wilhelmina Children's Hospital, University Medical Center, Lundlaan 6, 3508 AB Utrecht, The Netherlands.
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264
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Barton JC, Bertoli LF, Barton JC, Acton RT. Selective subnormal IgG3 in 121 adult index patients with frequent or severe bacterial respiratory tract infections. Cell Immunol 2015; 299:50-7. [PMID: 26410396 DOI: 10.1016/j.cellimm.2015.09.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/12/2015] [Accepted: 09/14/2015] [Indexed: 11/18/2022]
Abstract
We characterized 121 adults with frequent or severe bacterial respiratory tract infections at diagnosis of selective subnormal IgG3. Mean age was 47 ± 13 (SD)y; 87.6% were women. Associated disorders included: autoimmune conditions 33.1%; hypothyroidism 14.9%; atopy 29.8%; and other allergy manifestations 41.3%. In 34.1%, proportions of protective Streptococcus pneumoniae serotype-specific IgG levels did not increase after polyvalent pneumococcal polysaccharide vaccination. Blood CD19+, CD3+/CD4+, CD3+/CD8+, and CD56+/CD16+ lymphocyte levels were within reference limits in most patients. In regression analyses, independent variables age; sex; autoimmune conditions; hypothyroidism; atopy; allergy manifestations; corticosteroid therapy; and lymphocyte subsets were not significantly associated with IgG subclass, IgA, or IgM levels. Frequencies of HLA haplotypes A*01, B*08; A*02, B*14; A*02, B*15; A*02, B*44; A*02, B*57; and A*03, B*07 were greater in 80 patients than 751 controls. We conclude that subnormal IgG3 and non-protective S. pneumoniae IgG levels contribute to increased susceptibility to respiratory tract infections.
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Affiliation(s)
- James C Barton
- Department of Medicine, Brookwood Medical Center, Birmingham, AL, United States; Southern Iron Disorders Center, Birmingham, Birmingham, AL, United States; Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Luigi F Bertoli
- Department of Medicine, Brookwood Medical Center, Birmingham, AL, United States; Southern Iron Disorders Center, Birmingham, Birmingham, AL, United States; Brookwood Biomedical, Birmingham, AL, United States.
| | - J Clayborn Barton
- Southern Iron Disorders Center, Birmingham, Birmingham, AL, United States.
| | - Ronald T Acton
- Southern Iron Disorders Center, Birmingham, Birmingham, AL, United States; Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, United States.
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265
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Bonilla FA, Khan DA, Ballas ZK, Chinen J, Frank MM, Hsu JT, Keller M, Kobrynski LJ, Komarow HD, Mazer B, Nelson RP, Orange JS, Routes JM, Shearer WT, Sorensen RU, Verbsky JW, Bernstein DI, Blessing-Moore J, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller D, Spector SL, Tilles S, Wallace D. Practice parameter for the diagnosis and management of primary immunodeficiency. J Allergy Clin Immunol 2015; 136:1186-205.e1-78. [PMID: 26371839 DOI: 10.1016/j.jaci.2015.04.049] [Citation(s) in RCA: 400] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 04/18/2015] [Accepted: 04/23/2015] [Indexed: 02/07/2023]
Abstract
The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma & Immunology (ACAAI) have jointly accepted responsibility for establishing the "Practice parameter for the diagnosis and management of primary immunodeficiency." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
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266
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Abstract
Patients with specific antibody deficiency (SAD) have a deficient immunologic response to polysaccharide antigens. Such patients experience sinopulmonary infections with increased frequency, duration, or severity compared with the general population. SAD is definitively diagnosed by immunologic challenge with a pure polysaccharide vaccine in patients 2 years old and older who have otherwise intact immunity, using the 23-valent pneumococcal polysaccharide vaccine as the current gold standard. Specific antibody deficiencies comprise multiple immunologic phenotypes. Treatment must be tailored based on the severity of symptoms. Most patients have a good prognosis. The deficiency may resolve over time, especially in children.
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267
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Eibl MM, Wolf HM. Vaccination in patients with primary immune deficiency, secondary immune deficiency and autoimmunity with immune regulatory abnormalities. Immunotherapy 2015; 7:1273-92. [PMID: 26289364 DOI: 10.2217/imt.15.74] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Vaccination has been an important healthcare measure in preventing infectious diseases. The response to vaccination is reduced in immunocompromised patients, primary immune deficiency (PID) and secondary immune deficiency (SID), but vaccination studies still demonstrated a protective effect resulting in reducing complications, hospitalization, treatment costs and even mortality. The primary physician and the specialist directing patient care are responsible for vaccination. Live vaccines are contraindicated in patients with severe immune impairment, killed vaccines are highly recommended in PID and SID. Criteria have been defined to distinguish high- or low-level immune impairment in the different disease entities among PID and SID patients. For patients who do not respond to diagnostic vaccination as characterized by antibody failure immunoglobulin replacement is the mainstay of therapy.
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Affiliation(s)
- Martha M Eibl
- Immunology Outpatient Clinic, Schwarzspanierstrasse 15,1090 Vienna, Austria
| | - Hermann M Wolf
- Immunology Outpatient Clinic, Schwarzspanierstrasse 15,1090 Vienna, Austria
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268
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Browning MJ, Chandra A, Carbonaro V, Okkenhaug K, Barwell J. Cowden's syndrome with immunodeficiency. J Med Genet 2015; 52:856-9. [PMID: 26246517 DOI: 10.1136/jmedgenet-2015-103266] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/26/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cowden's syndrome is a rare, autosomal dominant disease caused by mutations in the phosphoinositide 3-kinase and phosphatase and tensin homolog (PTEN) gene. It is associated with hamartomatous polyposis of the gastrointestinal tract, mucocutaneous lesions and increased risk of developing certain types of cancer. In addition to increased risk of tumour development, mutations in PTEN have also been associated with autoimmunity in both mice and humans. Until now, however, an association between Cowden's syndrome and immune deficiency has been reported in a single patient only. METHODS AND RESULTS Two patients with Cowden's syndrome and an increased frequency of infections were investigated for possible underlying immunodeficiency. In one patient, hypogammaglobulinaemia with a functional antibody deficiency was identified, while the other patient had a persisting CD4+ T cell lymphopenia (with normal antibody production). CONCLUSIONS Our data indicate that Cowden's syndrome may be associated with both T cell and B cell immune dysfunction. We recommend that patients with Cowden's syndrome and an increased frequency of infections are investigated for associated immunodeficiency.
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Affiliation(s)
| | - Anita Chandra
- Department of Biochemistry and Immunology, Addenbrooke's Hospital, Cambridge, UK Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Babraham, UK
| | - Valentina Carbonaro
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Babraham, UK
| | - Klaus Okkenhaug
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Babraham, UK
| | - Julian Barwell
- Department of Genetics, Leicester Royal Infirmary, Leicester, UK
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269
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Lindsley AW, Saal HM, Burrow TA, Hopkin RJ, Shchelochkov O, Khandelwal P, Xie C, Bleesing J, Filipovich L, Risma K, Assa'ad AH, Roehrs PA, Bernstein JA. Defects of B-cell terminal differentiation in patients with type-1 Kabuki syndrome. J Allergy Clin Immunol 2015; 137:179-187.e10. [PMID: 26194542 DOI: 10.1016/j.jaci.2015.06.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/28/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Kabuki syndrome (KS) is a complex multisystem developmental disorder associated with mutation of genes encoding histone-modifying proteins. In addition to craniofacial, intellectual, and cardiac defects, KS is also characterized by humoral immune deficiency and autoimmune disease, yet no detailed molecular characterization of the KS-associated immune phenotype has been reported. OBJECTIVE We sought to characterize the humoral immune defects found in patients with KS with lysine methyltransferase 2D (KMT2D) mutations. METHODS We comprehensively characterized B-cell function in a cohort (n = 13) of patients with KS (age, 4 months to 27 years). RESULTS Three quarters (77%) of the cohort had a detectable heterozygous KMT2D mutation (50% nonsense, 20% splice site, and 30% missense mutations), and 70% of the reported mutations are novel. Among the patients with KMT2D mutations (KMT2D(Mut/+)), hypogammaglobulinemia was detected in all but 1 patient, with IgA deficiency affecting 90% of patients and a deficiency in at least 1 other isoform seen in 40% of patients. Numbers of total memory (CD27(+)) and class-switched memory B cells (IgM(-)) were significantly reduced in patients with KMT2D(Mut/+) mutations compared with numbers in control subjects (P < .001). Patients with KMT2D(Mut/+) mutations also had significantly reduced rates of somatic hypermutation in IgG (P = .003) but not IgA or IgM heavy chain sequences. Impaired terminal differentiation was noted in primary B cells from patients with KMT2D(Mut/+) mutations. Autoimmune pathology was observed in patients with missense mutations affecting the SET domain and its adjacent domains. CONCLUSIONS In patients with KS, autosomal dominant KMT2D mutations are associated with dysregulation of terminal B-cell differentiation, leading to humoral immune deficiency and, in some cases, autoimmunity. All patients with KS should undergo serial clinical immune evaluations.
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Affiliation(s)
- Andrew W Lindsley
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.
| | - Howard M Saal
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Thomas A Burrow
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert J Hopkin
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Oleg Shchelochkov
- Division of Genetics, Stead Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Pooja Khandelwal
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Changchun Xie
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio
| | - Jack Bleesing
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lisa Filipovich
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; Division of Bone Marrow Transplantation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly Risma
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Amal H Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Phillip A Roehrs
- Division of Pediatric Hematology/Oncology, University of North Carolina, Chapel Hill, NC
| | - Jonathan A Bernstein
- Division of Immunology, Allergy and Rheumatology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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270
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Hoffman TW, van Kessel DA, van Velzen-Blad H, Grutters JC, Rijkers GT. Antibody replacement therapy in primary antibody deficiencies and iatrogenic hypogammaglobulinemia. Expert Rev Clin Immunol 2015; 11:921-33. [DOI: 10.1586/1744666x.2015.1049599] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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271
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Schaballie H, Vermeulen F, Verbinnen B, Frans G, Vermeulen E, Proesmans M, De Vreese K, Emonds MP, De Boeck K, Moens L, Picard C, Bossuyt X, Meyts I. Value of allohaemagglutinins in the diagnosis of a polysaccharide antibody deficiency. Clin Exp Immunol 2015; 180:271-9. [PMID: 25516411 DOI: 10.1111/cei.12571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2014] [Indexed: 11/28/2022] Open
Abstract
Polysaccharide antibody deficiency is characterized by a poor or absent antibody response after vaccination with an unconjugated pneumococcal polysaccharide vaccine. Allohaemagglutinins (AHA) are antibodies to A or B polysaccharide antigens on the red blood cells, and are often used as an additional or alternative measure to assess the polysaccharide antibody response. However, few studies have been conducted to establish the clinical significance of AHA. To investigate the value of AHA to diagnose a polysaccharide antibody deficiency, pneumococcal polysaccharide antibody titres and AHA were studied retrospectively in 180 subjects in whom both tests had been performed. Receiver operating characteristic curves for AHA versus the pneumococcal vaccine response as a marker for the anti-polysaccharide immune response revealed an area under the curve between 0·5 and 0·573. Sensitivity and specificity of AHA to detect a polysaccharide antibody deficiency, as diagnosed by vaccination response, were low (calculated for cut-off 1/4-1/32). In subjects with only low pneumococcal antibody response, the prevalence of bronchiectasis was significantly higher than in subjects with only low AHA (45·5 and 1·3%, respectively) or normal pneumococcal antibody response and AHA (2·4%). A logistic regression model showed that low pneumococcal antibody response but not AHA was associated with bronchiectasis (odds ratio 46·2). The results of this study do not support the routine use of AHA to assess the polysaccharide antibody response in patients with suspected immunodeficiency, but more studies are warranted to clarify the subject further.
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Affiliation(s)
- H Schaballie
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium; Department Microbiology and Immunology, KU Leuven - University of Leuven, Leuven, Belgium
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272
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Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, Orlandi RR, Palmer JN, Patel ZM, Peters A, Walsh SA, Corrigan MD. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1-S39. [PMID: 25832968 DOI: 10.1177/0194599815572097] [Citation(s) in RCA: 495] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS). PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. ACTION STATEMENTS The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.
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Affiliation(s)
- Richard M Rosenfeld
- Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Jay F Piccirillo
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, School of Medicine, St Louis, Missouri, USA
| | | | - Itzhak Brook
- Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Kaparaboyna Ashok Kumar
- Department of Family Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Maggie Kramper
- Department of Otolaryngology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Richard R Orlandi
- Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James N Palmer
- Department Otolaryngology, University of Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
| | - Zara M Patel
- Department of Otolaryngology Head & Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Anju Peters
- Department of Internal Medicine, Northwestern University Allergy Division, Chicago, Illinois, USA
| | - Sandra A Walsh
- Consumers United for Evidence-Based Healthcare, Davis, California, USA
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273
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Immunodeficiencies with hypergammaglobulinemia: a review. LYMPHOSIGN JOURNAL-THE JOURNAL OF INHERITED IMMUNE DISORDERS 2015. [DOI: 10.14785/lpsn-2014-0019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Primary immunodeficiencies (PID) can present with recurrent infections, autoimmunity, inflammation, or malignancy and each of these conditions can be associated with elevated immunoglobulin. A high level of immunoglobulin G (IgG) is an uncommon finding, especially in pediatrics, and does not rule out primary immunodeficiency. Deficiencies in varied aspects of immune response have been described with high IgG. Reported PID conditions with elevated IgG include defects in humoral, cellular, and innate immunity. Some of these immunodeficiencies can have fatal outcomes, some require hematopoetic stem cell transplantation, and some require systemic medications. The mechanisms driving elevated IgG are not well understood, but in some cases abnormal cytokine production has been proposed. The evaluation of a patient with high IgG is guided by the patient's history and a physical examination, with special attention to autoimmunity in pediatrics and malignancy and liver disease in adults. In the setting of autoimmunity, chronic gastrointestinal disease, or chronic infections, the measurement of specific antibodies to evaluate the function of the IgG should be considered. An increased appreciation of elevation in IgG reflecting immune dysregulation may lead to earlier PID diagnoses.
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274
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IrohTam PY, Hanisch BR, Forward B. Serotype 19A Bacteremic Pneumococcal Pneumonia After 4 Doses of 13-Valent Conjugate Vaccine: A Review of Pneumococcal Conjugate Vaccine Effectiveness. Clin Pediatr (Phila) 2015; 54:591-3. [PMID: 25500500 PMCID: PMC4465057 DOI: 10.1177/0009922814562550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report a case of bacteremic pneumococcal pneumonia due to serotype 19A in a child who had received four doses of the 13-valent pneumococcal conjugate vaccine, and review the literature on effectiveness of this vaccine. Pediatricians should be alert to the fact that up-to-date immunization status with pneumococcal vaccine does not preclude illness from invasive disease caused by a vaccine serotype.
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Affiliation(s)
- Pui-Ying IrohTam
- Division of Pediatric Infectious Diseases and Immunology, University of Minnesota Children’s Hospital, Minneapolis, MN, USA,Corresponding author: 3-210 MTRF, 2001 6 St SE, Minneapolis, MN 55414; Ph: 612-626-8903; Fax: 612-624-8927;
| | - Benjamin R. Hanisch
- Division of Pediatric Infectious Diseases and Immunology, University of Minnesota Children’s Hospital, Minneapolis, MN, USA
| | - Brennan Forward
- Division of Pediatrics, University of Minnesota Children’s Hospital, Minneapolis, MN, USA
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275
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Impaired Antigen-Specific Immune Response to Vaccines in Children with Antibody Production Defects. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 22:875-82. [PMID: 26018535 DOI: 10.1128/cvi.00148-15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/19/2015] [Indexed: 12/16/2022]
Abstract
The impaired synthesis of antigen-specific antibodies, which is indispensable for an adaptive immune response to infections, is a fundamental pathomechanism that leads to clinical manifestations in children with antibody production defects. The aim of this study was to evaluate the synthesis of antigen-specific antibodies following immunization in relation to peripheral blood B cell subsets in young children with hypogammaglobulinemia. Twenty-two children, aged from 8 to 61 months, with a deficiency in one or more major immunoglobulin classes participated in the study. Postvaccination antibodies against tetanus and diphtheria toxoids, the surface antigen of the hepatitis B virus, and the capsular Haemophilus influenzae type b polysaccharide antigen were assessed along with an immunophenotypic evaluation of peripheral blood B lymph cell maturation. A deficiency of antibodies against the tetanus toxoid was assessed in 73% of cases and that against the diphtheria toxoid was assessed in 68% of cases, whereas a deficiency of antibodies against the surface antigen of the hepatitis B virus was revealed in 59% of the children included in the study. A defective response to immunization with a conjugate vaccine with the Haemophilus influenzae type b polysaccharide antigen was demonstrated in 55% of hypogammaglobulinemic patients. Increased proportions of transitional B lymph cells and an accumulation of plasmablasts accompanied antibody deficiencies. The defective response to vaccine protein and polysaccharide antigens is a predominating disorder of humoral immunity in children with hypogammaglobulinemia and may result from a dysfunctional state of the cellular elements of the immune system.
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276
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Quezada A, Norambuena X, Inostroza J, Rodríguez J. Specific antibody deficiency with normal immunoglobulin concentration in children with recurrent respiratory infections. Allergol Immunopathol (Madr) 2015; 43:292-7. [PMID: 25498324 DOI: 10.1016/j.aller.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/22/2014] [Accepted: 07/31/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Response to polysaccharide antigens is a test to evaluate the immunological competence of children with recurrent respiratory infections (RRI) of unknown cause and no other immune system abnormality. In order to detect specific antibody deficiency (SAD), a group of children with RRI without other immunodeficiency were prospectively studied. METHODS We included 20 children (12 male), age range 3-14 years, with six or more annual episodes of respiratory infections (RI); one or more monthly episodes of RI during the winter months; or three or more annual episodes of lower RI. The children were immunised with 23-valent polysaccharide anti-pneumococcal vaccine, and ELISA was used to measure anti-polysaccharide IgG antibody levels for 10 pneumococcal serotypes at baseline (T0), and 45 days (T1) and one year post-immunisation (T2). Post-immunisation response above 1.3 μg/ml for more than 50% of the serotypes was considered normal for children 2-5 years, and for more than 70% of the serotypes in children older than 5 years. RESULTS At T1 19/20 children showed a normal response for their age, and only one patient showed a deficient response, suggestive of classic moderate SAD. At T2, 8/20 patients showed deficient responses, suggestive of impaired persistence of specific antibodies. There was a noteworthy association between deficient response and asthma and allergic rhinitis. CONCLUSIONS We propose first ruling out local or systemic causes, then performing serum immunoglobulin IgM, IgG, IgA, IgE and IgG subclass levels, and finally measuring response to polysaccharide pneumococcal antigens for detection of SAD.
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277
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Peters AT, Spector S, Hsu J, Hamilos DL, Baroody FM, Chandra RK, Grammer LC, Kennedy DW, Cohen NA, Kaliner MA, Wald ER, Karagianis A, Slavin RG. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol 2015; 113:347-85. [PMID: 25256029 DOI: 10.1016/j.anai.2014.07.025] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023]
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278
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Aung T, Azar AE, Ballas ZK. Hypogammaglobulinemia with normal antibody response progressing to common variable immunodeficiency. Ann Allergy Asthma Immunol 2015; 114:522-3. [PMID: 25843162 DOI: 10.1016/j.anai.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/22/2015] [Accepted: 03/05/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Tania Aung
- Immunology Division, Department of Internal Medicine, University of Iowa Health Care, The Iowa City VA Medical Center, Iowa City, Iowa
| | - Antoine E Azar
- Immunology Division, Department of Internal Medicine, University of Iowa Health Care, The Iowa City VA Medical Center, Iowa City, Iowa.
| | - Zuhair K Ballas
- Immunology Division, Department of Internal Medicine, University of Iowa Health Care, The Iowa City VA Medical Center, Iowa City, Iowa
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279
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Jolles S, Orange JS, Gardulf A, Stein MR, Shapiro R, Borte M, Berger M. Current treatment options with immunoglobulin G for the individualization of care in patients with primary immunodeficiency disease. Clin Exp Immunol 2015; 179:146-60. [PMID: 25384609 DOI: 10.1111/cei.12485] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2014] [Indexed: 11/29/2022] Open
Abstract
Primary antibody deficiencies require lifelong replacement therapy with immunoglobulin (Ig)G to reduce the incidence and severity of infections. Both subcutaneous and intravenous routes of administering IgG can be effective and well tolerated. Treatment regimens can be individualized to provide optimal medical and quality-of-life outcomes in infants, children, adults and elderly people. Frequency, dose, route of administration, home or infusion-centre administration, and the use of self- or health-professional-administered infusion can be tailored to suit individual patient needs and circumstances. Patient education is needed to understand the disease and the importance of continuous therapy. Both the subcutaneous and intravenous routes have advantages and disadvantages, which should be considered in selecting each patient's treatment regimen. The subcutaneous route is attractive to many patients because of a reduced incidence of systemic adverse events, flexibility in scheduling and its comparative ease of administration, at home or in a clinic. Self-infusion regimens, however, require independence and self-reliance, good compliance on the part of the patient/parent and the confidence of the physician and the nurse. Intravenous administration in a clinic setting may be more appropriate in patients with reduced manual dexterity, reluctance to self-administer or a lack of self-reliance, and intravenous administration at home for those with good venous access who prefer less frequent treatments. Both therapy approaches have been demonstrated to provide protection from infections and improve health-related quality of life. Data supporting current options in IgG replacement are presented, and considerations in choosing between the two routes of therapy are discussed.
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Affiliation(s)
- S Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
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280
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Stevens WW, Peters AT. Immunodeficiency in Chronic Sinusitis: Recognition and Treatment. Am J Rhinol Allergy 2015; 29:115-8. [DOI: 10.2500/ajra.2015.29.4144] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Chronic rhinosinusitis (CRS) is estimated to affect over 35 million people. However, not all patients with the diagnosis respond to standard medical and surgical treatments. Although there are a variety of reasons a patient may be refractory to therapy, one possible etiology is the presence of an underlying immunodeficiency. This review will focus on the description, recognition, and treatment of several antibody deficiencies associated with CRS, including common variable immunodeficiency (CVID), selective IgA deficiency, IgG subclass deficiency, and specific antibody deficiency (SAD). The diagnosis of antibody deficiency in patients with CRS is important because of the large clinical implications it can have on sinus disease management. CVID is treated with immunoglobulin replacement, whereas SAD may be managed symptomatically and sometimes with prophylactic antibiotics and/or immunoglobulin replacement.
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Affiliation(s)
- Whitney W. Stevens
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anju T. Peters
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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281
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Rider NL, Boisson B, Jyonouchi S, Hanson EP, Rosenzweig SD, Cassanova JL, Orange JS. Novel TTC37 Mutations in a Patient with Immunodeficiency without Diarrhea: Extending the Phenotype of Trichohepatoenteric Syndrome. Front Pediatr 2015; 3:2. [PMID: 25688341 PMCID: PMC4311608 DOI: 10.3389/fped.2015.00002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/09/2015] [Indexed: 11/13/2022] Open
Abstract
Unbiased genetic diagnosis has increasingly associated seemingly unrelated somatic and immunological phenotypes. We report a male infant who presented within the first year of life with physical growth impairment, feeding difficulties, hyperemesis without diarrhea, and abnormal hair findings suggestive of trichorrhexis nodosa. With advancing age, moderate global developmental delay, susceptibility to frequent viral illnesses, otitis media, and purulent conjunctivitis were identified. Because of the repeated infections, an immunological evaluation was pursued and identified impaired antibody memory responses following pneumococcal vaccine administration. Immunoglobulin replacement therapy and nutritional support were employed as mainstays of therapy. The child is now aged 12 years and still without diarrhea. Whole exome sequencing identified compound heterozygous mutations in the TTC37 gene, a known cause of the trichohepatoenteric syndrome (THES). This case extends the known phenotype of THES and defines a potential subset for inclusion as an immune overlap syndrome.
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Affiliation(s)
- Nicholas L Rider
- Department of Immunology, Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital , Houston, TX , USA
| | - Bertrand Boisson
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller University , New York, NY , USA
| | - Soma Jyonouchi
- Department of Allergy-Immunology, The Children's Hospital of Philadelphia , Philadelphia, PA , USA
| | - Eric P Hanson
- Immunodeficiency and Inflammation Unit, National Institute of Arthritis, Musculoskeletal and Skin Disease, National Institutes of Health , Bethesda, MD , USA
| | - Sergio D Rosenzweig
- Laboratory of Host Defense, National Institute of Allergy and Infectious Disease, National Institutes of Health , Bethesda, MD , USA
| | - Jean-Laurent Cassanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller University , New York, NY , USA ; Necker Hospital for Sick Children, Imagine Institute, INSERM, HHMI, Paris Descartes University , Paris , France ; Howard Hughes Medical Institute , New York, NY , USA
| | - Jordan S Orange
- Department of Immunology, Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital , Houston, TX , USA
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282
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Use and clinical interpretation of pneumococcal antibody measurements in the evaluation of humoral immune function. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2014; 22:148-52. [PMID: 25520149 DOI: 10.1128/cvi.00735-14] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pneumococcal vaccination is a commonly used technique for assessing the humoral immune status of a patient suspected of having immunodeficiency. Interpretation of what constitutes an adequate response, however, can be challenging. This is due to the complexity of the data generated from serotype-specific assays, historical variations in the assays used to measure pneumococcal antibodies, and varying recommendations on the relevant cut points that define response. In this review, we summarize the historical evolution of assays used for this purpose and discuss the analytical considerations that have influenced published data. We also examine current clinical recommendations for defining an adequate response to vaccination, with a particular focus on the interpretation of serotype-specific data generated by multiplex assays.
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283
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Chapel H, Prevot J, Gaspar HB, Español T, Bonilla FA, Solis L, Drabwell J. Primary immune deficiencies - principles of care. Front Immunol 2014; 5:627. [PMID: 25566243 PMCID: PMC4266088 DOI: 10.3389/fimmu.2014.00627] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 11/24/2014] [Indexed: 12/01/2022] Open
Abstract
Primary immune deficiencies (PIDs) are a growing group of over 230 different disorders caused by ineffective, absent or an increasing number of gain of function mutations in immune components, mainly cells and proteins. Once recognized, these rare disorders are treatable and in some cases curable. Otherwise untreated PIDs are often chronic, serious, or even fatal. The diagnosis of PIDs can be difficult due to lack of awareness or facilities for diagnosis, and management of PIDs is complex. This document was prepared by a worldwide multi-disciplinary team of specialists; it aims to set out comprehensive principles of care for PIDs. These include the role of specialized centers, the importance of registries, the need for multinational research, the role of patient organizations, management and treatment options, the requirement for sustained access to all treatments including immunoglobulin therapies and hematopoietic stem cell transplantation, important considerations for developing countries and suggestions for implementation. A range of healthcare policies and services have to be put into place by government agencies and healthcare providers, to ensure that PID patients worldwide have access to appropriate and sustainable medical and support services.
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Affiliation(s)
| | - Johan Prevot
- International Patient Organisation for Primary Immunodeficiencies (IPOPI) , Downderry , UK
| | | | | | | | - Leire Solis
- International Patient Organisation for Primary Immunodeficiencies (IPOPI) , Downderry , UK
| | - Josina Drabwell
- International Patient Organisation for Primary Immunodeficiencies (IPOPI) , Downderry , UK
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284
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Browning MJ, Lim MT, Kenia P, Whittle M, Doffinger R, Barcenas-Morales G, Kumararatne D, Viskaduraki M, O'Callaghan C, Gaillard EA. Pneumococcal polysaccharide vaccine responses are impaired in a subgroup of children with cystic fibrosis. J Cyst Fibros 2014; 13:632-8. [DOI: 10.1016/j.jcf.2014.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/30/2014] [Accepted: 02/06/2014] [Indexed: 11/26/2022]
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285
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Kashani S, Carr TF, Grammer LC, Schleimer RP, Hulse KE, Kato A, Kern RC, Conley DB, Chandra RK, Tan BK, Peters AT. Clinical characteristics of adults with chronic rhinosinusitis and specific antibody deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 3:236-42. [PMID: 25609325 DOI: 10.1016/j.jaip.2014.09.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 09/21/2014] [Accepted: 09/22/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Specific antibody deficiency (SAD) involves a deficient response to a polysaccharide vaccine in the setting of normal immunoglobulin G (IgG) levels and chronic infections. Patients with chronic rhinosinusitis (CRS) are often evaluated for SAD. There are limited data that describe patients with CRS and SAD. OBJECTIVE The objective of this study was to better characterize the role of SAD in CRS. METHODS We reviewed electronic records of adults with CRS who were evaluated for immunodeficiency with quantitative Ig levels and pre- and postantibody titers to a pneumococcal polysaccharide vaccine (PPV). RESULTS Fourteen pneumococcal serotypes were determined in 239 subjects from 2002 to 2009. Of these subjects, 64 had adequate protective titers of 1.3 μg/mL or higher in 7 or more serotypes of the 14 serotypes checked; 56 (23%) had less than 7 protective titers post-PPV and were diagnosed with SAD; and 119 had an adequate response to the vaccine with 7 or more serotypes being higher than 1.3 μg/mL (>50% response) and were characterized as "responders." Subjects with SAD received more antibiotic courses relative to responders in the 2 years after immunization (3.19 ± 2.64 vs 2.19 ± 2.24, P < .05). Of 56 subjects with SAD, 10 (17.9%) received Ig replacement therapy. Subjects who received Ig had fewer numbers of protective pneumococcal titers post-PPV and had more pneumonia (40.0%) versus subjects with SAD who did not receive Ig (10.9%). CONCLUSIONS Of the 239 patients with CRS with normal IgG levels evaluated for immunodeficiency, 56 (23.4%) had SAD. A majority of patients with SAD may not need Ig replacement; however, a subset of patients with SAD benefit from Ig replacement.
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Affiliation(s)
- Sara Kashani
- Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Tara F Carr
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Ariz
| | - Leslie C Grammer
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Robert P Schleimer
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill; Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Kathryn E Hulse
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Atsushi Kato
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Robert C Kern
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - David B Conley
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Rakesh K Chandra
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Bruce K Tan
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Anju T Peters
- Division of Allergy-Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill.
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286
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Locke BA, Dasu T, Verbsky JW. Laboratory diagnosis of primary immunodeficiencies. Clin Rev Allergy Immunol 2014; 46:154-68. [PMID: 24569953 DOI: 10.1007/s12016-014-8412-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Primary immune deficiency disorders represent a highly heterogeneous group of disorders with an increased propensity to infections and other immune complications. A careful history to delineate the pattern of infectious organisms and other complications is important to guide the workup of these patients, but a focused laboratory evaluation is essential to the diagnosis of an underlying primary immunodeficiency. Initial workup of suspected immune deficiencies should include complete blood counts and serologic tests of immunoglobulin levels, vaccine titers, and complement levels, but these tests are often insufficient to make a diagnosis. Recent advancements in the understanding of the immune system have led to the development of novel immunologic assays to aid in the diagnosis of these disorders. Classically utilized to enumerate lymphocyte subsets, flow cytometric-based assays are increasingly utilized to test immune cell function (e.g., neutrophil oxidative burst, NK cytotoxicity), intracellular cytokine production (e.g., TH17 production), cellular signaling pathways (e.g., phosphor-STAT analysis), and protein expression (e.g., BTK, Foxp3). Genetic testing has similarly expanded greatly as more primary immune deficiencies are defined, and the use of mass sequencing technologies is leading to the identification of novel disorders. In order to utilize these complex assays in clinical care, one must have a firm understanding of the immunologic assay, how the results are interpreted, pitfalls in the assays, and how the test affects treatment decisions. This article will provide a systematic approach of the evaluation of a suspected primary immunodeficiency, as well as provide a comprehensive list of testing options and their results in the context of various disease processes.
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Affiliation(s)
- Bradley A Locke
- Department of Pediatrics, Division of Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
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287
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Boeck L, Gencay M, Roth M, Hirsch HH, Christ-Crain M, Mueller B, Tamm M, Stolz D. Adenovirus-specific IgG maturation as a surrogate marker in acute exacerbations of COPD. Chest 2014; 146:339-347. [PMID: 24722914 DOI: 10.1378/chest.13-2307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND B cells in airways and lung parenchyma may be involved in COPD evolution; however, whether their pathogenic role is beneficial or harmful remains controversial. The objective of this study was to investigate the maturation of adenovirus-specific immunoglobulins in patients with COPD with respect to clinical outcome. METHODS The presence of adenovirus-specific immunoglobulins during acute exacerbation of COPD (AECOPD) was analyzed at exacerbation and 2 to 3 weeks later. Patients with detectable adenovirus-specific IgM and low IgG avidity were grouped into fast and delayed IgG maturation. The clinical outcome of both groups was evaluated. RESULTS Of 208 patients, 43 (20.7%) had serologic evidence of recent adenovirus infection and were grouped by fast IgG maturation (26 patients) and delayed IgG maturation (17 patients). Baseline characteristics, AECOPD therapy, and duration of hospitalization were similar in both groups, but the AECOPD recurrence rate within 6 months was higher (P = .003), and there was a trend for earlier AECOPD-related rehospitalizations (P = .061) in the delayed IgG maturation group. The time to rehospitalization or death within 2 years was shorter in patients with delayed IgG maturation (P = .003). Adenovirus-specific IgG maturation was an independent predictor of the number of AECOPD recurrences within 6 months (P = .001) and the occurrence of hospitalization or death within 2 years (P = .005). CONCLUSIONS Delayed immunoglobulin avidity maturation following COPD exacerbation is associated with worse outcomes. TRIAL REGISTRY ISRCTN Register; No.: ISRCTN77261143; URL: www.isrctn.org.
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Affiliation(s)
- Lucas Boeck
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland
| | - Mikael Gencay
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland
| | - Michael Roth
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland
| | - Hans H Hirsch
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland
| | - Michael Tamm
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland
| | - Daiana Stolz
- Clinic of Pulmonary Medicine and Pulmonary Cell Research (Drs Boeck, Gencay, Roth, Tamm, and Stolz), University Hospital Basel, Basel; Department of Biomedicine (Dr Hirsch), University Basel, Basel; Department of Endocrinology, Diabetes and Metabolism (Dr Christ-Crain), University Basel, Basel; Medical University Department (Dr Mueller), Kantonsspital Aarau, Aarau, Switzerland.
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288
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Jyonouchi H, Geng L, Davidow AL. Cytokine profiles by peripheral blood monocytes are associated with changes in behavioral symptoms following immune insults in a subset of ASD subjects: an inflammatory subtype? J Neuroinflammation 2014; 11:187. [PMID: 25344730 PMCID: PMC4213467 DOI: 10.1186/s12974-014-0187-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 10/16/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Some children with autism spectrum disorders (ASD) are characterized by fluctuating behavioral symptoms following immune insults, persistent gastrointestinal (GI) symptoms, and a lack of response to the first-line intervention measures. These children have been categorized as the ASD-inflammatory subtype (ASD-IS) for this study. We reported a high prevalence of non-IgE mediated food allergy (NFA) in young ASD children before, but not all ASD/NFA children reveal such clinical features of ASD-IS. This study addressed whether behavioral changes of ASD-IS are associated with innate immune abnormalities manifested in isolated peripheral blood (PB) monocytes (Mo), major innate immune cells in the PB. METHODS This study includes three groups of ASD subjects (ASD-IS subjects (N = 24), ASD controls with a history of NFA (ASD/NFA (N = 20), and ASD/non-NFA controls (N = 20)) and three groups of non-ASD controls (non-ASD/NFA subjects (N = 16), those diagnosed with pediatric acute onset-neuropsychiatric syndrome (PANS, N = 18), and normal controls without NFA or PANS (N = 16)). Functions of purified PB Mo were assessed by measuring the production of inflammatory and counter-regulatory cytokines with or without stimuli of innate immunity (lipopolysaccharide (LPS), zymosan, CL097, and candida heat extracts as a source of β-lactam). In ASD-IS and PANS subjects, these assays were done in the state of behavioral exacerbation ('flare') and in the stable ('non-flare') condition. ASD-IS children in the 'flare' state revealed worsening irritability, lethargy and hyperactivity. RESULTS 'Flare' ASD-IS PB Mo produced higher amounts of inflammatory cytokines (IL-1β and IL-6) without stimuli than 'non-flare' ASD-IS cells. With zymosan, 'flare' ASD-IS cells produced more IL-1β than most control cells, despite spontaneous production of large amounts of IL-1ß. Moreover, 'flare' ASD-IS Mo produced less IL-10, a counterregulatory cytokine, in response to stimuli than 'non-flare' cells or other control cells. These changes were not observed in PANS cells. CONCLUSIONS We observed an imbalance in the production of inflammatory (IL-1ß and IL-6) and counterregulatory (IL-10) cytokines by 'flare' ASD-IS monocytes, which may indicate an association between intrinsic abnormalities of PB Mo and changes in behavioral symptoms in the ASD-IS subjects.
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289
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Lederman HM, Connolly MA, Kalpatthi R, Ware RE, Wang WC, Luchtman-Jones L, Waclawiw M, Goldsmith JC, Swift A, Casella JF. Immunologic effects of hydroxyurea in sickle cell anemia. Pediatrics 2014; 134:686-95. [PMID: 25180279 PMCID: PMC4179098 DOI: 10.1542/peds.2014-0571] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Susceptibility to encapsulated bacteria is well known in sickle cell disease (SCD). Hydroxyurea use is common in adults and children with SCD, but little is known about hydroxyurea's effects on immune function in SCD. Because hydroxyurea inhibits ribonucleotide reductase, causing cell cycle arrest at the G1-S interface, we postulated that hydroxyurea might delay transition from naive to memory T cells, with inhibition of immunologic maturation and vaccine responses. METHODS T-cell subsets, naive and memory T cells, and antibody responses to pneumococcal and measles, mumps, and rubella vaccines were measured among participants in a multicenter, randomized, double-blind, placebo-controlled trial of hydroxyurea in infants and young children with SCD (BABY HUG). RESULTS Compared with placebo, hydroxyurea treatment resulted in significantly lower total lymphocyte, CD4, and memory T-cell counts; however, these numbers were still within the range of historical healthy controls. Antibody responses to pneumococcal vaccination were not affected, but a delay in achieving protective measles antibody levels occurred in the hydroxyurea group. Antibody levels to measles, mumps, and rubella showed no differences between groups at exit, indicating that effective immunization can be achieved despite hydroxyurea use. CONCLUSIONS Hydroxyurea does not appear to have significant deleterious effects on the immune function of infants and children with SCD. Additional assessments of lymphocyte parameters of hydroxyurea-treated children may be warranted. No changes in current immunization schedules are recommended; however, for endemic disease or epidemics, adherence to accelerated immunization schedules for the measles, mumps, and rubella vaccine should be reinforced.
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Affiliation(s)
- Howard M Lederman
- Eudowood Division of Allergy and Immunology, Department of Pediatrics, and
| | | | - Ram Kalpatthi
- Pediatric Hematology, Children's Mercy Hospital, Kansas City, Missouri
| | - Russell E Ware
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Winfred C Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Lori Luchtman-Jones
- Division of Hematology, Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia; and
| | - Myron Waclawiw
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Jonathan C Goldsmith
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Andrea Swift
- Eudowood Division of Allergy and Immunology, Department of Pediatrics, and
| | - James F Casella
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland;
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290
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Ameratunga R, Brewerton M, Slade C, Jordan A, Gillis D, Steele R, Koopmans W, Woon ST. Comparison of diagnostic criteria for common variable immunodeficiency disorder. Front Immunol 2014; 5:415. [PMID: 25309532 PMCID: PMC4164032 DOI: 10.3389/fimmu.2014.00415] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/17/2014] [Indexed: 12/21/2022] Open
Abstract
Common variable immunodeficiency disorders (CVIDs) are the most frequent symptomatic primary immune deficiency condition in adults. The genetic basis for the condition is not known and no single clinical feature or laboratory test can establish the diagnosis; it has been a diagnosis of exclusion. In areas of uncertainty, diagnostic criteria can provide valuable clinical information. Here, we compare the revised European society of immune deficiencies (ESID) registry (2014) criteria with the diagnostic criteria of Ameratunga et al. (2013) and the original ESID/pan American group for immune deficiency (ESID/PAGID 1999) criteria. The ESID/PAGID (1999) criteria either require absent isohemagglutinins or impaired vaccine responses to establish the diagnosis in patients with primary hypogammaglobulinemia. Although commonly encountered, infective and autoimmune sequelae of CVID were not part of the original ESID/PAGID (1999) criteria. Also excluded were a series of characteristic laboratory and histological abnormalities, which are useful when making the diagnosis. The diagnostic criteria of Ameratunga et al. (2013) for CVID are based on these markers. The revised ESID registry (2014) criteria for CVID require the presence of symptoms as well as laboratory abnormalities to establish the diagnosis. Once validated, criteria for CVID will improve diagnostic precision and will result in more equitable and judicious use of intravenous or subcutaneous immunoglobulin therapy.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand ; Department of Clinical Immunology, Auckland Hospital , Auckland , New Zealand
| | - Maia Brewerton
- Department of Clinical Immunology, Royal Melbourne Hospital , Melbourne, VIC , Australia
| | - Charlotte Slade
- Department of Clinical Immunology, Royal Melbourne Hospital , Melbourne, VIC , Australia
| | - Anthony Jordan
- Department of Clinical Immunology, Auckland Hospital , Auckland , New Zealand
| | - David Gillis
- Department of Clinical Immunology, Royal Brisbane Hospital , Brisbane, QLD , Australia
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand
| | - Wikke Koopmans
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital , Auckland , New Zealand
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291
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Comparisons of CVID and IgGSD: referring physicians, autoimmune conditions, pneumovax reactivity, immunoglobulin levels, blood lymphocyte subsets, and HLA-A and -B typing in 432 adult index patients. J Immunol Res 2014; 2014:542706. [PMID: 25295286 PMCID: PMC4180398 DOI: 10.1155/2014/542706] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/13/2014] [Accepted: 08/14/2014] [Indexed: 12/11/2022] Open
Abstract
Common variable immunodeficiency (CVID) and immunoglobulin (Ig) G subclass deficiency (IgGSD) are heterogeneous disorders characterized by respiratory tract infections, selective Ig isotype deficiencies, and impaired antibody responses to polysaccharide antigens. Using univariable analyses, we compared observations in 34 CVID and 398 IgGSD adult index patients (81.9% women) referred to a hematology/oncology practice. Similarities included specialties of referring physicians, mean ages, proportions of women, reactivity to Pneumovax, median serum IgG3 and IgG4 levels, median blood CD56+/CD16+ lymphocyte levels, positivity for HLA-A and -B types, and frequencies of selected HLA-A, -B haplotypes. Dissimilarities included greater prevalence of autoimmune conditions, lower median IgG, IgA, and IgM, and lower median CD19+, CD3+/CD4+, and CD3+/CD8+ blood lymphocytes in CVID patients. Prevalence of Sjögren's syndrome and hypothyroidism was significantly greater in CVID patients. Combined subnormal IgG1/IgG3 occurred in 59% and 29% of CVID and IgGSD patients, respectively. Isolated subnormal IgG3 occurred in 121 IgGSD patients (88% women). Logistic regression on CVID (versus IgGSD) revealed a significant positive association with autoimmune conditions and significant negative associations with IgG1, IgG3, and IgA and CD56+/CD16+ lymphocyte levels, but the odds ratio was increased for autoimmune conditions alone (6.9 (95% CI 1.3, 35.5)).
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292
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Ryan MW. AAOA allergy primer: immunodeficiency. Int Forum Allergy Rhinol 2014; 4 Suppl 2:S74-8. [DOI: 10.1002/alr.21379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 07/01/2014] [Accepted: 07/02/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Matthew W. Ryan
- Department of Otolaryngology; University of Texas Southwestern Medical Center; Dallas TX
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293
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Smith LL, Buckley R, Lugar P. Diagnostic Immunization with Bacteriophage ΦX 174 in Patients with Common Variable Immunodeficiency/Hypogammaglobulinemia. Front Immunol 2014; 5:410. [PMID: 25221555 PMCID: PMC4148716 DOI: 10.3389/fimmu.2014.00410] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/13/2014] [Indexed: 11/23/2022] Open
Abstract
Purpose: Use of the T cell-dependent neoantigen bacteriophage ΦX 174 has been described since the 1960s as a method to assess specific antibody response in patients with primary immunodeficiencies. We reviewed a cohort of patients at Duke University Medical Center who received immunization with bacteriophage and report the clinical utility and safety of the immunization, as well as patient characteristics. Methods: A retrospective chart review was performed of all Duke Immunology Clinic patients (pediatric and adult) who received immunizations with bacteriophage, from 1976 to 2012. Subjects were selected for inclusion if their diagnosis at the time of bacteriophage was either presumed or confirmed common variable immunodeficiency (CVID), hypogammaglobulinemia, transient hypogammaglobulinemia, or antibody deficiency unspecified. Follow up post-immunization was also recorded. Results: One hundred twenty-six patients were identified, 36 adults and 90 pediatric patients. Diagnoses prior to bacteriophage were CVID (n = 100), hypogammaglobulinemia (n = 23), and antibody deficiency (n = 3). Post-immunization diagnoses were CVID (n = 65), hypogammaglobulinemia (n = 19), unknown (n = 23), no primary immune deficiency (n = 10), and other primary immunodeficiency (n = 9). Seventy-five patients had abnormal bacteriophage results, 37 were normal, and 14 were borderline. There were 257 recorded administrations of the immunization. Information was available on adverse reactions for 171 administrations. Fourteen immunizations were associated with minor adverse events. Nineteen patients stopped their immunoglobulin replacement therapy based on reported normal responses to immunization. Conclusion: Bacteriophage ΦX 174 immunization is a safe, well-tolerated, and clinically useful method to assess antibody response in patients with suspected antibody-mediated immunodeficiencies, particularly those who are on immunoglobulin replacement therapy at the time of immunization.
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Affiliation(s)
- Lauren L Smith
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Duke University Medical Center , Durham, NC , USA
| | - Rebecca Buckley
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Duke University Medical Center , Durham, NC , USA ; Department of Immunology, Duke University School of Medicine , Durham, NC , USA
| | - Patricia Lugar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center , Durham, NC , USA
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294
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Rituximab and immune deficiency: case series and review of the literature. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:594-600. [PMID: 25213054 DOI: 10.1016/j.jaip.2014.06.003] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 06/12/2014] [Accepted: 06/14/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND As the indications and use of rituximab continue to expand, the reports of long-term effects of anti-CD20--mediated B-cell depletion on the immune system accumulate. OBJECTIVE We report a group of patients with immunodeficiency who were treated with rituximab and present their immunologic data. METHODS A retrospective chart review identified patients with immunodeficiency who received rituximab for treatment of their primary disease and required immunoglobulin replacement therapy (IGRT). Pre-IGRT immunoglobulins, specific antibodies, B-cells, and B-cell phenotype were recorded and analyzed. RESULTS We identified 11 patients with immunodeficiency who received rituximab and required IGRT. Two of these patients were diagnosed with common variable immunodeficiency before rituximab treatment. Nine other patients had hypogammaglobulinemia and did not achieve an adequate response to polysaccharide vaccine. There was a significant delay in B-cell recovery. B-cell phenotypes identified predominantly naive B cells in the blood of these patients with significant decrease in switched and memory B cells. CONCLUSION There are patients with persistent B-cell dysfunction long after rituximab treatment was discontinued. Some of these patients required IGRT. These patients should be distinguished from patients with primary immunodeficiency diseases. Routine baseline B-cell numbers and serum immunoglobulin levels before starting immunomodulatory therapy are required to help distinguish primary immunodeficiency diseases from secondary rituximab-induced, transient, and, at times, prolonged immune suppression. Periodic monitoring is prudent to identify immune recovery. Post-rituximab B-cell phenotyping may help identify the patients who will develop persistent immune dysfunction caused by an unidentified underlying disease or the prolonged effect of rituximab treatment.
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295
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Peter JG, Chapel H. Immunoglobulin replacement therapy for primary immunodeficiencies. Immunotherapy 2014; 6:853-69. [DOI: 10.2217/imt.14.54] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Exogenous antibody therapy to protect patients against infections and toxins is over 100 years old, yet progress continues to be made in the manufacture, administration and application of this type of immunotherapy, known as therapeutic human immunoglobulin. For the majority of patients with primary immunodeficiencies, immunoglobulin replacement is the only life-saving therapy and treatment is life-long, since the vast majority of primary immunodeficiency patients have primary antibody failure. Successful treatment depends on multiple factors: the availability of products, the type of immunodeficiency and any comorbidities of the individual patient. Essential components include long-term follow-up, regular monitoring and a close relationship between the patient and the multidisciplinary clinical immunology team. In this article, we describe the current immunoglobulin products and the types of adverse reactions. We provide evidence for clinical decision-making regarding dosing, route of administration and location of therapy, highlighting current ‘best practice’ recommendations.
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Affiliation(s)
- Jonathan G Peter
- Primary Immunodeficiency Unit, Level 7, Nuffield Department of Medicine, Oxford University Hospital, John Radcliffe Site, Headley Way, Oxford, OX3 9DU, UK
- Division of Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen Chapel
- Primary Immunodeficiency Unit, Level 7, Nuffield Department of Medicine, Oxford University Hospital, John Radcliffe Site, Headley Way, Oxford, OX3 9DU, UK
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296
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Duraisingham SS, Buckland M, Dempster J, Lorenzo L, Grigoriadou S, Longhurst HJ. Primary vs. secondary antibody deficiency: clinical features and infection outcomes of immunoglobulin replacement. PLoS One 2014; 9:e100324. [PMID: 24971644 PMCID: PMC4074074 DOI: 10.1371/journal.pone.0100324] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 05/23/2014] [Indexed: 12/04/2022] Open
Abstract
Secondary antibody deficiency can occur as a result of haematological malignancies or certain medications, but not much is known about the clinical and immunological features of this group of patients as a whole. Here we describe a cohort of 167 patients with primary or secondary antibody deficiencies on immunoglobulin (Ig)-replacement treatment. The demographics, causes of immunodeficiency, diagnostic delay, clinical and laboratory features, and infection frequency were analysed retrospectively. Chemotherapy for B cell lymphoma and the use of Rituximab, corticosteroids or immunosuppressive medications were the most common causes of secondary antibody deficiency in this cohort. There was no difference in diagnostic delay or bronchiectasis between primary and secondary antibody deficiency patients, and both groups experienced disorders associated with immune dysregulation. Secondary antibody deficiency patients had similar baseline levels of serum IgG, but higher IgM and IgA, and a higher frequency of switched memory B cells than primary antibody deficiency patients. Serious and non-serious infections before and after Ig-replacement were also compared in both groups. Although secondary antibody deficiency patients had more serious infections before initiation of Ig-replacement, treatment resulted in a significant reduction of serious and non-serious infections in both primary and secondary antibody deficiency patients. Patients with secondary antibody deficiency experience similar delays in diagnosis as primary antibody deficiency patients and can also benefit from immunoglobulin-replacement treatment.
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Affiliation(s)
| | - Matthew Buckland
- Immunology Department, Barts Health NHS Trust, London, United Kingdom
| | - John Dempster
- Immunology Department, Barts Health NHS Trust, London, United Kingdom
| | - Lorena Lorenzo
- Immunology Department, Barts Health NHS Trust, London, United Kingdom
| | - Sofia Grigoriadou
- Immunology Department, Barts Health NHS Trust, London, United Kingdom
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297
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Sadler R, Bateman EAL, Heath V, Patel SY, Schwingshackl PP, Cullinane AC, Ayers L, Ferry BL. Establishment of a healthy human range for the whole blood "OX40" assay for the detection of antigen-specific CD4+ T cells by flow cytometry. CYTOMETRY PART B-CLINICAL CYTOMETRY 2014; 86:350-61. [PMID: 24827553 DOI: 10.1002/cyto.b.21165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 12/17/2013] [Accepted: 01/29/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical investigation of antigen-specific T cells in potentially immunodeficient patients is an important and often challenging aspect of patient diagnostic work up. Methods for detection of microbial exposure to the T-cell compartment exist but are laborious and time consuming. Recently, a whole blood technique involving flow cytometry and detection of CD25 and OX40 (CD134) expression on the surface of activated CD4+ T cells was shown to be accurate and concordant when compared with more traditional methods of antigen-specific T-cell detection. METHODS Whole heparinized blood was collected from healthy donors and set up using the "OX40" assay to detect antigen-specific CD4+ T-cell responses to Varicella Zoster Virus, Epstein-Barr Virus (EBV), Cytomegalovirus, Candida albicans, and Streptococcus pneumoniae. RESULTS The "OX40" assay technique was clinically validated for routine use in an NHS clinical immunology laboratory by analysis of incubation length (40-50 h), sample transport time (up to 24 h at room temperature), concordance with serology testing, proliferation and interferon-gamma production. In addition, 63 healthy controls (age range 21-78) were tested for responses to generate a healthy control reference range. CONCLUSIONS The OX40 assay, as presented in this report, represents an economical, rapid, robust whole blood technique to detect antigen-specific T cells, which is suitable for clinical immunology diagnostic laboratory use.
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Affiliation(s)
- Ross Sadler
- Department of Immunology, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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298
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Multilaboratory assessment of threshold versus fold-change algorithms for minimizing analytical variability in multiplexed pneumococcal IgG measurements. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2014; 21:982-8. [PMID: 24807051 DOI: 10.1128/cvi.00235-14] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pneumococcal vaccination is frequently used to assess a patient's humoral immune function. The comparison of pre- and postvaccination levels of antipneumococcal antibodies is widely held to be the gold standard for documenting a response. However, many of the published criteria for defining an adequate response are based on assays that are no longer widely available. We compared the clinical classification of patient response by multiplex pneumococcal assays currently performed at three large reference laboratories using a variety of published criteria for defining responses in adults. The classification of responders agreed for 79% of the patients when using a threshold-based algorithm compared to 57 to 96% of the patients when using various fold-change-based algorithms. The highest rate of discordance was seen when the most stringent criteria for response were used (4-fold increase postvaccination in 70% of serotypes). The discordant samples tended to show similar patterns of response across all three assays, with small variations in the final number of serotypes converting postvaccination. We conclude that the use of published cut points for documenting response to pneumococcal vaccination can be affected by interlaboratory differences in pneumococcal assays, particularly for algorithms that require large fold changes for a response to be documented. However, the overall patterns of response were similar in virtually all samples, regardless of the assay used.
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299
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Boon M, De Boeck K, Jorissen M, Meyts I. Primary ciliary dyskinesia and humoral immunodeficiency--is there a missing link? Respir Med 2014; 108:931-4. [PMID: 24768622 DOI: 10.1016/j.rmed.2014.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 03/05/2014] [Accepted: 03/17/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Primary ciliary dyskinesia (PCD) and humoral mmunodeficiency (HID) are both rare disorders which cause recurrent upper and lower respiratory tract infections. OBJECTIVE To examine the concurrence of PCD and HID in a patient cohort with known PCD. METHODS Retrospective review of the patient files. RESULTS We describe 11 patients of a cohort of 168 patients with PCD (6.5%) with a combination of PCD and some form of HID. The patients all presented with typical clinical symptoms for PCD, however the role of the concomitant immunological abnormalities is not clear. CONCLUSION PCD and HID coincided in 6.5% of the patients. We suggest that a common pathophysiological pathway results in both disorders.
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Affiliation(s)
- Mieke Boon
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.
| | - Kris De Boeck
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
| | - Mark Jorissen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Gasthuisberg Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Isabelle Meyts
- Department of Pediatrics, Pediatric Immunology, University Hospital Gasthuisberg, Herestraat 49, Leuven, Belgium
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300
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Duraisingham SS, Buckland MS, Grigoriadou S, Longhurst HJ. Secondary antibody deficiency. Expert Rev Clin Immunol 2014; 10:583-91. [PMID: 24684706 DOI: 10.1586/1744666x.2014.902314] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Secondary antibody deficiencies are defined by a quantitative or qualitative decrease in antibodies that occur most commonly as a consequence of renal or gastrointestinal immunoglobulin loss, hematological malignancies and corticosteroid, immunosuppressive or anticonvulsant medications. Patients with hematological malignancies or requiring immunosuppressive medications are known to be at increased risk of infection, but few studies directly address this relationship in the context of antibody deficiency. Immunoglobulin replacement therapy has been shown to be effective in reducing infections in primary and some secondary antibody deficiencies. The commonly encountered causes of secondary antibody deficiencies and their association with infection-related morbidity and mortality are discussed. Recommendations are made for screening and clinical management of those at risk.
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Affiliation(s)
- Sai S Duraisingham
- Immunology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
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