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Biggs SE, Gilchrist B, May KR. Chromosome 22q11.2 Deletion (DiGeorge Syndrome): Immunologic Features, Diagnosis, and Management. Curr Allergy Asthma Rep 2023; 23:213-222. [PMID: 36897497 PMCID: PMC9999075 DOI: 10.1007/s11882-023-01071-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE OF REVIEW This review focuses on immunologic findings, relationships among immunologic findings and associated conditions of autoimmunity and atopy, and management of immunologic disease in chromosome 22q11.2 deletion syndrome (22q11.2DS, historically known as DiGeorge syndrome). RECENT FINDINGS The implementation of assessment of T cell receptor excision circles (TRECs) in newborn screening has led to increased detection of 22q11.2 deletion syndrome. While not yet applied in clinical practice, cell-free DNA screening for 22q11.2DS also has the potential to improve early detection, which may benefit prompt evaluation and management. Multiple studies have further elucidated phenotypic features and potential biomarkers associated with immunologic outcomes, including the development of autoimmune disease and atopy. The clinical presentation of 22q11.2DS is highly variable particularly with respect to immunologic manifestations. Time to recovery of immune system abnormalities is not well-defined in current literature. An understanding of the underlying causes of immunologic changes found in 22q11.2DS, and the progression and evolution of immunologic changes over the lifespan have expanded over time and with improved survival. An included case highlights the variability of presentation and potential severity of T cell lymphopenia in partial DiGeorge syndrome and demonstrates successful spontaneous immune reconstitution in partial DiGeorge syndrome despite initial severe T cell lymphopenia.
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Affiliation(s)
- Sarah E Biggs
- Division of Allergy-Immunology & Pediatric Rheumatology, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Bailee Gilchrist
- Division of Allergy-Immunology & Pediatric Rheumatology, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Kathleen R May
- Division of Allergy-Immunology & Pediatric Rheumatology, Department of Pediatrics, Medical College of Georgia at Augusta University, Augusta, GA, USA.
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2
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Infections in Inborn Errors of Immunity with Combined Immune Deficiency: A Review. Pathogens 2023; 12:pathogens12020272. [PMID: 36839544 PMCID: PMC9958715 DOI: 10.3390/pathogens12020272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/13/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
Enhanced susceptibility to microbes, often resulting in severe, intractable and frequent infections due to usually innocuous organisms at uncommon sites, is the most striking feature in individuals with an inborn error of immunity. In this narrative review, based on the International Union of Immunological Societies' 2022 (IUIS 2022) Update on phenotypic classification of human inborn errors of immunity, the focus is on commonly encountered Combined Immunodeficiency Disorders (CIDs) with susceptibility to infections. Combined immune deficiency disorders are usually commensurate with survival beyond infancy unlike Severe Combined Immune Deficiency (SCID) and are often associated with clinical features of a syndromic nature. Defective humoral and cellular immune responses result in susceptibility to a broad range of microbial infections. Although disease onset is usually in early childhood, mild defects may present in late childhood or even in adulthood. A precise diagnosis is imperative not only for determining management strategies, but also for providing accurate genetic counseling, including prenatal diagnosis, and also in deciding empiric treatment of infections upfront before investigation reports are available.
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3
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Mustillo PJ, Sullivan KE, Chinn IK, Notarangelo LD, Haddad E, Davies EG, de la Morena MT, Hartog N, Yu JE, Hernandez-Trujillo VP, Ip W, Franco J, Gambineri E, Hickey SE, Varga E, Markert ML. Clinical Practice Guidelines for the Immunological Management of Chromosome 22q11.2 Deletion Syndrome and Other Defects in Thymic Development. J Clin Immunol 2023; 43:247-270. [PMID: 36648576 PMCID: PMC9892161 DOI: 10.1007/s10875-022-01418-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/04/2022] [Indexed: 01/18/2023]
Abstract
Current practices vary widely regarding the immunological work-up and management of patients affected with defects in thymic development (DTD), which include chromosome 22q11.2 microdeletion syndrome (22q11.2del) and other causes of DiGeorge syndrome (DGS) and coloboma, heart defect, atresia choanae, retardation of growth and development, genital hypoplasia, ear anomalies/deafness (CHARGE) syndrome. Practice variations affect the initial and subsequent assessment of immune function, the terminology used to describe the condition and immune status, the accepted criteria for recommending live vaccines, and how often follow-up is needed based on the degree of immune compromise. The lack of consensus and widely varying practices highlight the need to establish updated immunological clinical practice guidelines. These guideline recommendations provide a comprehensive review for immunologists and other clinicians who manage immune aspects of this group of disorders.
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Affiliation(s)
- Peter J Mustillo
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, 43205, USA.
| | - Kathleen E Sullivan
- Division of Allergy Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Ivan K Chinn
- Division of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, 77030, USA
| | - Luigi D Notarangelo
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Elie Haddad
- Department of Pediatrics, Department of Microbiology, Infectious Diseases and Immunology, CHU Sainte-Justine, University of Montreal, Montreal, QC, H3T 1C5, Canada
| | - E Graham Davies
- Department of Immunology, Great Ormond Street Hospital and UCL Great Ormond Street Institute of Child Health, London, WC1N 3HJ, UK
| | - Maria Teresa de la Morena
- Division of Immunology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, 98105, USA
| | - Nicholas Hartog
- Spectrum Health Helen DeVos Children's Hospital Department of Allergy and Immunology, Michigan State University College of Human Medicine, East Lansing, USA
| | - Joyce E Yu
- Division of Allergy, Immunology & Rheumatology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Winnie Ip
- Department of Immunology, Great Ormond Street Hospital and UCL Great Ormond Street Institute of Child Health, London, WC1N 3JH, UK
| | - Jose Franco
- Grupo de Inmunodeficiencias Primarias, Facultad de Medicina, Universidad de Antioquia UdeA, Medellin, Colombia
| | - Eleonora Gambineri
- Department of "NEUROFARBA", Section of Child's Health, University of Florence, Florence, Italy
- Centre of Excellence, Division of Pediatric Oncology/Hematology, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Scott E Hickey
- Division of Genetic & Genomic Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Elizabeth Varga
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - M Louise Markert
- Department of Immunology, Duke University Medical Center, Durham, NC, 27710, USA
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Crockett AM, Kebir H, Benallegue N, Adelman P, Gur RE, Sullivan K, Anderson SA, Alvarez JI. Immune status of the murine 22q11.2 deletion syndrome model. Eur J Immunol 2023; 53:e2249840. [PMID: 36337041 DOI: 10.1002/eji.202249840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 09/15/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Mice modeling the hemizygous deletion of chromosome 22q11.2 (22qMc) have been utilized to address various clinical phenotypes associated with the disease, including cardiac malformations, altered neural circuitry, and behavioral deficits. Yet, the status of the T cell compartment, an important clinical concern among 22q11.2 deletion syndrome (22qDS) patients, has not been addressed. While infancy and early childhood in 22qDS are associated with deficient T cell numbers and thymic hypoplasia, which can be severe in a small subset of patients, studies suggest normalization of the T cell counts by adulthood. We found that adult 22qMc do not exhibit thymic hypoplasia or altered thymic T cell development. Our findings that immune cell counts and inflammatory T cell activation are unaffected in 22qMc lend support to the hypothesis that human 22qDS immunodeficiencies are secondary to thymic hypoplasia, rather than intrinsic effects due to the deletion. Furthermore, the 22q11.2 deletion does not impact the differentiation capacity of T cells, nor their activity and response during inflammatory activation. Thus, 22qMc reflects the T cell compartment in adult 22qDS patients, and our findings suggest that 22qMc may serve as a novel model to address experimental and translational aspects of immunity in 22qDS.
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Affiliation(s)
- Alexis M Crockett
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hania Kebir
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Naïl Benallegue
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Inserm, Université de Nantes, CHU Nantes, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, F-44000, France
| | - Philippa Adelman
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raquel E Gur
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen Sullivan
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stewart A Anderson
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jorge I Alvarez
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Urschel D, Hernandez-Trujillo VP. Spectrum of Genetic T-Cell Disorders from 22q11.2DS to CHARGE. Clin Rev Allergy Immunol 2022; 63:99-105. [PMID: 35133619 DOI: 10.1007/s12016-022-08927-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 01/12/2023]
Abstract
Improved genetic testing has led to recognition of a diverse group of disorders of inborn errors of immunity that present as primarily T-cell defects. These disorders present with variable degrees of immunodeficiency, autoimmunity, multiple organ system dysfunction, and neurocognitive defects. 22q11.2 deletion syndrome, commonly known as DiGeorge syndrome, represents the most common disorder on this spectrum. In most individuals, a 3 Mb deletion of 22q11 results in haploinsufficiency of 90 known genes and clinical complications of varying severity. These include cardiac, endocrine, gastrointestinal, renal, palatal, genitourinary, and neurocognitive anomalies. Multidisciplinary treatment also includes pediatrics/general practitioners, genetic counseling, surgery, interventional therapy, and psychology/psychiatry. Chromosome 10p deletion, TBX1 mutation, CHD7 mutation, Jacobsen syndrome, and FOXN1 deficiency manifest with similar overlapping clinical presentations and T-cell defects. Recognition of the underlying disorder and pathogenesis is essential for improved outcomes. Diagnosing and treating these heterogenous conditions are a challenge and rapidly improving with new diagnostic tools. Collectively, these disorders are an example of the complex penetrance and severity of genetic disorders, importance of translational diagnostics, and a guide for multidisciplinary treatment.
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Affiliation(s)
- Daniel Urschel
- Department of Medical Education, Nicklaus Children's Hospital, Miami, FL, USA. .,Division of Allergy and Immunology, Nicklaus Children's Hospital, Miami, FL, USA. .,Allergy and Immunology Care Center of South Florida, Miami Lakes, FL, USA.
| | - Vivian P Hernandez-Trujillo
- Department of Medical Education, Nicklaus Children's Hospital, Miami, FL, USA.,Division of Allergy and Immunology, Nicklaus Children's Hospital, Miami, FL, USA.,Allergy and Immunology Care Center of South Florida, Miami Lakes, FL, USA
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Soshnick SH, Joseph T, Bennett NJ. Humoral Immunodeficiency and Immune Globulin Replacement Therapy (IGRT) Usage in DiGeorge Syndrome. J Clin Immunol 2021; 41:1208-1212. [PMID: 33740168 DOI: 10.1007/s10875-021-01012-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 03/02/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE An analysis of patients in the United States Immunodeficiency Network (USIDNET) registry previously described a discordance in the reported prevalence of humoral immune deficiency in patients with DiGeorge syndrome (DGS) and its treatment. The primary purpose of this study is to evaluate the rates of humoral immunodeficiency and immune globulin replacement therapy (IGRT) use in patients with DiGeorge syndrome in the USIDNET registry as of September 2016, and to correlate IGRT use with prior infections and laboratory evidence of immune deficiency. METHODS Current patients in the USIDNET registry with DGS were identified. Patients who were treated with immune globulin replacement therapy (IGRT) were compared with those who were untreated with respect to their laboratory findings and clinical history. RESULTS Four hundred seventy-three patients were identified. The use of IGRT in patients with DGS has increased over time from 3 to 6.6%. IGRT was more common in patients with humoral immune deficiency (18.2% of those with hypogammaglobulinemia, 39.1% of those with documented low vaccine titers), but most patients with evidence of humoral immune deficiency remain untreated with IGRT. Patients treated with IGRT were more likely to have experienced episodes of pneumonia, sepsis, and bacterial skin infections (p < 0.01 for all). CONCLUSIONS Humoral immune deficiencies were more common among patients with DGS than previously reported. IGRT was used most commonly in patients with DGS who demonstrated frequent or severe bacterial infections. There is still a significant deficit between those with DGS who have laboratory evidence of a humoral immune deficiency and those being treated for it.
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Affiliation(s)
- Sara H Soshnick
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Albert Einstein College of Medicine, Children's Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA.
| | - Tuhina Joseph
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA
| | - Nicholas J Bennett
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Immunology, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA.
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Abstract
In the fetus, the cardiac neural crest gives rise to both the thymus and the conotruncus of the heart. In newborn screening for severe T-cell lymphopenia neonates with congenital heart defects may be detected. In this study, we investigated the occurrence of T-cell lymphopenia in neonates with or without 22q11.2 deletion syndrome (del) suffering from heart defects. This retrospective cohort study included 125 patients with heart defects. T-cell receptor excision circles (TRECs), a measure for T-cell lymphopenia, were quantified by RT-PCR using stored newborn screening blood spots. Three patient groups were compared: non-conotruncal defects (n = 57), conotruncal defects (n = 42), and 22q11.2 del with conotruncal defects (n = 26). Significantly lower TREC values were detected in patients with 22q11.2 del and conotruncal heart defects compared to those with non-syndromic conotruncal (p < 0.001) and non-conotruncal (p < 0.001) defects. In contrast, no significant difference was found between patients with non-syndromic conotruncal and non-conotruncal heart defects (p = 0.152). Low TREC levels were obtained in neonates treated with heart surgery/intervention within 2 weeks after birth and in those with a fatal outcome (p = 0.02) independent of patient group. A correlation was found between low TREC numbers and oxygen saturation, SpO2 below 95% (p = 0.017). The SpO2 was significantly lower in the non-syndromic conotruncal group compared to non-conotruncal (p < 0.001) and 22q11.2 del group (p = 0.015). No correlation was found between low neonatal TRECs and infections needing hospitalization later in life (p = 0.135). Patients with 22q11.2 del and conotruncal defects have significantly lower TREC levels compared to patients with heart defects without this syndrome.
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8
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Nain E, Kiykim A, Ogulur I, Kasap N, Karakoc-Aydiner E, Ozen A, Baris S. Immune system defects in DiGeorge syndrome and association with clinical course. Scand J Immunol 2019; 90:e12809. [PMID: 31322747 DOI: 10.1111/sji.12809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/27/2019] [Accepted: 07/05/2019] [Indexed: 12/11/2022]
Abstract
We evaluated 18 DiGeorge syndrome (DGS) patients and aimed to investigate the immunological changes in this population. DGS patients with low naive CD4+ T and CD8+ T cells were defined as high-risk (HR) patients, whereas patients with normal numbers of naive CD4+ and CD8+ T cells were defined as standard risk (SR) patients. Level of serum IgM, CD3+ T cell counts and percentages of class-switched memory B cells were significantly low in HR group compared to SR ones. Severe infections and persistent hypoparathyroidism were detected significantly higher in HR group. Patients with reduced percentages of class-switched B cells had earlier onset of infection, lower blood IgM, lower CD4+ and CD8+ T counts than patients with normal class-switched memory B cells. Decreased levels of IgM were associated with low numbers of naive CD4+ and recent thymic emigrants T cells. Monitoring the immune changes of patients with DGS would be useful to predict the severe phenotype of disease.
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Affiliation(s)
- Ercan Nain
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Ayca Kiykim
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Ismail Ogulur
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Nurhan Kasap
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey.,Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Ahmet Ozen
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey.,Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Safa Baris
- Faculty of Medicine, Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey.,Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
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Nabekura T, Chen Z, Schroeder C, Park T, Vivier E, Lanier LL, Liu D. Crk Adaptor Proteins Regulate NK Cell Expansion and Differentiation during Mouse Cytomegalovirus Infection. THE JOURNAL OF IMMUNOLOGY 2018; 200:3420-3428. [PMID: 29618525 DOI: 10.4049/jimmunol.1701639] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 03/13/2018] [Indexed: 11/19/2022]
Abstract
Natural killer cells are critical in the immune response to infection and malignancy. Prior studies have demonstrated that Crk family proteins can influence cell apoptosis, proliferation, and cell transformation. In this study, we investigated the role of Crk family proteins in mouse NK cell differentiation and host defense using a mouse CMV infection model. The number of NK cells, maturational state, and the majority of the NKR repertoire was similar in Crk x Crk-like (CrkL)-double-deficient and wild type NK cells. However, Crk family proteins were required for optimal activation, IFN-γ production, expansion, and differentiation of Ly49H+ NK cells, as well as host defense during mouse CMV infection. The diminished function of Crk x CrkL-double-deficient NK cells correlated with decreased phosphorylation of STAT4 and STAT1 in response to IL-12 and IFN-α stimulation, respectively. Together, our findings analyzing NK cell-specific Crk-deficient mice provide insights into the role of Crk family proteins in NK cell function and host defense.
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Affiliation(s)
- Tsukasa Nabekura
- Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, CA 94143.,Parker Institute for Cancer Immunotherapy, San Francisco, CA 94143.,Life Science Center, Tsukuba Advanced Research Alliance, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Zhiying Chen
- Center for Inflammation and Epigenetics, Houston Methodist Research Institute, Houston, TX 77030
| | - Casey Schroeder
- Center for Inflammation and Epigenetics, Houston Methodist Research Institute, Houston, TX 77030
| | - Taeju Park
- Children's Research Institute, Children's Mercy Kansas City, Kansas City, MO 64108
| | - Eric Vivier
- Centre d'Immunologie de Marseille-Luminy, Aix Marseille Université, INSERM, CNRS, 13288 Marseille, France.,Service d'Immunologie, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13288 Marseille, France; and
| | - Lewis L Lanier
- Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, CA 94143; .,Parker Institute for Cancer Immunotherapy, San Francisco, CA 94143
| | - Dongfang Liu
- Center for Inflammation and Epigenetics, Houston Methodist Research Institute, Houston, TX 77030; .,Department of Microbiology and Immunology, Weill Cornell Medical College, Cornell University, New York, NY 10065
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Crowley B, Ruffner M, McDonald McGinn DM, Sullivan KE. Variable immune deficiency related to deletion size in chromosome 22q11.2 deletion syndrome. Am J Med Genet A 2018; 176:2082-2086. [PMID: 29341423 DOI: 10.1002/ajmg.a.38597] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 12/12/2017] [Indexed: 12/13/2022]
Abstract
The clinical features of 22q11.2 deletion syndrome include virtually every organ of the body. This review will focus on the immune system and the differences related to deletion breakpoints. A hypoplastic thymus was one of the first features described in this syndrome and low T cell counts, as a consequence of thymic hypoplasia, are the most commonly described immunologic feature. These are most prominently seen in early childhood and can be associated with increased persistence of viruses. Later in life, evidence of T cell exhaustion may be seen and secondary deficiencies of antibody function have been described. The relationship of the immunodeficiency to the deletion breakpoints has been understudied due to the infrequent analysis of people carrying smaller deletions. This manuscript will review the immune deficiency in 22q11.2 deletion syndrome and describe differences in the T cell counts related to the deletion breakpoints. Distal, non-TBX1 inclusive deletions, were found to be associated with better T cell counts. Another new finding is the relative preservation of T cell counts in those patients with a 22q11.2 duplication.
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Affiliation(s)
- Blaine Crowley
- The Division of Clinical Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melanie Ruffner
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donna M McDonald McGinn
- The Division of Clinical Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathleen E Sullivan
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Sullivan KE, Crowley TB, Maurer K, Goldmuntz E, Gaynor JW, Zackai E, McDonald-McGinn D. T-cell lymphopenia in 22q11.2 deletion syndrome: Relationship to cardiac disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:690-691. [PMID: 28964704 DOI: 10.1016/j.jaip.2017.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/01/2017] [Accepted: 08/07/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Kathleen E Sullivan
- Division of Allergy Immunology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
| | - T Blaine Crowley
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, the Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Kelly Maurer
- Division of Allergy Immunology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, the Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Elaine Zackai
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, the Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Donna McDonald-McGinn
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, the Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
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12
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Morsheimer M, Brown Whitehorn TF, Heimall J, Sullivan KE. The immune deficiency of chromosome 22q11.2 deletion syndrome. Am J Med Genet A 2017. [PMID: 28627729 DOI: 10.1002/ajmg.a.38319] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The syndrome originally described by Dr. Angelo DiGeorge had immunodeficiency as a central component. When a 22q11.2 deletion was identified as the cause in the majority of patients with DiGeorge syndrome, the clinical features of 22q11.2 deletion syndrome became so expansive that the immunodeficiency became less prominent in our thinking about the syndrome. This review will focus on the immune system and the changes in our understanding over the past 50 years. Initially characterized as a pure defect in T cell development, we now appreciate that many of the clinical features related to the immunodeficiency are well downstream of the limitation imposed by a small thymus. Dysfunctional B cells presumed to be secondary to compromised T cell help, issues related to T cell exhaustion, and high rates of atopy and autoimmunity are aspects of management that require consideration for optimal clinical care and for designing a cogent monitoring approach. New data on atopy are presented to further demonstrate the association.
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Affiliation(s)
- Megan Morsheimer
- Nemours Children's Health System, DuPont Hospital for Children, Wilmington, Delaware
| | - Terri F Brown Whitehorn
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Jennifer Heimall
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Kathleen E Sullivan
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
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13
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Suksawat Y, Sathienkijkanchai A, Veskitkul J, Jirapongsananuruk O, Visitsunthorn N, Vichyanond P, Pacharn P. Resolution of Primary Immune Defect in 22q11.2 Deletion Syndrome. J Clin Immunol 2017; 37:375-382. [DOI: 10.1007/s10875-017-0394-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 04/03/2017] [Indexed: 12/23/2022]
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14
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Reduction of CRKL expression in patients with partial DiGeorge syndrome is associated with impairment of T-cell functions. J Allergy Clin Immunol 2016; 138:229-240.e3. [PMID: 26875746 DOI: 10.1016/j.jaci.2015.10.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 10/07/2015] [Accepted: 10/28/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Partial DiGeorge syndrome (pDGS) is caused by deletion of the 22q11.2 region. Within this region lies CrK-like (CRKL), a gene encoding an adapter protein belonging to the Crk family that is involved in the signaling cascade of IL-2, stromal cell-derived factor 1α, and type I interferon. Although recurrent infections can be observed in patients with deletion of chromosome 22 syndrome, the immune pathogenesis of this condition is yet not fully understood. OBJECTIVE We aimed to investigate the role of CRKL in T-cell functional responses in patients affected with pDGS. METHODS Protein expression levels and phosphorylation of CRKL were evaluated in patients with pDGS. T-cell functional assays in vitro and gene-silencing experiments were also performed. RESULTS CRKL protein expression, as well as its phosphorylation, were reduced in all patients with pDGS, especially on IL-2 stimulation. Moreover, T cells presented impaired proliferation and reduced IL-2 production on anti-CD3/CD28 stimulation and decreased c-Fos expression. Finally, CRKL silencing in Jurkat T cells resulted in impaired T-cell proliferation and reduced c-Fos expression. CONCLUSIONS The impaired T-cell proliferation and reduction of CRKL, phosphorylated CRKL, and c-Fos levels suggest a possible role of CRKL in functional deficiencies of T cells in patients with pDGS.
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Abstract
22q11.2 deletion syndrome (22q11.2DS) is the most common chromosomal microdeletion disorder, estimated to result mainly from de novo non-homologous meiotic recombination events occurring in approximately 1 in every 1,000 fetuses. The first description in the English language of the constellation of findings now known to be due to this chromosomal difference was made in the 1960s in children with DiGeorge syndrome, who presented with the clinical triad of immunodeficiency, hypoparathyroidism and congenital heart disease. The syndrome is now known to have a heterogeneous presentation that includes multiple additional congenital anomalies and later-onset conditions, such as palatal, gastrointestinal and renal abnormalities, autoimmune disease, variable cognitive delays, behavioural phenotypes and psychiatric illness - all far extending the original description of DiGeorge syndrome. Management requires a multidisciplinary approach involving paediatrics, general medicine, surgery, psychiatry, psychology, interventional therapies (physical, occupational, speech, language and behavioural) and genetic counselling. Although common, lack of recognition of the condition and/or lack of familiarity with genetic testing methods, together with the wide variability of clinical presentation, delays diagnosis. Early diagnosis, preferably prenatally or neonatally, could improve outcomes, thus stressing the importance of universal screening. Equally important, 22q11.2DS has become a model for understanding rare and frequent congenital anomalies, medical conditions, psychiatric and developmental disorders, and may provide a platform to better understand these disorders while affording opportunities for translational strategies across the lifespan for both patients with 22q11.2DS and those with these associated features in the general population.
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17
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Fung WLA, Butcher NJ, Costain G, Andrade DM, Boot E, Chow EW, Chung B, Cytrynbaum C, Faghfoury H, Fishman L, García-Miñaúr S, George S, Lang AE, Repetto G, Shugar A, Silversides C, Swillen A, van Amelsvoort T, McDonald-McGinn DM, Bassett AS. Practical guidelines for managing adults with 22q11.2 deletion syndrome. Genet Med 2015; 17:599-609. [PMID: 25569435 PMCID: PMC4526275 DOI: 10.1038/gim.2014.175] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/29/2014] [Indexed: 02/03/2023] Open
Abstract
22q11.2 Deletion syndrome (22q11.2DS) is the most common microdeletion syndrome in humans, estimated to affect up to 1 in 2,000 live births. Major features of this multisystem condition include congenital anomalies, developmental delay, and an array of early- and later-onset medical and psychiatric disorders. Advances in pediatric care ensure a growing population of adults with 22q11.2DS. Informed by an international panel of multidisciplinary experts and a comprehensive review of the existing literature concerning adults, we present the first set of guidelines focused on managing the neuropsychiatric, endocrine, cardiovascular, reproductive, psychosocial, genetic counseling, and other issues that are the focus of attention in adults with 22q11.2DS. We propose practical strategies for the recognition, evaluation, surveillance, and management of the associated morbidities.Genet Med 17 8, 599-609.
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Affiliation(s)
- Wai Lun Alan Fung
- The Dalglish Family Hearts and Minds Clinic for 22q11.2 Deletion Syndrome, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry and Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Nancy J. Butcher
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Costain
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Danielle M. Andrade
- The Dalglish Family Hearts and Minds Clinic for 22q11.2 Deletion Syndrome, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurology, Toronto Western Hospital, Krembil Neurosciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Erik Boot
- The Dalglish Family Hearts and Minds Clinic for 22q11.2 Deletion Syndrome, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry and Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Eva W.C. Chow
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Brian Chung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Cheryl Cytrynbaum
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hanna Faghfoury
- The Fred A. Litwin and Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Leona Fishman
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sixto García-Miñaúr
- Institute of Medical and Molecular Genetics, Hospital Universitario La Paz, Universidad Autónoma de Madrid, IdiPAZ, Madrid, Spain
| | - Susan George
- The Dalglish Family Hearts and Minds Clinic for 22q11.2 Deletion Syndrome, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
| | - Anthony E. Lang
- Division of Neurology, Toronto Western Hospital, Krembil Neurosciences Centre, University of Toronto, Toronto, Ontario, Canada
- The Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Gabriela Repetto
- Center for Genetics and Genomics, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Andrea Shugar
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Candice Silversides
- The Dalglish Family Hearts and Minds Clinic for 22q11.2 Deletion Syndrome, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Obstetric Medicine, Medical Disorders of Pregnancy Program, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ann Swillen
- Center for Human Genetics, University Hospital Gasthuisberg, Leuven, Flanders, Belgium
- Department of Human Genetics, University of Leuven (KU Leuven), Leuven, Flanders, Belgium
| | - Therese van Amelsvoort
- Department of Psychiatry and Psychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Donna M. McDonald-McGinn
- Division of Human Genetics, 22q and You Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Genetics Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne S. Bassett
- The Dalglish Family Hearts and Minds Clinic for 22q11.2 Deletion Syndrome, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Clinical Genetics Research Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry and Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Abstract
Chromosome 22q11 is characterized by the presence of chromosome-specific low-copy repeats or segmental duplications. This region of the chromosome is very unstable and susceptible to mutations. The misalignment of low-copy repeats during nonallelic homologous recombination leads to the deletion of the 22q11.2 region, which results in 22q11 deletion syndrome (22q11DS). The 22q11.2 deletion is associated with a wide variety of phenotypes. The term 22q11DS is an umbrella term that is used to encompass all 22q11.2 deletion-associated phenotypes. The haploinsufficiency of genes located at 22q11.2 affects the early morphogenesis of the pharyngeal arches, heart, skeleton, and brain. TBX1 is the most important gene for 22q11DS. This syndrome can ultimately affect many organs or systems; therefore, it has a very wide phenotypic spectrum. An increasing amount of information is available related to the pathogenesis, clinical phenotypes, and management of this syndrome in recent years. This review summarizes the current clinical and genetic status related to 22q11DS.
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Affiliation(s)
- Bülent Hacıhamdioğlu
- Department of Pediatric Endocrinology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Duygu Hacıhamdioğlu
- Department of Pediatric Nephrology, GATA Haydarpasa Training Hospital, Marmara University, School of Medicine, Istanbul, Turkey
| | - Kenan Delil
- Department of Medical Genetics, Marmara University, School of Medicine, Istanbul, Turkey
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Ferrando-Martínez S, Lorente R, Gurbindo D, De José MI, Leal M, Muñoz-Fernández MA, Correa-Rocha R. Low thymic output, peripheral homeostasis deregulation, and hastened regulatory T cells differentiation in children with 22q11.2 deletion syndrome. J Pediatr 2014; 164:882-9. [PMID: 24461789 DOI: 10.1016/j.jpeds.2013.12.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/29/2013] [Accepted: 12/06/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To perform an extensive analysis of the immune status of asymptomatic children with the 22q11.2 deletion syndrome, with special emphasis on the regulatory T cells (Treg) population. STUDY DESIGN Analysis of thymic function, frequency and absolute counts of immune subsets, and phenotype of Treg were performed in 10 asymptomatic children bearing the 22q11.2 deletion and compared with 12 age-matched, healthy children. RESULTS Children with 22q11.2 deletion syndrome showed a curtailed thymic output, lower T-cell levels, and a homeostatic deregulation in the CD4 T-cell compartment, characterized by a greater proliferative history in the naïve CD4 T-cell subset. Treg numbers were markedly reduced in children with 22q11.2 deletion syndrome, and remaining Treg showed mostly an activated phenotype. CONCLUSIONS Reduced thymic output in children with 22q11.2 deletion syndrome could be related with an increased proliferation in the naïve CD4 T-cell compartment and the consequent Treg activation to ensure that T-cell expansion remains under control. Deregulated peripheral homeostasis and loss of suppressive capacity by Treg could compromise the integrity of T-cell immunity during adulthood and play a relevant role in the increased incidence of autoimmune diseases reported in patients with the 22q11.2 deletion syndrome.
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Affiliation(s)
- Sara Ferrando-Martínez
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Laboratorio de Inmunovirología, Instituto de Biomedicina de Sevilla (IBIS), Unidad clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Raquel Lorente
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | - Dolores Gurbindo
- Sección de Inmunopediatría, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ma Isabel De José
- Servicio de Enfermedades Infecciosas Infantil, Hospital Universitario "La Paz", Madrid, Spain
| | - Manuel Leal
- Laboratorio de Inmunovirología, Instituto de Biomedicina de Sevilla (IBIS), Unidad clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Ma Angeles Muñoz-Fernández
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain; Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - Rafael Correa-Rocha
- Laboratory of Molecular Immunobiology, Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.
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20
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Abstract
Otitis media (OM) is a common cause of childhood hearing loss. The large medical costs involved in treating this condition have meant that research to understand the pathology of this disease and identify new therapeutic interventions is important. There is evidence that susceptibility to OM has a significant genetic component, although little is known about the key genetic pathways involved. Mouse models for disease have become an important resource to understand a variety of human pathologies, including OM, due to the ability to easily manipulate their genetic components. This has enabled researchers to create models of acute OM, and has aided in the identification of a number of new genes associated with chronic disease, through the use of mutagenesis programs. The use of mouse models has identified a number of key molecular signalling pathways involved in the development of this condition, with genes identified from models shown to be associated with human OM.
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Ta-Shma A, El-lahham N, Edvardson S, Stepensky P, Nir A, Perles Z, Gavri S, Golender J, Yaakobi-Simhayoff N, Shaag A, Rein AJJT, Elpeleg O. Conotruncal malformations and absent thymus due to a deleterious NKX2-6 mutation. J Med Genet 2014; 51:268-70. [PMID: 24421281 DOI: 10.1136/jmedgenet-2013-102100] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Truncus arteriosus (TA) accounts for ~1% of congenital heart defects. The aetiology of isolated TA is largely unknown but when occurring as part of a syndrome, it is mostly associated with chromosome 22q11 deletion. Vice versa, the most common congenital heart defects associated with chromosome 22q11 deletion are conotruncal malformations. In this study we investigated the cause of multiple conotruncal malformations accompanied by athymia in a consanguineous family. METHODS AND RESULTS Whole exome analysis revealed a homozygous deleterious mutation in the NKX2-6 gene. CONCLUSIONS NKX2-6 encodes a homeobox-containing protein which is expressed in mouse embryo at E8.0-E9.5 at the caudal pharyngeal arches and the outflow tract. A single missense mutation was previously implicated in the aetiology of familial isolated TA; however, null mice are entirely normal. The clear phenotype associated with a homozygous deleterious mutation in the present report, falls well within the spectrum of the cardiac defects seen in DiGeorge syndrome, is in agreement with NKX2-6 downstream location in the TBX1 signalling pathway and confirms NKX2-6 role in human cardiogenesis.
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Affiliation(s)
- Asaf Ta-Shma
- Department of Pediatric Cardiology, Hadassah, Hebrew University Medical Center, Jerusalem, Israel
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22
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Hagan JB, Wasserman RL, Baggish JS, Spycher MO, Berger M, Shashi V, Lohrmann E, Sullivan KE. Safety ofL-proline as a stabilizer for immunoglobulin products. Expert Rev Clin Immunol 2014; 8:169-78. [DOI: 10.1586/eci.11.97] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Davies EG. Immunodeficiency in DiGeorge Syndrome and Options for Treating Cases with Complete Athymia. Front Immunol 2013; 4:322. [PMID: 24198816 PMCID: PMC3814041 DOI: 10.3389/fimmu.2013.00322] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/23/2013] [Indexed: 11/13/2022] Open
Abstract
The commonest association of thymic stromal deficiency resulting in T-cell immunodeficiency is the DiGeorge syndrome (DGS). This results from abnormal development of the third and fourth pharyngeal arches and is most commonly associated with a microdeletion at chromosome 22q11 though other genetic and non-genetic causes have been described. The immunological competence of affected individuals is highly variable, ranging from normal to a severe combined immunodeficiency when there is complete athymia. In the most severe group, correction of the immunodeficiency can be achieved using thymus allografts which can support thymopoiesis even in the absence of donor-recipient matching at the major histocompatibility loci. This review focuses on the causes of DGS, the immunological features of the disorder, and the approaches to correction of the immunodeficiency including the use of thymus transplantation.
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Affiliation(s)
- E Graham Davies
- Centre for Immunodeficiency, Institute of Child Health, University College London and Great Ormond Street Hospital , London , UK
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Maggadottir SM, Sullivan KE. The diverse clinical features of chromosome 22q11.2 deletion syndrome (DiGeorge syndrome). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:589-94. [PMID: 24565705 DOI: 10.1016/j.jaip.2013.08.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/24/2013] [Accepted: 08/06/2013] [Indexed: 01/15/2023]
Abstract
A 2-year-old boy with chromosome 22q11.2 deletion syndrome was referred for recurrent sinopulmonary infections. He was diagnosed shortly after birth by a fluorescence in situ hybridization test that was performed due to interrupted aortic arch type B. He had no hypocalcemia, and his recovery from cardiac repair was uneventful. He had difficulty feeding and gained weight slowly, but, otherwise, there were no concerns during his first year of life. At 15 months of age, he began to develop significant otitis media and bronchitis. He was hospitalized once for pneumonia at 18 months of age and has never been off antibiotics for more than 1 week since then. He has not had any previous immunologic evaluation. Recurrent sinopulmonary infections in a child with chromosome 22q11.2 deletion syndrome can have the same etiologies as in any other child. Atopy, anatomic issues, cystic fibrosis, and new environmental exposures could be considered in this setting. Early childhood can be problematic for patients with chromosome 22q11.2 deletion syndrome due to unfavorable drainage of the middle ear and sinuses. Atopy occurs at a higher frequency in 22q11.2 deletion syndrome, and these children also have a higher rate of gastroesophageal reflux and aspiration than the general population. As would be appropriate for any child who presents with recurrent infections at 2 years of age, an immunologic evaluation should be performed. In this review, we will highlight recent findings and new data on the management of children and adults with chromosome 22q11.2 deletion syndrome.
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Affiliation(s)
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pa.
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McDonald R, Dodgen A, Goyal S, Gossett JM, Shinkawa T, Uppu SC, Blanco C, Garcia X, Bhutta AT, Imamura M, Gupta P. Impact of 22q11.2 deletion on the postoperative course of children after cardiac surgery. Pediatr Cardiol 2013; 34:341-7. [PMID: 22864648 DOI: 10.1007/s00246-012-0454-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 07/13/2012] [Indexed: 11/27/2022]
Abstract
The primary objective of this study was to describe the impact of 22q11.2 deletion (del22q11) on the clinical characteristics, postoperative course, and short-term outcomes of children undergoing surgery for congenital heart disease. The charts of all children ages 1 day-18 years who received cardiac surgery for interrupted aortic arch (IAA), tetralogy of Fallot (TOF), or truncus arteriosus (TA) repair from 1 January 2001 to 31 December 2011 were retrospectively reviewed. The patients were divided into two groups: the 22q11 group including children with del22q11 undergoing surgery for TOF, IAA, or TA and the non-22q11 or control group including children with no chromosomal or genetic abnormality undergoing surgery for TOF, IAA, or TA. Demographic information, cardiac diagnoses, noncardiac abnormalities, preoperative factors, intraoperative details, surgical procedures performed, postoperative complications, and in-hospital deaths were collected. The outcome data collected included days of inotrope use, need for dialysis, length of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. The study enrolled 173 patients: 65 patients in the 22q11 group and 108 patients in the control group. Of the 65 patients in the 22q11 group, 36 (55 %) underwent repair for TOF, 13 (20 %) for IAA, and 16 (25 %) for TA. The two groups did not differ in terms of age or weight. The preexisting conditions were similar in the two groups. Unplanned noncardiac operations were more common in the children with del22q11, but delayed chest closure was similar in the two groups. The incidence of postoperative noncardiac complications such as reintubation, vocal cord paralysis, and diaphragmatic paralysis was similar in the two groups. However, increasing numbers of patients in del22q11 group needed dialysis in one form or the other during the immediate postoperative stay. The incidence of fungal infection and wound infection was higher in the del22q11 group than in the control group. Duration of mechanical ventilation, ICU LOS, and hospital LOS were similar in the two groups, except in certain subgroups. Mortality did not differ significantly between the two groups. In conclusion, children with del22q11 have a higher risk of postoperative complications after cardiac surgery, with no difference in length of mechanical ventilation, ICU LOS, hospital LOS, or mortality. However, short-term outcomes may differ in certain subgroups.
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Affiliation(s)
- Rachel McDonald
- Division of Pediatric Cardiology, University of Arkansas Medical Center, Little Rock, AR, USA
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Patel K, Akhter J, Kobrynski L, Benjamin Gathmann MA, Davis O, Sullivan KE. Immunoglobulin deficiencies: the B-lymphocyte side of DiGeorge Syndrome. J Pediatr 2012; 161:950-3. [PMID: 22809661 DOI: 10.1016/j.jpeds.2012.06.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/17/2012] [Accepted: 06/07/2012] [Indexed: 11/16/2022]
Abstract
DiGeorge syndrome is associated with a T-lymphocyte immunodeficiency. The prevalence of hypogammaglobulinemia has not been reported. We found that 3% of patients with DiGeorge syndrome were receiving immunoglobulin replacement therapy and 6% of patients over the age of 3 years had hypogammaglobulinemia. We conclude that DiGeorge syndrome is associated with significant humoral immune deficiency.
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Affiliation(s)
- Kiran Patel
- Division of Allergy Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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27
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Zrnová E, Vranová V, Soukalová J, Slámová I, Vilémová M, Gaillyová R, Kuglík P. Unique Combination of 22q11 and 14qter Microdeletion Syndromes Detected Using Oligonucleotide Array-CGH. Mol Syndromol 2012; 2:88-93. [PMID: 22511897 DOI: 10.1159/000335334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2011] [Indexed: 11/19/2022] Open
Abstract
We report an infant with a unique combination of 22q11 deletion syndrome and 14q terminal deletion syndrome. The proband had clinical symptoms compatible with diagnosis of 22q11 deletion syndrome: microcephaly, micrognathia, high-arched palate, hypertelorism, short palpebral fissures, square nasal root, prominent tubular nose, hypoplastic nasal alae, bulbous nasal tip, dysplastic low-set ears, short philtrum, and heart defect, but no cell-mediated immunodeficiency typical for the syndrome. G-banding and fluorescence in situ hybridization analyses revealed a karyotype 45,XY,der(14)t(14;22)(q32.3;q11.2),-22.ish del(14)(q32.33)(D14S1420-),del(22)(q11.2q11.2)(N25-). Subsequent analyses disclosed a translocation between chromosomes 14 and 22 in the proband's mother with a deleted 14q telomere. Using comparative genome hybridization on oligonucleotide-based microarray (array-CGH), the deletion at 22q11.21 in the size of ∼4.25 Mb was revealed in the proband as well as the deletion of the telomeric area at 14q32.33qter (∼3.24 Mb) in the proband and his mother. However, both the proband and his mother showed mild symptoms (microcephaly, thin lips, carp-shaped mouth) typical for patients with the described terminal 14q deletion syndrome.
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Affiliation(s)
- E Zrnová
- Department of Genetics and Molecular Biology, Institute of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
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Gennery AR. Immunological aspects of 22q11.2 deletion syndrome. Cell Mol Life Sci 2012; 69:17-27. [PMID: 21984609 PMCID: PMC11114664 DOI: 10.1007/s00018-011-0842-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 12/16/2022]
Abstract
Chromosome 22q11 deletion is the most common chromosomal deletion syndrome and is found in the majority of patients with DiGeorge syndrome and velo-cardio-facial syndrome. Patients with CHARGE syndrome may share similar features. Cardiac malformations, speech delay, and immunodeficiency are the most common manifestations. The immunological phenotype may vary widely between patients. Severe T lymphocyte immunodeficiency is rare-thymic transplantation offers a new approach to treatment, as well as insights into thymic physiology and central tolerance. Combined partial immunodeficiency is more common, leading to recurrent sinopulmonary infection in early childhood. Autoimmunity is an increasingly recognized complication. New insights into pathophysiology are reviewed.
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Affiliation(s)
- A R Gennery
- Institute of Cellular Medicine, Old Children's Outpatients, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
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Gambineri E. New frontiers in primary immunodeficiency disorders: immunology and beyond…. Cell Mol Life Sci 2012; 69:1-5. [PMID: 22009453 PMCID: PMC11115097 DOI: 10.1007/s00018-011-0833-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 11/24/2022]
Affiliation(s)
- Eleonora Gambineri
- Department of Sciences for Woman and Child's Health, Anna Meyer Children's Hospital, Haematology-Oncology Department, BMT Unit, University of Florence, Viale Gaetano Pieraccini, 24, 50139 Florence, Italy.
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Predicting 22q11.2 deletion syndrome: A novel method using the routine full blood count. Int J Cardiol 2011; 150:50-3. [DOI: 10.1016/j.ijcard.2010.02.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 02/07/2010] [Accepted: 02/13/2010] [Indexed: 11/22/2022]
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McLean-Tooke A, Barge D, Spickett GP, Gennery AR. Flow Cytometric Analysis of TCR Vβ Repertoire in Patients with 22q11.2 Deletion Syndrome. Scand J Immunol 2011; 73:577-85. [DOI: 10.1111/j.1365-3083.2011.02527.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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McDonald-McGinn DM, Sullivan KE. Chromosome 22q11.2 deletion syndrome (DiGeorge syndrome/velocardiofacial syndrome). Medicine (Baltimore) 2011; 90:1-18. [PMID: 21200182 DOI: 10.1097/md.0b013e3182060469] [Citation(s) in RCA: 268] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Chromosome 22q11.2 deletion syndrome is a common syndrome also known as DiGeorge syndrome and velocardiofacial syndrome. It occurs in approximately 1:4000 births, and the incidence is increasing due to affected parents bearing their own affected children. The manifestations of this syndrome cross all medical specialties, and care of the children and adults can be complex. Many patients have a mild to moderate immune deficiency, and the majority of patients have a cardiac anomaly. Additional features include renal anomalies, eye anomalies, hypoparathyroidism, skeletal defects, and developmental delay. Each child's needs must be tailored to his or her specific medical problems, and as the child transitions to adulthood, additional issues will arise. A holistic approach, addressing medical and behavioral needs, can be very helpful.
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Lima K, Abrahamsen TG, Foelling I, Natvig S, Ryder LP, Olaussen RW. Low thymic output in the 22q11.2 deletion syndrome measured by CCR9+CD45RA+ T cell counts and T cell receptor rearrangement excision circles. Clin Exp Immunol 2010; 161:98-107. [PMID: 20491792 DOI: 10.1111/j.1365-2249.2010.04152.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Thymic hypoplasia is a frequent feature of the 22q11.2 deletion syndrome, but we know little about patients' age-related thymic output and long-term consequences for their immune system. We measured the expression of T cell receptor rearrangement excision circles (TREC) and used flow cytometry for direct subtyping of recent thymic emigrant (RTE)-related T cells in 43 patients (aged 1-54 years; median 9 years) from all over Norway and in age-matched healthy controls. Thymic volumes were estimated by ultrasound in patients. TREC levels correlated well with RTE-related T cells defined by co-expression of CD3, CD45RA and CCR9 (r=0.84) as well as with the CD4+ and CD8+ T cell subtypes. RTE-related T cell counts also paralleled age-related TREC reductions. CD45RA+ T cells correlated well with absolute counts of CD4+ (r=0.87) and CD8+ (r=0.75) RTE-related T cells. Apart from CD45RA- T cells, all T cell subsets were lower in patients than in controls. Thymic volumes correlated better with RTE-related cells (r=0.46) than with TREC levels (r=0.38). RTE-related T cells and TREC levels also correlated well (r=0.88) in patients without an identifiable thymus. Production of RTEs is impaired in patients with a 22q11.2 deletion, and CCR9 appears to be a good marker for RTE-related T cells.
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Affiliation(s)
- K Lima
- Section of Endocrinology, Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway.
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Markert ML, Devlin BH, McCarthy EA. Thymus transplantation. Clin Immunol 2010; 135:236-46. [PMID: 20236866 DOI: 10.1016/j.clim.2010.02.007] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 02/12/2010] [Accepted: 02/12/2010] [Indexed: 11/29/2022]
Abstract
Thymus transplantation is a promising investigational therapy for infants born with no thymus. Because of the athymia, these infants lack T cell development and have a severe primary immunodeficiency. Although thymic hypoplasia or aplasia is characteristic of DiGeorge anomaly, in "complete" DiGeorge anomaly, there is no detectable thymus as determined by the absence of naive (CD45RA(+), CD62L(+)) T cells. Transplantation of postnatal allogeneic cultured thymus tissue was performed in sixty subjects with complete DiGeorge anomaly who were under the age of 2 years. Recipient survival was over 70%. Naive T cells developed 3-5 months after transplantation. The graft recipients were able to discontinue antibiotic prophylaxis, and immunoglobulin replacement. Immunosuppression was used in a subset of subjects but was discontinued when naive T cells developed. The adverse events have been acceptable with thyroid disease being the most common. Research continues on mechanisms underlying immune reconstitution after thymus transplantation.
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Affiliation(s)
- M Louise Markert
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
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McDonald-McGinn DM, Zackai EH. Genetic counseling for the 22q11.2 deletion. ACTA ACUST UNITED AC 2008; 14:69-74. [PMID: 18636638 DOI: 10.1002/ddrr.10] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Because of advances in palliative medical care, children with the 22q11.2 deletion syndrome are surviving into adulthood. An increase in reproductive fitness will likely follow necessitating enhanced access to genetic counseling for these patients and their families. Primary care physicians/obstetric practitioners are in a unique position to identify previously undiagnosed patients as they reach reproductive age and to refer them for genetic counseling. To date, most deletions are de novo, secondary to homologous recombination between low-copy repeat sequences located within 22q11.2. Nonetheless, both somatic and germ line mosaicism has been observed giving unaffected parents a small risk of recurrence. Once present though there is a 50% chance for a person with this contiguous deletion to have an affected child. With this in mind, a variety of prenatal monitoring techniques, as well as, preimplantation genetic diagnosis are available depending on the specific level of risk.
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Affiliation(s)
- Donna M McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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A 39-year-old father is diagnosed in adulthood as having partial DiGeorge anomaly with a combined T- and B-cell immunodeficiency after diagnosis of the condition in his daughter. Ann Allergy Asthma Immunol 2008; 100:620-1. [PMID: 18592832 DOI: 10.1016/s1081-1206(10)60066-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sullivan KE. Chromosome 22q11.2 deletion syndrome: DiGeorge syndrome/velocardiofacial Syndrome. Immunol Allergy Clin North Am 2008; 28:353-66. [PMID: 18424337 DOI: 10.1016/j.iac.2008.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
DiGeorge syndrome, or chromosome 22q11.2 deletion syndrome, is a disorder affecting multiple organ systems. The immunologist may be called on to coordinate complex medical care tailored to the specific needs and unique clinical features of each patient. This article focuses on the immune system, but patients require a holistic approach. Attention to cardiac, nutritional, and developmental needs in early infancy is important, and it is critical to identify the rare infants who require either a lymphocyte or thymus transplant. Later, speech and school issues dominate the picture. Allergies and autoimmune disorders also may be troubling for some school-age children.
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Affiliation(s)
- Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA.
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Markert ML, Devlin BH, Chinn IK, McCarthy EA, Li YJ. Factors affecting success of thymus transplantation for complete DiGeorge anomaly. Am J Transplant 2008; 8:1729-36. [PMID: 18557726 PMCID: PMC3667673 DOI: 10.1111/j.1600-6143.2008.02301.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Thymus transplantation shows promise for the treatment of athymia in complete DiGeorge anomaly. This report reviews the effects of dose of thymus tissue, ABO compatibility, HLA matching, culture conditions, age of donor and immunosuppression of recipient on immune outcomes at 1 year after transplantation. Forty-nine athymic subjects have been treated with cultured postnatal allogeneic thymus tissue; 36 (73%) survive with only one subject on immunosuppression at 1.5 years. Of 31 surviving subjects more than 1 year after transplantation, 30 (97%) developed naive T cells, T-cell proliferative responses to mitogens and a diverse T-cell receptor beta variable (TCRBV) repertoire. The dose of thymus tissue, HLA matching and use of immunosuppression had nonsignificant effects on these outcome variables. Removal of deoxyguanosine from culture medium and length of culture did not adversely affect outcomes. Use of thymus tissue from donors over 1 month of age, versus under 1 month, resulted in higher total T-cell numbers (p = 0.03). However, this finding must be confirmed in a prospective trial. Although subtle immune effects may yet be associated with some of the factors tested, it is remarkable that consistently good immune outcomes result despite variation in dose, HLA matching and use of immunosuppression.
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Affiliation(s)
- M L Markert
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.
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Immunologic defects in 22q11.2 deletion syndrome. J Allergy Clin Immunol 2008; 122:362-7, 367.e1-4. [PMID: 18485468 DOI: 10.1016/j.jaci.2008.03.033] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 03/28/2008] [Accepted: 03/28/2008] [Indexed: 01/07/2023]
Abstract
BACKGROUND 22q11.2 Deletion syndrome, the most common congenital chromosome deletion syndrome, is associated with developmental defects including cardiac abnormalities and hypoplasia or abnormal migration of the thymus. These patients have variable defects in T-cell immunity with an increased incidence of infection and autoimmune disease. OBJECTIVE To investigate the immunologic constitution of children with 22q11.2 deletion syndrome. METHODS We characterized the immunologic constitution of 27 children with 22q11.2 deletion syndrome and 54 healthy controls by flow-cytometric analysis of peripheral blood lymphocyte populations. RESULTS Patients exhibited decreased T-cell numbers, although the normal age-related decrease in T-cell numbers was slower than in healthy children. There was a significant decrease in FoxP3(+) natural regulatory T (nTreg) cells with a strong correlation between nTreg cells and recent T-cell emigrants from the thymus, suggesting a link between the nTreg cell population and thymic function. Although total B-cell numbers were unaffected, patients showed a significantly decreased proportion of memory B cells in the B-cell pool. CONCLUSION Lower nTreg cells in patients suggest that the generation and maintenance of these cells in children is related to thymic function. In addition to T-cell abnormalities classically seen in this syndrome, subtle defects in the B-cell compartment may also be seen.
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Cichocki M, Singer G, Beyerlein S, Zeder SL, Schober P, Höllwarth M. A case of necrotizing enterocolitis associated with adenovirus infection in a term infant with 22q11 deletion syndrome. J Pediatr Surg 2008; 43:e5-8. [PMID: 18405699 DOI: 10.1016/j.jpedsurg.2007.11.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 11/12/2007] [Accepted: 11/14/2007] [Indexed: 11/26/2022]
Abstract
Infections with adenoviruses are a common problem in the pediatric population. Normally asymptomatic to mild, those infections tend to take a more severe course in immunocompromised patients. 22q11 deletion syndrome (22q11DS) represents a common genetic disorder causing immunodeficiency from thymic hypoplasia or aplasia, heart defects, a characteristic facial appearance, and velopharyngeal dysfunction. Necrotizing enterocolitis (NEC) is a frequent gastrointestinal emergency observed in neonatal intensive care units. The occurrence of NEC is more prevalent in preterm infants. However, there are cases in term infants, but usually, they are associated with predisposing disorders. In this case report, a child is presented with 22q11DS that postnatally developed NEC associated with an adenoviral infection. Although other viruses such as toroviruses or cytomegaloviruses have been implicated in the pathogenesis of NEC in preterm infants, we could not find any report in the recent medical literature describing an association between adenoviral infections, NEC, and 22q11DS in a term infant.
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Affiliation(s)
- Martin Cichocki
- Department of Pediatric Surgery, Medical University of Graz, 8036 Graz, Austria.
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Abstract
Velocardiofacial syndrome, DiGeorge syndrome, and some other clinical syndromes have in common a high frequency of hemizygous deletions of chromosome 22q11.2. This deletion syndrome is very common, affecting nearly one in 3000 children. Here, we focus on recent advances in cardiac assessment, speech, immunology, and pathophysiology of velocardiofacial syndrome. The complex medical care of patients needs a multidisciplinary approach, and every patient has his own unique clinical features that need a tailored approach. Patients with chromosome 22q11.2 deletion syndrome might have high level of functioning, but most often need interventions to improve the function of many organ systems.
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Affiliation(s)
- Lisa J Kobrynski
- Department of Pediatrics, Allergy and Immunology Section, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
22q11.2 deletion syndrome is the commonest chromosome deletion syndrome. 22q11.2 deletion may result in variable clinical phenotypes which may differ even between patients with identical deletions. Abnormal pharyngeal arch development results in defects in the development of the parathyroid glands, thymus and conotruncal region of the heart. Defective thymic development is associated with impaired immune function. 'Complete' DiGeorge syndrome with total absence of the thymus and a severe T-cell immunodeficiency accounts for <0.5% of patients. The majority of patients with 22q11.2 deletion syndromes have 'partial' defects with impaired thymic development rather than complete absence with variable defects in T-cell numbers. Immunodeficiency in these patients is not solely due to T-cell deficiency and abnormalities of T-cell clonality or impairment of proliferative responses may play a role. Humoral deficiencies including defects in the B-cell compartment have also been identified in these patients. 22q11.2 deletion syndrome patients are at increased risk of a variety of autoimmune diseases. A number of immune defects may predispose to the development of autoimmunity in these patients including increased infection, impaired development of natural T-regulatory cells and impaired thymic central tolerance.
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Affiliation(s)
- A McLean-Tooke
- Department of Immunology, Royal Victoria InfirmaryDepartment of Paediatric Immunology, Newcastle General Hospital, Newcastle-Upon-Tyne, UK
| | - G P Spickett
- Department of Immunology, Royal Victoria InfirmaryDepartment of Paediatric Immunology, Newcastle General Hospital, Newcastle-Upon-Tyne, UK
| | - A R Gennery
- Department of Immunology, Royal Victoria InfirmaryDepartment of Paediatric Immunology, Newcastle General Hospital, Newcastle-Upon-Tyne, UK
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Jatana V, Gillis J, Webster BH, Adès LC. Deletion 22q11.2 syndrome--implications for the intensive care physician. Pediatr Crit Care Med 2007; 8:459-63; quiz 464. [PMID: 17873780 DOI: 10.1097/01.pcc.0000290023.89437.58] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report on the experience of a pediatric intensive care unit (PICU) with patients with deletion 22q11.2 syndrome: 1) to delineate the clinical characteristics and management of these patients; 2) to assess whether these patients were managed appropriately, especially in terms of blood transfusion; and 3) to make recommendations for PICU management. DESIGN Retrospective assessment of medical records of patients with fluorescent in situ hybridization-proven 22q11 deletion admitted to the PICU at the Children's Hospital at Westmead, Sydney. SETTING PICU in a tertiary university-affiliated children's hospital. PATIENTS Sixty-five consecutive admissions in 40 patients with diagnosis of 22q11 deletion over a 4-yr period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirty-seven (57%) of 65 admissions were postoperative cardiac surgical and accounted for the most common reason for admission to the PICU. Thirteen (20%) admissions were for velopharyngeal/laryngeal problems. Four (6%) admissions were associated with hypocalcemia, with two being first presentations. Five (12.5%) of 40 patients had immune dysfunction, one of whom developed cytomegalovirus pneumonitis. Twenty-nine (72.5%) patients received blood products either immediately before PICU admission or in the PICU. Of these, 16 received nonirradiated cellular blood products. There were two deaths from complications of congenital heart disease. CONCLUSIONS PICUs need to be familiar with deletion 22q11.2 syndrome, especially the recommended use of irradiated and cytomegalovirus-seronegative blood components in these immunocompromised patients. The guidelines were inconsistently followed in the cohort of patients reported here. The extent of this problem may be more widespread in PICUs, and we recommend that individual units review their practice in this regard. Hypocalcemia may manifest at any time, and a regular survey of the calcium status is required in the intensive care setting. Admission to PICU should afford the opportunity to invite subspecialty referral and optimize extended care.
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Affiliation(s)
- Vishal Jatana
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, New South Wales, Australia.
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Klingberg G, Lingström P, Oskarsdóttir S, Friman V, Bohman E, Carlén A. Caries-related saliva properties in individuals with 22q11 deletion syndrome. ACTA ACUST UNITED AC 2007; 103:497-504. [PMID: 17234437 DOI: 10.1016/j.tripleo.2006.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Revised: 09/04/2006] [Accepted: 09/25/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aims were to compare saliva secretion rate, buffer capacity, cariogenic bacteria, total protein, IgA, and electrolytes between patients with 22q11 deletion syndrome (22q11DS) and control subjects and to study correlations between saliva and serum levels of IgA and electrolytes in 22q11DS patients. STUDY DESIGN Twenty-nine consecutive 22q11DS patients (mean age 12.6 years) and matched healthy control subjects were clinically examined, and stimulated saliva samples were collected. RESULTS Patients with 22q11DS had impaired salivary secretion rate (P < .01) and buffer capacity (P < .05), higher numbers of cariogenic bacteria (P < .01), increased saliva protein concentrations (P < .001), and reduced output of electrolytes (P < .001-.05) compared with control subjects. A correlation between concentration in serum and saliva was found only for IgA (r = .622; P < .01). CONCLUSIONS Different salivary components were affected in patients with 22q11DS, which may explain the increased caries risk seen in these patients.
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Al-Jenaidi F, Makitie O, Grunebaum E, Sochett E. Parathyroid gland dysfunction in 22q11.2 deletion syndrome. HORMONE RESEARCH 2006; 67:117-22. [PMID: 17057408 DOI: 10.1159/000096421] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 07/07/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND 22q11 deletion syndrome (22q11DS) is characterized by conotruncal cardiac defects and hypoplasia of parathyroid glands and thymus, which result in variable hypoparathyroidism (HPT) and immune deficiency. METHODS To study the course of HPT and the spectrum of other associated manifestations we evaluated all patients with 22q11DS, confirmed by fluorescence in situ hybridization, and HPT who were under follow-up at the Calcium-bone clinic, The Hospital for Sick Children, Toronto. Patients were clinically assessed and their hospital records were reviewed. RESULTS Eighteen patients were included. At follow-up assessment at median age of 7.3 years HPT was judged complete in 11 (61%) and partial in 7 patients (39%). Patients with complete HPT presented with hypocalcemia later (median age at diagnosis 2.4 vs. 0.0 years) and more often with a hypocalcemic seizure than patients with partial HPT (73 vs. 29%). The spectrum of other associated manifestations did not differ between the groups. CONCLUSIONS HPT in patients with 22q11DS is often partial. Many of the patients present with a hypocalcemic seizure which is predictive of complete HPT. Patients with complete and partial HPT do not differ in respect to their other associated features. Patients with features of 22q11DS should be actively screened for hypocalcemia to prevent development of symptomatic hypocalcemia.
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Affiliation(s)
- Fayza Al-Jenaidi
- Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Finocchi A, Di Cesare S, Romiti ML, Capponi C, Rossi P, Carsetti R, Cancrini C. Humoral immune responses and CD27+ B cells in children with DiGeorge syndrome (22q11.2 deletion syndrome). Pediatr Allergy Immunol 2006; 17:382-8. [PMID: 16846458 DOI: 10.1111/j.1399-3038.2006.00409.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The spectrum of T-cell abnormalities in 22q11.2 syndrome is quite broad, ranging from profound and life threatening to non-existent defects. Humoral abnormalities have been described in some of these patients, although no data are currently available on their phenotypical and functional B cell subsets. The purpose of this study was to investigate humoral immune function in a cohort of 13 children with DiGeorge syndrome by immunophenotyping B and by analysing their functionality in vivo. Humoral immunity was assessed by serum immunoglobulin evaluation, IgG subclasses determination, and testing of specific antibody titers to recall antigens. B cells were analyzed by flow cytometry and the relevant percentage of membrane surface expression of CD27, IgM, IgD was evaluated. In our cohort, one of 13 children (7.7%) had a complete IgA deficiency, four of 13 (30.7%) had minor immunoglobulin abnormalities, and five (38%) had an impaired production of specific antibodies. Five of 13 children (38%) had recurrent infections. Interestingly, peripheral CD27+ B cells were reduced in our patients as compared with age-matched healthy controls, and this decrement was statistically significant for IgM+ IgD+ CD27+ B cells. Immunoglobulin abnormalities were associated with the occurrence of recurrent infections. We conclude that a significant proportion of patients with DiGeorge syndrome have defective humoral immunity, which may represent an additional pathogenic mechanism underlying the increased susceptibility to infections. Whether the decreased CD27+ B-cell subset might be one of the defects that contribute to impaired humoral immunity, and to susceptibility to infection remains to be elucidated.
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Affiliation(s)
- A Finocchi
- Department of Paediatrics, Tor Vergata University, Rome, Italy.
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Sullivan KE. The clinical, immunological, and molecular spectrum of chromosome 22q11.2 deletion syndrome and DiGeorge syndrome. Curr Opin Allergy Clin Immunol 2006; 4:505-12. [PMID: 15640691 DOI: 10.1097/00130832-200412000-00006] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW New findings regarding the clinical manifestations and care of patients with DiGeorge syndrome or chromosome 22q11.2 deletion syndrome will be reviewed. Immunologists and primary care providers often are in a position to coordinate the complex care needs of these patients and an awareness of the clinical features is essential. RECENT FINDINGS DiGeorge syndrome typically occurs in association with a hemizygous deletion of chromosome 22q11.2. Approximately 5-10% of patients with the clinical entity of DiGeorge syndrome do not have the deletion. Recent evidence indicates that the T cell compartment in both patients with the deletion and patients with clinical DiGeorge syndrome without the deletion is less robust than is often indicated by standard T cell enumeration. SUMMARY This past year has seen a dramatic increase in our understanding of the clinical features of patients with the deletion. Advances in our understanding of the immunodeficiency have been particularly exciting and clinicians should be aware of the characteristics of the immunodeficiency and its changes with age.
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Affiliation(s)
- Kathleen E Sullivan
- Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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48
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Kanaya Y, Ohga S, Ikeda K, Furuno K, Ohno T, Takada H, Kinukawa N, Hara T. Maturational alterations of peripheral T cell subsets and cytokine gene expression in 22q11.2 deletion syndrome. Clin Exp Immunol 2006; 144:85-93. [PMID: 16542369 PMCID: PMC1809624 DOI: 10.1111/j.1365-2249.2006.03038.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chromosome 22q11.2 deletion syndrome is a common disorder characterized by thymic hypoplasia, conotruncal cardiac defect and hypoparathyroidism. Patients have a risk of infections and autoimmunity associated with T lymphocytopenia. To assess the immunological constitution of patients, the numerical changes and cytokine profile of circulating T cells were analysed by flow cytometry and real-time polymerase chain reaction (PCR). CD3+, CD4+, T cell receptor (TCR)alphabeta+ or CD8alphaalpha+ cell counts were lower, and CD56+ cell counts were higher in patients than in controls during the period from birth to adulthood. The ageing decline of CD3+ or CD4+ cell counts was slower in patients than in controls. The proportion of CD8alphaalpha+ cells increased in controls, and the slope index was larger than in patients. On the other hand, both the number and proportion of Valpha24+ cells increased in patients, and the slope indexes tended to be larger than in controls. The positive correlation of the number of T cells with CD8alphaalpha+ cells was observed only in patients, and that with Valpha24+ cells was seen only in controls. No gene expression levels of interferon (IFN)-gamma, interleukin (IL)-10, transforming growth factor (TGF)-beta, cytotoxic T lymphocyte antigen 4 (CTLA4) or forkhead box p3 (Foxp3) in T cells differed between patients and controls. There was no significant association between the lymphocyte subsets or gene expression levels and clinical phenotype including the types of cardiac disease, hypocalcaemia and frequency of infection. These results indicated that T-lymphocytopenia in 22q11.2 deletion patients became less severe with age under the altered composition of minor subsets. The balanced cytokine profile in the limited T cell pool may represent a T cell homeostasis in thymic deficiency syndrome.
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MESH Headings
- Adolescent
- Adult
- Aging/genetics
- Aging/immunology
- Antigens, CD
- Antigens, Differentiation/analysis
- CD3 Complex/immunology
- CD4-Positive T-Lymphocytes
- CD8-Positive T-Lymphocytes/immunology
- CTLA-4 Antigen
- Child
- Child, Preschool
- Chromosome Deletion
- Chromosomes, Human, Pair 22/genetics
- Chromosomes, Human, Pair 22/immunology
- Cytokines/immunology
- DiGeorge Syndrome/genetics
- DiGeorge Syndrome/immunology
- Female
- Forkhead Transcription Factors/analysis
- Gene Expression/genetics
- Gene Expression/immunology
- Humans
- Infant
- Interferon-gamma/analysis
- Interleukin-10/analysis
- Lymphocyte Count
- Male
- RNA, Messenger/analysis
- Receptors, Antigen, T-Cell/immunology
- T-Lymphocytes/immunology
- Transforming Growth Factor beta/analysis
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Affiliation(s)
- Y Kanaya
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Maidashi, Fukuoka, Japan
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49
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Paylor R, Lindsay E. Mouse models of 22q11 deletion syndrome. Biol Psychiatry 2006; 59:1172-9. [PMID: 16616724 DOI: 10.1016/j.biopsych.2006.01.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Revised: 01/26/2006] [Accepted: 01/27/2006] [Indexed: 11/17/2022]
Abstract
22q11 deletion syndrome (22q11DS) is caused by an interstitial chromosomal microdeletion that encompasses about 40 genes. It is the most common of the microdeletion syndromes. The clinical phenotype, which is complex and variable, includes specific congenital defects of the cardiovascular system, craniofacies, and immune system. In early childhood, patients manifest cognitive impairment, behavioral disorders, and delays in motor development and language acquisition. Adult patients have a high risk for developing serious psychiatric disorders, especially schizophrenia, schizoaffective disorder, and bipolar disorder. The great majority of patients have an identical or near identical chromosomal deletion, and genotype-phenotype correlations have not been established. Indeed, little progress was made toward resolving the complex clinical phenotype until the deletion was successfully modeled in the mouse. In recent years, through a variety of mouse mutants that carry multigene and single gene mutations, we have learned that mutation in a single gene, Tbx1, is responsible for most of the congenital defects seen in the mouse models and in patients. We now face a greater challenge as we attempt to use the mouse to address the pathogenesis of the behavioral and psychiatric disorders associated with 22q11DS. Significant progress has already been made, and recent studies in the mouse suggest that several genes from the deleted region affect behavior and might contribute to disease burden in patients.
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Affiliation(s)
- Richard Paylor
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas 77030, USA
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Abstract
Most patients with the clinical features of DiGeorge, velocardiofacial, and conotruncal anomaly face syndromes share a common genetic cause, namely, a deletion of chromosome 22q11, and define the most common deletion syndrome known at this time. The clinical features of the 22q11 deletion syndrome are highly variable between individuals; some have subtle findings, whereas others are severely affected. The most common clinical features include specific types of congenital heart disease, hypocalcemia, immunodeficiency, facial dysmorphia, palate anomalies, velopharyngeal dysfunction, renal anomalies, and speech and feeding disorders as well as neurocognitive, behavioral, and psychiatric disorders. A significant number of patients with tetralogy of Fallot, truncus arteriosus, an interrupted aortic arch, isolated aortic arch anomalies, and perimembranous ventricular septal defects have a 22q11 deletion. Routine testing for a 22q11 deletion in this subset of patients should be considered to provide anticipatory medical intervention and appropriate family counseling.
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Affiliation(s)
- Elizabeth Goldmuntz
- Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104-4318, USA.
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