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Marri L, Contini P, Ivaldi F, Schiavi C, Magnani O, Vassallo C, Guastalla A, Traversone N, Angelini C, Del Zotto G, De Maria A, De Palma R. Evaluation of Frequency of CMV Replication and Disease Complications Reveals New Cellular Defects and a Time Dependent Pattern in CVID Patients. J Clin Immunol 2024; 44:142. [PMID: 38847943 PMCID: PMC11161436 DOI: 10.1007/s10875-024-01744-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE Common Variable Immunodeficiency (CVID) is characterized by hypogammaglobulinemia and failure of specific antibody production due to B-cell defects. However, studies have documented various T-cell abnormalities, potentially linked to viral complications. The frequency of Cytomegalovirus (CMV) replication in CVID cohorts is poorly studied. To address this gap in knowledge, we set up an observational study with the objectives of identifying CVID patients with active viraemia (CMV, Epstein-Barr virus (EBV)), evaluating potential correlations with immunophenotypic characteristics, clinical outcome, and the dynamic progression of clinical phenotypes over time. METHODS 31 CVID patients were retrospectively analysed according to viraemia, clinical and immunologic characteristics. 21 patients with non CVID humoral immunodeficiency were also evaluated as control. RESULTS Active viral replication of CMV and/or EBV was observed in 25% of all patients. CMV replication was detected only in CVID patients (16%). CVID patients with active viral replication showed reduced HLA-DR+ NK counts when compared with CMV-DNA negative CVID patients. Viraemic patients had lower counts of LIN-DNAMbright and LIN-CD16+ inflammatory lymphoid precursors which correlated with NK-cell subsets. Analysis of the dynamic progression of CVID clinical phenotypes over time, showed that the initial infectious phenotype progressed to complicated phenotypes with time. All CMV viraemic patients had complicated disease. CONCLUSION Taken together, an impaired production of inflammatory precursors and NK activation is present in CVID patients with active viraemia. Since "Complicated" CVID occurs as a function of disease duration, there is need for an accurate evaluation of this aspect to improve classification and clinical management of CVID patients.
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Affiliation(s)
- Luca Marri
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
- Unit of Clinical Immunology and Translational Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Paola Contini
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Federico Ivaldi
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Chiara Schiavi
- Unit of Clinical Immunology and Translational Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ottavia Magnani
- Unit of Clinical Immunology and Translational Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Chiara Vassallo
- Unit of Clinical Immunology and Translational Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Guastalla
- Unit of Clinical Immunology and Translational Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Noemi Traversone
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
- Unit of Clinical Immunology and Translational Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Claudia Angelini
- Institute for Applied Mathematics "Mauro Picone", National Research Council, Naples, Italy
| | - Genny Del Zotto
- Integrated Department of Services and Laboratories, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea De Maria
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
- Infections in Immunocompromised Host Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Raffaele De Palma
- Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy.
- Unit of Clinical Immunology and Translational Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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Chan S, Godsell J, Horton M, Farchione A, Howson LJ, Margetts M, Jin C, Chatelier J, Yong M, Sasadeusz J, Douglass JA, Slade CA, Bryant VL. Case Report: Cytomegalovirus Disease Is an Under-Recognized Contributor to Morbidity and Mortality in Common Variable Immunodeficiency. Front Immunol 2022; 13:815193. [PMID: 35242131 PMCID: PMC8885594 DOI: 10.3389/fimmu.2022.815193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Common Variable Immunodeficiency (CVID) is classified as a ‘Predominantly Antibody Deficiency’ (PAD), but there is emerging evidence of cellular immunodeficiency in a subset of patients. This evidence includes CVID patients diagnosed with cytomegalovirus (CMV) infection, a hallmark of ‘combined immunodeficiency’. CMV infection also has the potential to drive immune dysregulation contributing to significant morbidity and mortality in CVID. We aim to determine the extent of cellular immune dysfunction in CVID patients, and whether this correlates with CMV infection status. Methods We conducted a single-center retrospective cohort study of individuals with CVID at the Royal Melbourne Hospital, and identified patients with and without CMV disease or viraemia. We then isolated T-cells from patient and healthy donor blood samples and examined T-cell proliferation and function. Results Six patients (7.6%, 6/79) had either CMV disease (pneumonitis or gastrointestinal disease), or symptomatic CMV viraemia. A high mortality rate in the cohort of patients with CVID and CMV disease was observed, with 4 deaths in the period of analysis (66.6%, 4/6). Individuals with CMV infection showed reduced T-cell division in response to T-cell receptor (TCR) stimulation when compared with CMV-negative patients. Discussion This study demonstrates the morbidity and mortality associated with CMV in CVID, and highlights the need for focused interventions for patients with CVID at risk of CMV disease.
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Affiliation(s)
- Samantha Chan
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Jack Godsell
- Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Miles Horton
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Anthony Farchione
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Lauren J Howson
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Mai Margetts
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Celina Jin
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Josh Chatelier
- Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Yong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Joseph Sasadeusz
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jo A Douglass
- Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Charlotte A Slade
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Vanessa L Bryant
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
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Jones TPW, Buckland M, Breuer J, Lowe DM. Viral infection in primary antibody deficiency syndromes. Rev Med Virol 2019; 29:e2049. [PMID: 31016825 DOI: 10.1002/rmv.2049] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 12/22/2022]
Abstract
Patients with primary antibody deficiency syndromes such as X-linked agammaglobulinemia (XLA) and common variable immunodeficiency (CVID) are at increased risk of severe and invasive infection. Viral infection in these populations has been of increasing interest as evidence mounts that viruses contribute significant morbidity and mortality: this is mediated both directly and via aberrant immune responses. We explain the importance of the humoral immune system in defence against viral pathogens before highlighting several significant viral syndromes in patients with antibody deficiency. We explore historical cases of hepatitis C via contaminated immunoglobulin products, the predisposition to invasive enteroviral infections, prolonged excretion of vaccine-derived poliovirus, the morbidity of chronic norovirus infection, and recent literature revealing the importance of respiratory viral infections. We discuss evidence that herpesviruses may play a role in driving the inflammatory disease seen in a subset of patients. We explore the phenomenon of within-host evolution during chronic viral infection and the potential emergence of new pathogenic strains. We highlight novel and emerging viruses identified via deep sequencing techniques. We describe the treatment strategies that have been attempted in all these scenarios and the urgent outstanding questions for research.
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Affiliation(s)
- Timothy P W Jones
- Department of Infectious Disease and Microbiology, Royal Free Hospital, London, UK
| | - Matthew Buckland
- Institute of Immunity and Transplantation, Royal Free Campus, University College, London, UK
| | - Judith Breuer
- Division of Infection and Immunity, University College London, London, UK
| | - David M Lowe
- Institute of Immunity and Transplantation, Royal Free Campus, University College, London, UK
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Aghamohammadi A, Abolhassani H, Hirbod-Mobarakeh A, Ghassemi F, Shahinpour S, Behniafard N, Naghibzadeh G, Imanzadeh A, Rezaei N. The Uncommon Combination of Common Variable Immunodeficiency, Macrophage Activation Syndrome, and Cytomegalovirus Retinitis. Viral Immunol 2012; 25:161-5. [DOI: 10.1089/vim.2011.0060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Armin Hirbod-Mobarakeh
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fariba Ghassemi
- Eye Research Center, Farabi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shervin Shahinpour
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Behniafard
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ghazal Naghibzadeh
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Imanzadeh
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Molecular Immunology Research Center, and Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Gastrointestinal tract pathology in patients with common variable immunodeficiency (CVID): a clinicopathologic study and review. Am J Surg Pathol 2008; 31:1800-12. [PMID: 18043034 DOI: 10.1097/pas.0b013e3180cab60c] [Citation(s) in RCA: 220] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is characterized by a host of gastrointestinal (GI) lesions that can mimic other conditions. METHODS We reviewed clinical documentation and samples from 132 separate GI biopsy or resection sites on 20 CVID patients obtained over a 26-year period, including biopsies from the colon (34), esophagus (19), small intestine (38), and stomach (35), a partial gastrectomy, small bowel resection, colectomy, 2 cholecystectomies, and 1 appendectomy. RESULTS There were 13 males and 7 females. Nine patients were children (10 y and younger) and 11 were adults. Age at diagnosis ranged from 6 months to 62 years (median, 35.5 y), and age at biopsy ranged from 10 months to 67 years (median, 38 y). Esophageal samples often showed intraepithelial neutrophils, accompanied by candida. Half of patients' esophageal biopsies had prominent intraepithelial lymphocytosis, one of which also had prominent apoptosis. The stomachs of 67% of patients lacked plasma cells. Most showed lymphoid aggregates. An increase in apoptosis was detected in biopsies from a third. About 20% had a lymphocytic gastritis pattern. Intraepithelial neutrophils were found in a subset, accompanied by various infections [cytomegalovirus (CMV), Helicobacter pylori, and Cryptosporidium]. Granulomas were found in 1 patient. Gastric adenocarcinoma was identified in one patient. There was a paucity of small bowel plasma cells in the majority of patients (68%). The small bowel showed prominent lymphoid aggregates in about half (47%). An increase in apoptosis was detected in specimens from about 20%. Increased intraepithelial lymphocytes (IELs) were found in samples from over half of patients (63%), most of whom (83%) also had villous blunting, mimicking celiac disease. Intraepithelial neutrophils were found in a subset (32%) and correlated with CMV and Cryptosporidium infections. Granulomas were seen in biopsies from 2 patients (11%). One patient had a collagenous enteritis pattern (accompanied by a collagenous colitis pattern). One patient had autoimmune enteritis; biopsies from this patient were initially relatively normal but later displayed prominent crypt apoptosis and loss of goblet cells. In colon samples, a paucity of plasma cells was seen in 10 patients (63%). The colon showed lymphoid aggregates in most patients (81%). Apoptosis was prominent in samples from half of the patients (50%). Biopsies from 6 patients had a lymphocytic colitis pattern (38%) and 2 patients had a collagenous colitis pattern. Intraepithelial neutrophils were found in samples from most patients (88%). Crypt distortion was seen in 6 of these patients (43%), thereby mimicking ulcerative or Crohn colitis. Granulomas were found in 3 patients (19%). CMV was detected in 1 patient. The appendix from 1 patient showed Cryptosporidium and acute serositis with a paucity of plasma cells and an increase in apoptosis. The gallbladder from 1 patient showed acute cholecystitis, and another patient's gallbladder lacked plasma cells. CONCLUSIONS GI tract CVID displays a wide spectrum of histologic patterns. Its features can mimic lymphocytic colitis, collagenous enterocolitis, celiac disease, lymphocytic gastritis, granulomatous disease, acute graft-versus-host disease, and inflammatory bowel disease. In fact, in our series, we found patients with a prior diagnosis of celiac disease (25%) and inflammatory bowel disease (35%), including Crohn disease (15%). The diagnosis of CVID may be suspected on the basis of the lack of plasma cells in a GI biopsy, but because this feature is only present in about two-thirds of patients, the diagnosis cannot always be suggested in isolation of other clinical and laboratory findings.
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Vlková M, Thon V, Sárfyová M, Bláha L, Svobodník A, Lokaj J, Litzman J. Age dependency and mutual relations in T and B lymphocyte abnormalities in common variable immunodeficiency patients. Clin Exp Immunol 2006; 143:373-9. [PMID: 16412063 PMCID: PMC1809591 DOI: 10.1111/j.1365-2249.2006.02999.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Common variable immunodeficiency (CVID) is primary hypogammaglobulinaemia with an unknown aetiopathogenesis. Although various abnormalities of T and B cells have been described, their pathogenetic roles are unclear. We determined T and B lymphocyte subsets known to be abnormal in CVID in order to disclose possible relations between numerical abnormalities in those cells. Markers associated with B cell development (CD21, CD27, IgM, IgD) were determined on B lymphocytes (CD19+); T lymphocyte development (CD45RA, CD45RO, CD62L) and activation markers (CD25, CD27, CD28, CD29, CD38, CD57, HLA-DR) were determined on CD4+ and CD8+ T lymphocytes in 42 CVID patients and in 33 healthy controls. Abnormalities in CD4+ T lymphocyte activation markers (increase in CD29, HLA-DR, CD45RO, decrease in CD27, CD62L, CD45RA) were observed particularly in patients with a decreased number of memory (CD27+) and mature (CD21+) B cells (group Ia according to the Freiburg group's classification), while abnormalities observed in CD8+ cells (increase in CD27 and CD28 and decrease in HLA-DR, CD57 and CD38) did not depend upon grouping patients together according to B lymphocyte developmental subpopulations. We observed correlations between immature B cells (IgM+ CD21-) and expression of CD27, CD62L, CD45RA, CD45RO and HLA-DR on CD4+ T cells in CVID patients but not in the control group. The expression of CD27 and CD45RA on CD4+ T lymphocytes, such as the percentage of IgD+ CD27- and IgD+ CD27+ cells in B lymphocytes, showed age dependency to be more significant than in the control group. Our study demonstrates that T and B lymphocyte abnormalities in CVID are partially related to each other. Some of those abnormalities are not definite, but may evolve with age of the patient.
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Affiliation(s)
- M Vlková
- Department of Clinical Immunology and Allergology, St Anne's University Hospital, Masaryk University, Brno, Czech Republic.
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Kokron CM, Errante PR, Barros MT, Baracho GV, Camargo MM, Kalil J, Rizzo LV. Clinical and laboratory aspects of common variable immunodeficiency. AN ACAD BRAS CIENC 2004; 76:707-26. [PMID: 15558152 DOI: 10.1590/s0001-37652004000400007] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Common variable immunodeficiency (CVID) is an immunological disorder characterized by defective antibody production, recurrent infections, most notably of the respiratory tract, autoimmune phenomena and cancer. Some CVID patients may also present disturbances of the cellular immune response such as a decrease in the number and proportion of different lymphocyte populations, diminished lymphoproliferative response to mitogens and antigens, altered production of cytokines, and deficient expression of cell-surface molecules. Most Brazilian CVID patients included in this study show a decrease in T and B lymphocyte counts in the peripheral blood. Furthermore, their lymphocytes are more susceptible to apoptosis following activation than normal individuals, and they have a decrease in the expression of activation molecules like CD25, CD69, CD40L and CD70. Moreover, they show a decreased synthesis of IL-4 and IL-5 in comparison with normal individuals. The increase in susceptibility to apoptosis following activation, may also be responsible for the decrease in the expression of activation molecules and CD40L, decrease in Th2 cytokines synthesis, and in the number of T and B circulating cells. In this study we discuss some of these immunological disturbances correlating them to the patients' clinical features and comparing our patients' findings to the literature.
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Affiliation(s)
- Cristina M Kokron
- Serviço de Imunologia, Av. Dr. Anéas de Carvalho Aguilar, 155, 8 andar, bloco 3, 05403-010 São Paulo, SP, Brazil
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Abstract
A woman with previously undiagnosed common variable immunodeficiency presented with diarrhea and volume depletion. Biopsies from upper and lower endoscopy revealed atrophic gastritis, villous atrophy, and an inflammatory bowel disease-like chronic colitis, with absence of plasma cells in all sites. Cytomegalovirus inclusions were demonstrated in the colon and small bowel mucosa. Despite therapy with intravenous immunoglobulin and ganciclovir, the patient deteriorated rapidly and subsequently died. This case report highlights the potential for cytomegalovirus to cause extensive disease in patients with common variable immunodeficiency and, thus, the importance of considering it in the initial differential diagnosis so that further morbidity and mortality might be prevented.
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Affiliation(s)
- Elizabeth Stack
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-5280, USA
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Sewell WA, Marshall SE, Mullighan CG, Bird AG. A hypogammaglobulinaemic man with respiratory failure. Postgrad Med J 1998; 74:503-4. [PMID: 9926133 PMCID: PMC2360881 DOI: 10.1136/pgmj.74.874.503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- W A Sewell
- Department of Clinical Immunology, Royal Free Hospital, London, UK
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