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Comprehensive Assessment of Skin Disorders in Patients with Common Variable Immunodeficiency (CVID). J Clin Immunol 2022; 42:653-664. [PMID: 35084691 DOI: 10.1007/s10875-022-01211-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/16/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is an inborn error of immunity (IEI) characterized by various clinical manifestations such as hypogammaglobulinemia, recurrent infections, and autoimmune diseases. Among different clinical manifestations, skin manifestations have been less reported in these patients. METHODS In this study, we investigated the prevalence of dermatologic features in 387 CVID patients. Demographic information, clinical manifestations, laboratory data, and genetic findings were collected from medical records. All data were analyzed based on the presence or absence of skin disorders in CVID patients. RESULTS We observed at least one skin manifestation in about 40% of these patients. Among these complications, skin infection (n = 64, 42.1%) was the most frequent presentation, followed by non-infectious skin lesions (n = 54, 35.6%). Among skin infections, abscesses (n = 34, 22.4%) were the most common complication. Skin infections such as cellulitis, impetigo, measles, and warts were also documented. Eczema (n = 34, 22.4%) was the most common complication in atopic lesions, and vitiligo (n = 13, 8.5%) was prevalent in autoimmune/pigmentation disorders. Among all the patients with genetic mutations, one-quarter had a deleterious mutation in the LRBA gene, relating to the autoimmune and atopic skin lesions. CONCLUSION This rate of skin disorders in our cohort demonstrating these manifestations could be significant in CVID patients, and they are not rare. Low data of skin complications in CVID patients could be attributed to insufficient attention of physicians and also might alert dermatologists to perform immunological investigations in children with certain skin manifestations.
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2
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van Stigt AC, Dik WA, Kamphuis LSJ, Smits BM, van Montfrans JM, van Hagen PM, Dalm VASH, IJspeert H. What Works When Treating Granulomatous Disease in Genetically Undefined CVID? A Systematic Review. Front Immunol 2021; 11:606389. [PMID: 33391274 PMCID: PMC7773704 DOI: 10.3389/fimmu.2020.606389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
Background Granulomatous disease is reported in at least 8–20% of patients with common variable immunodeficiency (CVID). Granulomatous disease mainly affects the lungs, and is associated with significantly higher morbidity and mortality. In half of patients with granulomatous disease, extrapulmonary manifestations are found, affecting e.g. skin, liver, and lymph nodes. In literature various therapies have been reported, with varying effects on remission of granulomas and related clinical symptoms. However, consensus recommendations for optimal management of extrapulmonary granulomatous disease are lacking. Objective To present a literature overview of the efficacy of currently described therapies for extrapulmonary granulomatous disease in CVID (CVID+EGD), compared to known treatment regimens for pulmonary granulomatous disease in CVID (CVID+PGD). Methods The following databases were searched: Embase, Medline (Ovid), Web-of-Science Core Collection, Cochrane Central, and Google Scholar. Inclusion criteria were 1) CVID patients with granulomatous disease, 2) treatment for granulomatous disease reported, and 3) outcome of treatment reported. Patient characteristics, localization of granuloma, treatment, and association with remission of granulomatous disease were extracted from articles. Results We identified 64 articles presenting 95 CVID patients with granulomatous disease, wherein 117 different treatment courses were described. Steroid monotherapy was most frequently described in CVID+EGD (21 out of 53 treatment courses) and resulted in remission in 85.7% of cases. In CVID+PGD steroid monotherapy was described in 15 out of 64 treatment courses, and was associated with remission in 66.7% of cases. Infliximab was reported in CVID+EGD in six out of 53 treatment courses and was mostly used in granulomatous disease affecting the skin (four out of six cases). All patients (n = 9) treated with anti-TNF-α therapies (infliximab and etanercept) showed remission of extrapulmonary granulomatous disease. Rituximab with or without azathioprine was rarely used for CVID+EGD, but frequently used in CVID+PGD where it was associated with remission of granulomatous disease in 94.4% (17 of 18 treatment courses). Conclusion Although the number of CVID+EGD patients was limited, data indicate that steroid monotherapy often results in remission, and that anti-TNF-α treatment is effective for granulomatous disease affecting the skin. Also, rituximab with or without azathioprine was mainly described in CVID+PGD, and only in few cases of CVID+EGD.
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Affiliation(s)
- Astrid C van Stigt
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Lieke S J Kamphuis
- Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pulmonary Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Bas M Smits
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre (UMC), Utrecht, Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre (UMC), Utrecht, Netherlands
| | - P Martin van Hagen
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Virgil A S H Dalm
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hanna IJspeert
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
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Maccora I, Marrani E, Ricci S, Azzari C, Simonini G, Cimaz R, Giani T. Common variable immunodeficiency presenting as sarcoidosis in a 9-year-old child. Int J Rheum Dis 2019; 23:448-453. [PMID: 31858744 DOI: 10.1111/1756-185x.13775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/05/2019] [Accepted: 11/28/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Granulomatous diseases are a heterogeneous group of conditions characterized by an inflammatory infiltrate with a core of macrophages, epithelioid, giant cells and a corona of fibroblasts and lymphocytes. They are associated with a wide range of disorders such as mycobacterial and fungal infections, neoplasms, immunodeficiencies and systemic inflammatory disorders as sarcoidosis. CASE REPORT We report the case of a previously healthy 9-year-old male child who presented with persistent cough, diffuse lymphadenopathy, enlargement of liver and spleen and protracted fever. Anemia, lymphopenia and reduced platelet count was reported, with an increase of inflammatory markers. High levels of Angiotensin-converting enzyme and chitotriosidases were noted. A PET-CT scan showed increased uptake of 18 F-FDG glucose in multiple lymph nodes in thorax and abdomen and in the spleen. Biopsy of inguinal and bronchial nodes showed nodal granulomatous inflammation. The child was diagnosed with sarcoidosis and treated with corticosteroids with only transient efficacy. Further tests reported panhypogammaglobulinaemia and a reduced pool of B-memory lymphocytes. Thus, the diagnosis was revised to common variable immunodeficiency (CVID). CONCLUSION Common variable immunodeficiency is a heterogeneous condition with a highly variable clinical phenotype and a strong association with autoimmune disorders. The presence of noncaseating granuloma and pulmonary lesions, along with extrapulmonary features required a step by step approach to differentiate between CVID and sarcoidosis. This enables early introduction of immunoglobulin replacement therapy and decreases the morbidity and mortality of CVID.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - Silvia Ricci
- Department of Sciences for Health of Women and Child, University of Florence, Florence, Italy.,Immunology Unit, Azienda Ospedaliero Universitaria Ospedale Pediatrico Meyer, Florence, Italy
| | - Chiara Azzari
- Department of Sciences for Health of Women and Child, University of Florence, Florence, Italy.,Immunology Unit, Azienda Ospedaliero Universitaria Ospedale Pediatrico Meyer, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Anna Meyer Children's Hospital, Florence, Italy.,Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Teresa Giani
- Rheumatology Unit, Anna Meyer Children's Hospital, Florence, Italy.,Department of Medical Biotechnology, University of Siena, Siena, Italy
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4
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Pugashetti JV, Adams JY, Zeki AA, Kuhn BT. A 51-Year-Old Man With Unresolved Pulmonary Infiltrates Following Streptococcus pneumoniae Pneumonia. Chest 2019; 155:e47-e50. [PMID: 30732702 PMCID: PMC11026171 DOI: 10.1016/j.chest.2018.08.1064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/09/2018] [Accepted: 08/16/2018] [Indexed: 10/27/2022] Open
Abstract
CASE PRESENTATION A 51-year-old man presented to the clinic 8 weeks after a 6-day hospital admission for severe multilobar pneumonia caused by Streptococcus pneumoniae. His productive cough resolved after antibiotics, but he reported persistent dyspnea. He recounted a lifelong history of recurrent sinusitis but no previous episodes of pneumonia. The patient denied fever, weight loss, or tobacco, alcohol, or drug use. He worked as an upholstery craftsman with no work-related exposures. He had no bird or exotic animal exposures, and no history of travel outside Sacramento, California, where he lived. Aside from the recently completed 2-week course of levofloxacin, he was not taking any medications.
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Affiliation(s)
| | - Jason Y Adams
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA
| | - Amir A Zeki
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA
| | - Brooks T Kuhn
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA.
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5
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Sharma D, Jindal AK, Rawat A, Singh S. Approach to a Child with Primary Immunodeficiency Made Simple. Indian Dermatol Online J 2017; 8:391-405. [PMID: 29204384 PMCID: PMC5707833 DOI: 10.4103/idoj.idoj_189_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Primary immunodeficiency disorders (PIDs) are a group of disorders affecting the capability to fight against infection. These include defects in T cells and B cells affecting cell-mediated and humoral immunity, respectively, combined humoral and cell-mediated immunodeficiency, defects in phagocytosis, complement defects, and defects in cytokine or cytokine signalling pathways which are detrimental for immune function. Depending upon the type and severity, age at onset of symptoms can vary from neonatal period to late childhood. Clinically, this group of disorders can involve any organ system of an individual such as respiratory system, gastrointestinal system, skin and mucous membrane, bone and joints, endocrine organs, and nervous system. Common dermatological manifestations include eczema, warts, molluscum contagiosum, mucocutaneous candidiasis, recurrent nonhealing ulcers, skin abscesses, erythroderma, petechiae, and nail changes. The common skin manifestations of various PIDs include eczema (seen in Wiskott-Aldrich syndrome and autosomal dominant hyper IgE syndrome); erythroderma (in Omen syndrome); viral warts or molluscum contagiosum (in autosomal recessive hyper IgE syndrome); chronic mucocutaneous candidiasis (in hyper IgE syndrome, autoimmune polyendocrinopathy candidiasis ectodermal dysplasia syndrome, Th17 cell defects); recurrent nonhealing ulcers (in leucocyte adhesion defect); skin abscesses (in antibody defects, hyper IgE syndrome, and chronic granulomatous disease); petechial or purpuric spots (in Wiskott-Aldrich syndrome).
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Affiliation(s)
- Dhrubajyoti Sharma
- Allergy Immunology Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur K. Jindal
- Allergy Immunology Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Allergy Immunology Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Allergy Immunology Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
PURPOSE OF REVIEW Diagnostic delay is a major problem for rare diseases including primary antibody deficiency (PAD). The aim of this review is to discuss the opportunities and challenges of current and future screening approaches for antibody deficiency, to reduce the delay and its impact on patients. (Figure is included in full-text article.) RECENT FINDINGS Diagnostic delay in PAD is known to result in increased morbidity, mortality, and permanent functional impairment. Approaches to prevent this have been only partially successful and the delay may still be many years as the clinical presentation of PAD is highly variable and may be at any age, making screening difficult. Patients often have numerous healthcare encounters generating repeated cycles of laboratory and clinical data before the diagnosis is made. Low immunoglobulin levels result in alterations in laboratory tests not directly aimed at measuring immunoglobulins. We describe these and highlight the growing evidence in support of using calculated globulin which is part of the liver function test profile as a screening tool for antibody deficiency. Additional approaches include using embedded algorithms to analyse data generated by repeated clinical encounters (e.g. infections, antibiotics, cytopenias), potentially in combination with laboratory results such as calculated globulin, to help bring forward the diagnosis of PAD in patients in whom this has not yet been considered. SUMMARY There is a strong case for the use of calculated globulin in screening for antibody deficiency. Further work is required to integrate laboratory results with clinical data to reduce diagnostic delay in patients with hitherto unsuspected antibody deficiency.
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Stenton S, Fernando M, Currie Z, Mudhar HS. Metachronous Diffuse Large B-Cell Lymphoma and Kaposi Sarcoma of the Right Eyelid and Lacrimal Gland in a Patient with Granulomatous Common Variable Immunodeficiency. Ocul Oncol Pathol 2016; 2:197-201. [PMID: 27239466 DOI: 10.1159/000444261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 01/18/2016] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To describe the ophthalmic and histopathological features of a female with granulomatous common variable immunodeficiency (CVID) who presented with upper-lid swelling. PROCEDURES The patient underwent a biopsy of the right upper lid/palpebral lacrimal gland with imaging showing a left-sided nasopharyngeal mass, multiple lymph nodes within the mediastinum, bilateral lung nodules and a peritoneal nodule in the right iliac fossa. The right upper-lid swelling progressed and was subject to a second biopsy. RESULTS The first right upper-lid biopsy revealed a diffuse large B-cell lymphoma (DLBCL), confirmed with clonal IgH gene rearrangement with PCR. The nasopharyngeal mass and lymph nodes were suspected clinically to be DLBCL. However, a biopsy of the nasopharyngeal mass showed Kaposi sarcoma (KS). The second biopsy of the right upper lid/palpebral lacrimal gland revealed KS with no evidence of DLBCL. CONCLUSION This is the first documentation of periocular/orbital metachronous DLBCL and KS in a patient with granulomatous CVID. We discuss the role of fluctuating immunity in CVID to explain the spontaneous regression of the DLBCL and the varying clinical picture.
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Affiliation(s)
- Sophie Stenton
- Department of Histopathology, Royal Hallamshire Hospital, Sheffield, UK
| | - Malee Fernando
- Department of Histopathology, Royal Hallamshire Hospital, Sheffield, UK
| | - Zanna Currie
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, UK
| | - Hardeep Singh Mudhar
- National Specialist Ophthalmic Pathology Service (NSOPS), Department of Histopathology, Royal Hallamshire Hospital, Sheffield, UK
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8
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Harp J, Coggshall K, Ruben BS, Ramírez-Valle F, He SY, Berger TG. Cutaneous granulomas in the setting of primary immunodeficiency: a report of four cases and review of the literature. Int J Dermatol 2015; 54:617-25. [PMID: 25773292 DOI: 10.1111/ijd.12765] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 04/10/2014] [Accepted: 05/20/2014] [Indexed: 11/30/2022]
Abstract
IMPORTANCE Cutaneous granulomas without an identifiable infectious etiology are a rare manifestation of primary immunodeficiency (ID). These cutaneous lesions can be misdiagnosed, often as sarcoidosis, when the skin findings precede the diagnosis of immunodeficiency. OBJECTIVE We present four cases from our institution and review the literature in order to emphasize the clinical relevance of this association, discuss the histologic and immunohistochemical features, and explore possible pathogenic mechanisms of granuloma formation. EVIDENCE REVIEW We retrospectively reviewed case reports of all patients presenting with cutaneous granulomas in the setting of primary immunodeficiency. Cases with insufficient information to confirm an immunodeficiency state were excluded. Four patients from our clinic were included, for 54 total cases. FINDINGS The majority of cutaneous granulomas are seen in three types of immunodeficiencies: ataxia-telangiectasia, severe combined immunodeficiency, and combined variable immunodeficiency. Twenty-six percent of patients developed cutaneous granulomas prior to their immunodeficiency diagnosis. Histologically, various granulomatous patterns have been described. Immunohistochemistry revealed a CD4+/CD8+ lymphocyte ratio of less than or equal to 1 in our four patients, which may help differentiate cutaneous granulomas in primary ID from sarcoidal granulomas that typically show a CD4+ predominance. CONCLUSIONS AND RELEVANCE Cutaneous granulomas are a rare manifestation of primary ID and occur predominantly in immunodeficiencies that affect T and B cell compartments.
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Affiliation(s)
- Joanna Harp
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
| | - Kathleen Coggshall
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Beth S Ruben
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA.,Department of Pathology, School of Medicine, University of California, San Francisco, CA, USA
| | - Francisco Ramírez-Valle
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Steven Y He
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
| | - Timothy G Berger
- Department of Dermatology, School of Medicine, University of California, San Francisco, CA, USA
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9
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Vitale J, Convers KD, Goretzke S, Guzman M, Noyes B, Parkar N, Knutsen AP. Serum IL-12 and soluble IL-2 receptor levels as possible biomarkers of granulomatous and lymphocytic interstitial lung disease in common variable immunodeficiency: A case report. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:273-6. [DOI: 10.1016/j.jaip.2014.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 09/15/2014] [Accepted: 09/18/2014] [Indexed: 11/28/2022]
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10
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Cutaneous granulomas and epidermodysplasia verruciformis in early onset combined immunodeficiency syndrome. Am J Dermatopathol 2014; 36:179-83. [PMID: 24247584 DOI: 10.1097/dad.0b013e3182a67f9b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cutaneous granulomas with prominent caseating necrosis are a rare manifestation of immunodeficiency. Extensive and recalcitrant cutaneous viral infections can also be seen. We present a case of an 18-year-old white man with an early onset poorly characterized combined immunodeficiency syndrome who, over the past 5 years, developed enlarging tender red-purple plaques on his extremities and pink near-confluent macules on his chest and back. Previous biopsies of the red-purple plaques showed features of granuloma annulare. Histopathological examination of old and new biopsies revealed both sarcoidal and palisading necrobiotic granulomas with perforating features and elastophagocytosis. Stains and tissue cultures were negative for bacterial and fungal organisms. In addition, biopsy of a macule on the back demonstrated verruca plana with characteristics of epidermodysplasia verruciformis. As an infant, the patient had failure to thrive and a combined immunodeficiency, but was lost to follow-up for 15 years. He currently continues to have severe hypogammaglobinemia and cellular immunodeficiency. Intravenous immunoglobulin and prednisone were initiated and his plaques improved rapidly. Topical imiquimod was ineffective for the verruca plana. The patient and his parents are currently undergoing whole exome sequencing including evaluation for epidermodysplasia verruciformis 1 and 2 gene mutations. This case highlights the importance of including genetic immunodeficiency disorders in the clinical and histopathological differential diagnosis for cutaneous sarcoidal or palisading necrobiotic granulomas and for extensive cutaneous viral infection.
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11
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Holding S, Khan S, Sewell WAC, Jolles S, Dore PC. Using calculated globulin fraction to reduce diagnostic delay in primary and secondary hypogammaglobulinaemias: results of a demonstration project. Ann Clin Biochem 2014; 52:319-26. [PMID: 25024432 DOI: 10.1177/0004563214545791] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2014] [Indexed: 12/11/2022]
Abstract
Background Median diagnostic delay of five to six years seen in primary hypogammaglobulinaemia results in morbidity including bronchiectasis. Patients typically have multiple health care encounters and blood tests before the diagnosis is considered. We report outcomes from using the difference between total protein and albumin (globulin fraction) to reduce diagnostic delay in unsuspected hypogammaglobulinaemia. Methods A prospective >5 year programme in the setting of a National Health Services Hospital Blood Sciences pathology service processing serum samples from primary and secondary care. Patients with globulin fraction below the first percentile were reviewed in the context of supplied clinical details. Immunoglobulin measurements were performed in selected patients. Results Of 2,910,850 globulin fractions 27,304 (0.9%) were below the 1st percentile globulin fraction (<18 g/L). After exclusions, 933 (3% of these) had immunoglobulins measured. Of these, 292 had IgG < 5 g/L, 186 < 4 g/L and 80 < 3 g/L, giving respective positive predictive values of 31%, 20% and 8.6%. Positive predictive value for common variable immunodeficiency was 1.3%. We identified 12 new cases of common variable immunodeficiency, 10 new haematological disorders and 20 hypogammaglobulinaemias secondary to medication. Locally derived cut-offs are required as small differences between analysers have a significant effect on screen-positive rates. Conclusions Use of a 1st percentile globulin fraction improved early detection of hypogammaglobulinaemia. This is a useful adjunct to alert clinicians to unsuspected hypogammaglobulinaemia but should not replace immunoglobulin measurement. Patients with globulin fraction below the first percentile should be reviewed for possible hypogammaglobulinaemia.
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Affiliation(s)
- Stephen Holding
- Immunology Department, Hull Royal Infirmary, Hull, UK
- Postgraduate Medical Institute, University of Hull, Hull, UK
| | - Sujoy Khan
- Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - William AC Sewell
- PathLinks Immunology, Scunthorpe, UK
- Hull York Medical School, Hull, UK
| | | | - Philip C Dore
- Immunology Department, Hull Royal Infirmary, Hull, UK
- Hull York Medical School, Hull, UK
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12
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Pacheco C, Morais A, Rolo R, Ferreira L, Nabiço R, Cunha J. Chronic granulomatous disease associated with common variable immunodeficiency - 2 clinical cases. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:219-22. [PMID: 24462347 DOI: 10.1016/j.rppneu.2013.09.005] [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: 05/13/2013] [Revised: 08/25/2013] [Accepted: 09/09/2013] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Chronic granulomatous disease associated with common variable immunodeficiency (GD-CVID), although well documented, is rare. Granulomatous lesions can affect several organs and are histologically indistinguishable from sarcoidosis. CLINICAL CASES Case 1: A 39-year-old male patient with CVID, asymptomatic although with thrombocytopenia and mediastinal-hilar adenopathies. GD-CVID was diagnosed by bone marrow biopsy. Progressive clinical and radiological improvement was obtained with corticotherapy. Case 2: A 38-year-old male patient with CVID, suffered from asthenia, anorexia, myalgia, lower limbs edemas, and dry cough. He had mediastinal and bilateral hilar adenopathies within which biopsy revealed non-necrotizing granulomatous infiltrate. A spontaneous resolution was detected after 9 months of evolution. CONCLUSION GD-CVID is rare and can mimetize other pathologies, namely, sarcoidosis; it should therefore be publicized and discussed so that it becomes a general clinical knowledge.
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Affiliation(s)
- C Pacheco
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal.
| | - A Morais
- Serviço de Pneumologia, Centro Hospitalar de São João; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - R Rolo
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal
| | - L Ferreira
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal
| | - R Nabiço
- Serviço de Medicina Interna, Hospital de Braga, Braga, Portugal
| | - J Cunha
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal
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13
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Ocular Involvement in Primary Immunodeficiency Diseases. J Clin Immunol 2013; 34:23-38. [DOI: 10.1007/s10875-013-9974-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 11/20/2013] [Indexed: 12/18/2022]
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Abstract
PURPOSE OF REVIEW To show that skin symptoms help in the recognition of primary immunodeficiencies (PIDs). To analyze whether recent molecular data help in understanding genotype/phenotype relations. RECENT FINDINGS Erythroderma in Omenn syndrome may be caused by either mutations in genes associated with severe combined immunodeficiency (SCID) in which the generation of some T cells is possible, which results in potentially autoreactive lymphoid clones, or by selective proliferation of revertant CD8 T cells in the skin due to clonal expansion in response to infections or autoantigens.The newborn eczematous eruption, which occurs mainly in the signal-transducer-and-activator-of-transcription-3 (STAT3) variant, helps to differentiate STAT3 from Dedicator of Cytokinesis 8-related Hyper-IgE-syndrome (HIES).Impaired T helper 17 cell (TH17) immunity [HIES and defects of autoimmune regulator element (AIRE), STAT-1, and interleukin17 receptor(IL17(R))] may give rise to localized chronic mucocutaneous candidiasis, whereas a defective innate immune system predisposes to systemic candidiasis [congenital neutropenia, neutrophil dysfunction, and caspase recruitment domain 9 (CARD9) deficiency].Noninfectious granulomas may be the presenting symptom in innate immunity defects [such as chronic granulomatous disease (CGD) or in predominantly humoral immunodeficiencies such as common variable immunodeficiency], as well as ataxia teleangiectasia or rare recombination-activating gene-deficient cases. SUMMARY The skin is important in the diagnosis of PIDs. In particular eczematous lesions, erythroderma, noninfectious granuloma, and microbial manifestations may help to direct further diagnostic laboratory analysis.
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Kamphuis LS, van Zelm MC, Lam KH, Rimmelzwaan GF, Baarsma GS, Dik WA, Thio HB, van Daele PL, van Velthoven ME, Batstra MR, van Hagen PM, van Laar JA. Perigranuloma Localization and Abnormal Maturation of B Cells. Am J Respir Crit Care Med 2013; 187:406-16. [DOI: 10.1164/rccm.201206-1024oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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16
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Granulomatous Disease in CVID: Retrospective Analysis of Clinical Characteristics and Treatment Efficacy in a Cohort of 59 Patients. J Clin Immunol 2012; 33:84-95. [DOI: 10.1007/s10875-012-9778-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022]
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17
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Pasquet F, Kodjikian L, Mura F, Riviere S, Harroche J, Blanc AP, Chaix F, Oksenhendler E, Seve P. Uveitis and Common Variable Immunodeficiency: Data from the DEF-I Study And Literature Review. Ocul Immunol Inflamm 2012; 20:163-70. [DOI: 10.3109/09273948.2012.674612] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Oltra EZ, Morris C, Birnbaum AD, Tessler HH, Goldstein DA. Chronic Anterior Uveitis in Common Variable Immunodeficiency. Ocul Immunol Inflamm 2011; 19:448-9. [DOI: 10.3109/09273948.2011.625136] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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[The many faces of paediatric sarcoidosis: the common variable immunodeficiency as an underlying cause]. An Pediatr (Barc) 2009; 72:161-2. [PMID: 19880359 DOI: 10.1016/j.anpedi.2009.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 08/25/2009] [Accepted: 08/26/2009] [Indexed: 10/20/2022] Open
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