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van Stigt AC, von der Thüsen JH, Mustafa DAM, van den Bosch TPP, Lila KA, Vadgama D, van Hagen M, Dalm VASH, Dik WA, IJspeert H. Granulomas in Common Variable Immunodeficiency Display Different Histopathological Features Compared to Other Granulomatous Diseases. J Clin Immunol 2024; 45:22. [PMID: 39373788 PMCID: PMC11458708 DOI: 10.1007/s10875-024-01817-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 09/26/2024] [Indexed: 10/08/2024]
Abstract
Granulomatous disease affects up to 20% of patients with Common Variable Immunodeficiency (CVID). Granulomas are comprised of highly activated immune cells, and emerge in response to antigenic triggers. In CVID granulomas however, the underlying pathophysiology is unclear and the specific trigger remains unknown. Granuloma formation in CVID is often compared to sarcoidosis, although clinical context and prognosis differ, suggesting a different pathogenesis. The aim of this study was to investigate if the cellular organization and proteomics of granulomas in CVID is different from other granulomatous diseases. Therefore, tissue slides from formaldehyde fixed paraffin embedded biopsies obtained from patients with CVID, sarcoidosis, tuberculosis and foreign-material induced pseudo-sarcoidosis were stained with hematoxylin and eosin and assessed for histopathological characteristics. Targeted spatial protein analysis was performed, and immune fluorescent multiplex assays were used to analyze the cellular organization. Histological analysis revealed that CVID granulomas were smaller, less circumscribed, with fewer multinucleated giant cells and minimal fibrosis compared to the other granulomatous diseases. Spatial protein analysis showed that granulomas in all diseases expressed CD68, CD11c, CD44, CD127, and PD-L1. However in CVID, reduced expression of the fibrosis-related protein fibronectin, but enrichment of CD163, CD3 and FAPα inside CVID granulomas was observed. Immunofluorescence analysis conformed a different cellular organization in CVID granulomas with increased influx of neutrophils, macrophages, T and B lymphocytes. In conclusion, granulomas in CVID display a different histological and cellular organization with increased influx of myeloid and lymphoid cells, compared to sarcoidosis, tuberculosis and pseudo-sarcoidosis, indicating a distinct pathogenesis underlying granuloma formation.
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Affiliation(s)
- Astrid C van Stigt
- Erasmus Medical Center, Laboratory of Medical Immunology, Department of Immunology, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan H von der Thüsen
- Department of Pathology and Clinical Bioinformatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dana A M Mustafa
- Department of Pathology and Clinical Bioinformatics, Erasmus Medical Center, Rotterdam, The Netherlands
- The Tumor Immuno-Pathology Laboratory, Department of pathology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Thierry P P van den Bosch
- Department of Pathology and Clinical Bioinformatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karishma A Lila
- Department of Pathology and Clinical Bioinformatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Disha Vadgama
- Department of Pathology and Clinical Bioinformatics, Erasmus Medical Center, Rotterdam, The Netherlands
- The Tumor Immuno-Pathology Laboratory, Department of pathology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Martin van Hagen
- Erasmus Medical Center, Laboratory of Medical Immunology, Department of Immunology, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Virgil A S H Dalm
- Erasmus Medical Center, Laboratory of Medical Immunology, Department of Immunology, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
- Department of Internal Medicine, Division of Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Willem A Dik
- Erasmus Medical Center, Laboratory of Medical Immunology, Department of Immunology, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Hanna IJspeert
- Erasmus Medical Center, Laboratory of Medical Immunology, Department of Immunology, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands.
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Salih A, Brown A, Grimes A, Hasan S, Silva-Carmona M, Tal L, Hajjar J. A case report navigating CVID and sarcoidosis overlaps in pediatric nephritis. Front Pediatr 2024; 12:1417724. [PMID: 39359743 PMCID: PMC11445013 DOI: 10.3389/fped.2024.1417724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 08/23/2024] [Indexed: 10/04/2024] Open
Abstract
Common variable immunodeficiency (CVID) can be complicated by granulomatous disease, often granulomatous lymphocytic interstitial lung disease (GLILD). Granulomatous interstitial nephritis represents an atypical presentation in pediatrics. Our patient is a previously healthy 13-year-old white male with a recent diagnosis of CVID. He presented with a rash and laboratory findings included pancytopenia (white blood cells 2.6 cells × 103/μl, hemoglobin 11.8 g/dl, platelets 60 × 103/μl), hypercalcemia (14.9 mg/dl), elevated Vit D 1,25 OH level (>200 pg/ml), hyperuricemia (8.8 mg/dl), and acute kidney injury (AKI) (serum creatinine 1.1 mg/dl; baseline 0.64 mg/dl). A broad infectious workup was unremarkable. The rash improved with empiric doxycycline. Hypercalcemia and hyperuricemia were managed with fluid resuscitation, calcitonin, and zoledronic acid. Evaluation for malignancy including a positron emission tomography scan, revealed multiple mediastinal hypermetabolic lymph nodes and pulmonary ground glass opacities, later reported as small pulmonary nodules by computed tomography (CT). Splenomegaly was confirmed by ultrasound and CT. Peripheral smear, bone marrow biopsy, and genetic testing were non-revealing. His angiotensin-converting enzyme level was elevated (359 U/L), raising concerns for sarcoidosis. Given Stage 1 AKI, a renal biopsy was pursued and identified non-caseating granulomatous interstitial nephritis. Treatment with 60 mg of prednisone began for presumed sarcoidosis for 4 months, causing steroid-induced hypertension and mood changes. Zoledronic acid minimally reduced serum creatinine. Pneumocystis jirovecii pneumonia prophylaxis was initiated due to T-cell cytopenia. Chest CT findings showed a suboptimal response to steroids. A bronchoalveolar lavage demonstrated >50% lymphocytes (normal <10%) and the lung biopsy exhibited non-caseating granulomas, indicating GLILD. Rubella was identified by staining. Following a fever, he was found to have elevated liver enzymes and confirmed hepatitis with portal hypertension on CT. A liver biopsy revealed epithelioid non-caseating granuloma and HHV6 was detected by PCR. He was treated with four cycles of rituximab and granulocyte-colony stimulating factor for persistent neutropenia. Subsequent treatment with mycophenolate led to the resolution of the granulomatous lesions and cytopenias. The rare complication of granulomatous interstitial nephritis in CVID illustrates the intricate nature of diagnosis. This case underscores the necessity for a holistic view of the patient's clinical and immune phenotype, including distinctive radiological presentations, for precise diagnoses and tailored management of CVID.
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Affiliation(s)
- Amanda Salih
- Division of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Baylor College of Medicine, William T. Shearer Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, United States
| | - Amanda Brown
- Division of Pediatric Rheumatology, Arkansas Children's Hospital, Little Rock, AR, United States
| | - Amanda Grimes
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Sana Hasan
- Division of Allergy/Immunology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Manuel Silva-Carmona
- Division of Pulmonology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Leyat Tal
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Joud Hajjar
- Division of Immunology, Allergy, and Retrovirology, Department of Pediatrics, Baylor College of Medicine, William T. Shearer Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, United States
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Buso H, Discardi C, Bez P, Muscianisi F, Ceccato J, Milito C, Firinu D, Landini N, Jones MG, Felice C, Rattazzi M, Scarpa R, Cinetto F. Sarcoidosis versus Granulomatous and Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency: A Comparative Review. Biomedicines 2024; 12:1503. [PMID: 39062076 PMCID: PMC11275071 DOI: 10.3390/biomedicines12071503] [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: 05/08/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
Sarcoidosis and Granulomatous and Lymphocytic Interstitial Lung Diseases (GLILD) are two rare entities primarily characterised by the development of Interstitial Lung Disease (ILD) in the context of systemic immune dysregulation. These two conditions partially share the immunological background and pathologic findings, with granuloma as the main common feature. In this narrative review, we performed a careful comparison between sarcoidosis and GLILD, with an overview of their main similarities and differences, starting from a clinical perspective and ending with a deeper look at the immunopathogenesis and possible target therapies. Sarcoidosis occurs in immunocompetent individuals, whereas GLILD occurs in patients affected by common variable immunodeficiency (CVID). Moreover, peculiar extrapulmonary manifestations and radiological and histological features may help distinguish the two diseases. Despite that, common pathogenetic pathways have been suggested and both these disorders can cause progressive impairment of lung function and variable systemic granulomatous and non-granulomatous complications, leading to significant morbidity, reduced quality of life, and survival. Due to the rarity of these conditions and the extreme clinical variability, there are still many open questions concerning their pathogenesis, natural history, and optimal management. However, if studied in parallel, these two entities might benefit from each other, leading to a better understanding of their pathogenesis and to more tailored treatment approaches.
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Affiliation(s)
- Helena Buso
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
| | - Claudia Discardi
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
| | - Patrick Bez
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
| | - Francesco Muscianisi
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
| | - Jessica Ceccato
- Haematology and Clinical Immunology Unit, Department of Medicine (DIMED), University of Padova, 35124 Padova, Italy
- Veneto Institute of Molecular Medicine (VIMM), 35131 Padova, Italy
| | - Cinzia Milito
- Department of Molecular Medicine, “Sapienza” University of Rome, 00161 Rome, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy
| | - Nicholas Landini
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, “Sapienza” University of Rome, 00161 Rome, Italy
| | - Mark G. Jones
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 YD, UK;
- Institute for Life Sciences, University of Southampton, Southampton SO17 1BJ, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Carla Felice
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
| | - Marcello Rattazzi
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
| | - Riccardo Scarpa
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Department of Medicine (DIMED), AULSS2 Marca Trevigiana, Ca’ Foncello Hospital, University of Padova, 35124 Padova, Italy (C.F.); (M.R.); (R.S.); (F.C.)
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Szaflarska A, Lenart M, Rutkowska-Zapała M, Siedlar M. Clinical and experimental treatment of primary humoral immunodeficiencies. Clin Exp Immunol 2024; 216:120-131. [PMID: 38306460 PMCID: PMC11036112 DOI: 10.1093/cei/uxae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/13/2023] [Accepted: 01/31/2024] [Indexed: 02/04/2024] Open
Abstract
Selective IgA deficiency (sIgAD), common variable immunodeficiency (CVID), and transient hypogammaglobulinemia of infancy (THI) are the most frequent forms of primary antibody deficiencies. Difficulties in initial diagnosis, especially in the early childhood, the familiar occurrence of these diseases, as well as the possibility of progression to each other suggest common cellular and molecular patomechanism and a similar genetic background. In this review, we discuss both similarities and differences of these three humoral immunodeficiencies, focusing on current and novel therapeutic approaches. We summarize immunoglobulin substitution, antibiotic prophylaxis, treatment of autoimmune diseases, and other common complications, i.e. cytopenias, gastrointestinal complications, and granulomatous disease. We discuss novel therapeutic approaches such as allogenic stem cell transplantation and therapies targeting-specific proteins, dependent on the patient's genetic defect. The diversity of possible therapeutics models results from a great heterogeneity of the disease variants, implying the need of personalized medicine approach as a future of primary humoral immunodeficiencies treatment.
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Affiliation(s)
- Anna Szaflarska
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
| | - Marzena Lenart
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
| | - Magdalena Rutkowska-Zapała
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
| | - Maciej Siedlar
- Department of Clinical Immunology, Institute of Paediatrics, Jagiellonian University Medical College, Wielicka 265, Cracow, Poland
- Deparment of Clinical Immunology, University Children’s Hospital, Wielicka 265, Cracow, Poland
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5
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Viallard JF, Lescure M, Oksenhendler E, Blanco P, Visentin J, Parrens M. STAT expression and TFH1 cells in CVID granulomatosis and sarcoidosis: immunological and histopathological comparisons. Virchows Arch 2024; 484:481-490. [PMID: 37924346 DOI: 10.1007/s00428-023-03684-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/10/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023]
Abstract
Granulomatous disease is a serious complication of common variable immunodeficiency (CVID-GD) that occurs in 8-22% of these patients and can mimic sarcoidosis, with which it shares certain clinical, biological, and radiological features. However, few studies to date have compared the two pathologies immunologically and histologically. Therefore, we analyzed the immunological-histological findings for different tissue samples from ten patients with CVID-GD and compared them to those of biopsy-proven sarcoidosis. Specifically, we wanted to know whether or not the signaling abnormalities observed in sarcoidosis granulomas are also present in CVID-GD. Morphological differences were found between CVID-GD histology and classical sarcoidosis: mainly, the former's notable lymphoid hyperplasia associated with granulomas not observed in the latter. All CVID-GD involved organs contained several follicular helper-T (TFH) cells within the granulomatosis, while those cells were inconstantly and more weakly expressed in sarcoidosis. Moreover, CVID and sarcoidosis granulomas expressed the phosphorylated-signal transducer and activator of transcription (pSTAT)1 and pSTAT3 factors, regardless of the organ studied and without any significant difference between entities. Our results suggest that the macrophage-activation mechanism in CVID resembles that of sarcoidosis, thereby suggesting that Janus kinase (JAK)-STAT-pathway blockade might be useful in currently difficult-to-treat CVID-GD.
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Affiliation(s)
- Jean-François Viallard
- Internal Medicine Department, Hôpital Haut-Lévêque, Bordeaux University Hospital, Avenue de Magellan, 33604, Pessac, France.
| | - Maëlig Lescure
- Internal Medicine Department, Hôpital Haut-Lévêque, Bordeaux University Hospital, Avenue de Magellan, 33604, Pessac, France
| | - Eric Oksenhendler
- Clinical Immunology Department, Saint-Louis Paris Diderot University Hospital, Paris, France
| | - Patrick Blanco
- Centre Hospitalier Universitaire de Bordeaux, Service d'Immunologie Et Immunogénétique FHU ACRONIM, Hôpital Pellegrin, Place Amélie-Raba-Léon, Bordeaux, France
| | - Jonathan Visentin
- Centre Hospitalier Universitaire de Bordeaux, Service d'Immunologie Et Immunogénétique FHU ACRONIM, Hôpital Pellegrin, Place Amélie-Raba-Léon, Bordeaux, France
| | - Marie Parrens
- Pathology Department, Hôpital du Haut-Lévêque, Bordeaux University Hospital, Avenue de Magellan, Pessac, France
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Hanitsch LG, Steiner S, Schumann M, Wittke K, Kedor C, Scheibenbogen C, Fischer A. Portal hypertension in common variable immunodeficiency disorders - a single center analysis on clinical and immunological parameter in 196 patients. Front Immunol 2023; 14:1268207. [PMID: 38187397 PMCID: PMC10769488 DOI: 10.3389/fimmu.2023.1268207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Liver manifestations and in particular portal hypertension (PH) contribute significantly to morbidity and mortality of patients with common variable immunodeficiency disorders (CVID). Screening strategies and early detection are limited due to the lack of specific diagnostic tools. Methods We evaluated clinical, immunological, histological, and imaging parameters in CVID patients with clinical manifestation of portal hypertension (CVID+PH). Results Portal hypertension was present in 5.6% of CVID patients and was associated with high clinical burden and increased mortality (18%). Longitudinal data on clinical and immunological parameters in patients before and during clinically manifest portal hypertension revealed a growing splenomegaly and increasing gamma-glutamyl transferase (GGT) and soluble interleukin 2 receptor (SIL-2R) levels with decreasing platelets over time. While ultrasound of the liver failed to detect signs of portal hypertension in most affected patients, transient elastography was elevated in all patients. All CVID+PH patients had reduced naïve CD45RA+CD4+ T-cells (mean of 6,2%). The frequency of severe B-lymphocytopenia (Euroclass B-) was higher in CVID+PH patients. The main histological findings included lymphocytic infiltration, nodular regenerative hyperplasia-like changes (NRH-LC), and porto(-septal) fibrosis. Conclusion CVID patients with lower naïve CD45RA+CD4+ T-cells or severely reduced B-cells might be at higher risk for portal hypertension. The combination of biochemical (increasing sIL-2R, GGT, and decreasing platelets) and imaging parameters (increasing splenomegaly) should raise suspicion of the beginning of portal hypertension.
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Affiliation(s)
- Leif G. Hanitsch
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Sophie Steiner
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Michael Schumann
- Department of Gastroenterology, Infectiology and Rheumatology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Kirsten Wittke
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Claudia Kedor
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Andreas Fischer
- Department of Internal Medicine and Gastroenterology, Caritas-Klinik Maria Heimsuchung Berlin-Pankow, Berlin, Germany
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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Roosens W, Staels F, Van Loo S, Humblet-Baron S, Meyts I, De Samblanx H, Verslype C, van Malenstein H, van der Merwe S, Laleman W, Schrijvers R. Rituximab and improved nodular regenerative hyperplasia-associated non-cirrhotic liver disease in common variable immunodeficiency: a case report and literature study. Front Immunol 2023; 14:1264482. [PMID: 37795099 PMCID: PMC10546204 DOI: 10.3389/fimmu.2023.1264482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/29/2023] [Indexed: 10/06/2023] Open
Abstract
Common variable immunodeficiency (CVID) associated liver disease is an underrecognized and poorly studied non-infectious complication that lacks an established treatment. We describe a CVID patient with severe multiorgan complications, including non-cirrhotic portal hypertension secondary to nodular regenerative hyperplasia leading to diuretic-refractory ascites. Remarkably, treatment with rituximab, administered for concomitant immune thrombocytopenia, resulted in the complete and sustained resolution of portal hypertension and ascites. Our case, complemented with a literature review, suggests a beneficial effect of rituximab that warrants further research.
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Affiliation(s)
- Willem Roosens
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Frederik Staels
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Sien Van Loo
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Stephanie Humblet-Baron
- Department of Microbiology, Immunology and Transplantation, Laboratory of Adaptive Immunology, KU Leuven, Leuven, Belgium
| | - Isabelle Meyts
- Department of Microbiology, Immunology and Transplantation Laboratory of Inborn Errors of Immunity, KU Leuven, Leuven, Belgium
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | | | - Chris Verslype
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, Leuven, Belgium
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Laboratory of Hepatology, KU Leuven, Leuven, Belgium
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Laboratory of Hepatology, KU Leuven, Leuven, Belgium
| | - Wim Laleman
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Laboratory of Hepatology, KU Leuven, Leuven, Belgium
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
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8
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Mongkonsritragoon W, Srivastava R, Seth D, Navalpakam A, Poowuttikul P. Non-infectious Pulmonary Complications in Children with Primary Immunodeficiency. Clin Med Insights Pediatr 2023; 17:11795565231196431. [PMID: 37692068 PMCID: PMC10492501 DOI: 10.1177/11795565231196431] [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: 05/04/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023] Open
Abstract
Primary immune deficiency (PID) is a large group of diseases characterized by defective immune function, leading to recurrent infections, and immune dysregulation. Clinical presentations, severity, and complications differ for each disease, based on the components of the immune system that are impacted. When patients with PID present with respiratory symptoms, infections should be initially suspected, investigated, and promptly managed. However, non-infectious complications of PID also frequently occur and can lead to significant morbidity and mortality. They can involve both the upper and lower respiratory systems, resulting in various presentations that mimic infectious diseases. Thus, clinicians should be able to detect these conditions and make an appropriate referral to an immunologist and a pulmonologist for further management. In this article, we use case-based scenarios to review the differential diagnosis, investigation, and multidisciplinary treatment of non-infectious pulmonary complications in patients with primary immune deficiencies.
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Affiliation(s)
- Wimwipa Mongkonsritragoon
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Central Michigan University College of Medicine, Mt. Pleasant, MI, USA
| | - Ruma Srivastava
- Division of Pulmonary Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
- Division of Pulmonary Medicine, Department of Pediatrics, Central Michigan University College of Medicine, Mt. Pleasant, MI, USA
| | - Divya Seth
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Central Michigan University College of Medicine, Mt. Pleasant, MI, USA
| | - Aishwarya Navalpakam
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Central Michigan University College of Medicine, Mt. Pleasant, MI, USA
| | - Pavadee Poowuttikul
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Central Michigan University College of Medicine, Mt. Pleasant, MI, USA
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Sorin B, Fadlallah J, Garzaro M, Vigneron J, Bertinchamp R, Boutboul D, Oksenhendler E, Fieschi C, Malphettes M, Galicier L. Real-life use of mTOR inhibitor-based therapy in adults with autoimmune cytopenia highlights strong efficacy in relapsing/refractory multi-lineage autoimmune cytopenia. Ann Hematol 2023:10.1007/s00277-023-05340-0. [PMID: 37386347 DOI: 10.1007/s00277-023-05340-0] [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: 03/01/2023] [Accepted: 06/25/2023] [Indexed: 07/01/2023]
Abstract
Data on mTOR inhibitors (mTORi) in autoimmune cytopenia (AIC), in adults are scarce. We retrospectively analysed 30 cases of refractory or relapsing AIC treated with an mTORi-based therapy. Eleven warm autoimmune hemolytic anaemia, 10 autoimmune thrombocytopenia, 6 acquired pure red cell aplasia, 3 autoimmune neutropenia were included. Twenty were multilineage AIC (67%) and 21 were secondary AIC (70%). mTORi were associated with other therapies in 23 AIC (77%). Twenty-two AIC (73%) responded to mTORi-based therapy: 5 reached a partial response (17%) and 17 a complete response (57%). Survival without unfavourable outcome (failure, requirement of a new therapy, or death) was longer in multilineage AIC compared to single-lineage AIC (p = 0.049) with a median event-free survival of 48 versus 12 months. Median event-free survival was 48 months in secondary AIC and 33 months in primary AIC (p = 0.79). mTORi were discontinued in 4 patients (15%) for safety reasons and in 3 patients for patient's choice (12%). In conclusion, mTORi could be considered as an alternative or an add-on therapy in refractory or relapsing AIC in adult patients, especially in multilineage AIC.
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Affiliation(s)
- Boris Sorin
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France.
| | - Jehane Fadlallah
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Margaux Garzaro
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Julien Vigneron
- Department of Biostatistics and Medical Information, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Rémi Bertinchamp
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - David Boutboul
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Eric Oksenhendler
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Claire Fieschi
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Marion Malphettes
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, Université de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
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10
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Fevang B. Treatment of inflammatory complications in common variable immunodeficiency (CVID): current concepts and future perspectives. Expert Rev Clin Immunol 2023; 19:627-638. [PMID: 36996348 DOI: 10.1080/1744666x.2023.2198208] [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] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Patients with Common variable immunodeficiency (CVID) have a high frequency of inflammatory complications like autoimmune cytopenias, interstitial lung disease and enteropathy. These patients have poor prognosis and effective, timely and safe treatment of inflammatory complications in CVID are essential, but guidelines and consensus on therapy are often lacking. AREAS COVERED This review will focus on current medical treatment of inflammatory complications in CVID and point out some future perspectives based on literature indexed in PubMed. There are a number of good observational studies and case reports on treatment of specific complications but randomized controlled trials are scarce. EXPERT OPINION In clinical practice, the most urgent issues that need to be addressed are the preferred treatment of GLILD, enteropathy and liver disease. Treating the underlying immune dysregulation and immune exhaustion in CVID is an alternative approach that potentially could alleviate these and other organ-specific inflammatory complications. Therapies of potential interest and wider use in CVID include mTOR-inhibitors like sirolimus, JAK-inhibitors like tofacitinib, the monoclonal IL-12/23 antibody ustekinumab, the anti-BAFF antibody belimumab and abatacept. For all inflammatory complications, there is a need for prospective therapeutic trials, preferably randomized controlled trials, and multi-center collaborations with larger cohorts of patients will be essential.
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Affiliation(s)
- Børre Fevang
- Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
- Research Institute for Internal Medicine, Oslo University Hospital, Oslo, Norway
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11
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Sasaki J, Tominaga M, Sudou M, Tokisawa S, Nishii Y, Zaizen Y, Matama G, Chikasue T, Fujimoto K, Tabata K, Fukuoka J, Takemura T, Kawayama T, Hoshino T. Granulomatous Lymphocytic Interstitial Lung Disease in Multiple Myeloma. Intern Med 2023; 62:439-444. [PMID: 35831114 PMCID: PMC9970795 DOI: 10.2169/internalmedicine.9758-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
An 82-year-old woman complained of recurring cough and shortness of breath and was diagnosed with progressive multiple myeloma (MM). Chest computed tomography (CT) revealed bilateral ground-glass opacity and interlobular septal thickening predominantly in the lower lung zones. Histopathologic findings obtained by a transbronchial lung cryobiopsy (TBLC) revealed alveolitis and granulomas consistent with granulomatous-lymphocytic interstitial lung disease (GLILD). Aggressive chemotherapy for MM contributed to the improvement in respiratory symptoms and abnormal chest CT findings. In cases of MM with lung abnormalities, the possibility of GLILD must be ruled out, and a TBLC should be considered to attain an accurate diagnosis.
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Affiliation(s)
- Jun Sasaki
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Masaki Tominaga
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Misa Sudou
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Saeko Tokisawa
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Yuuya Nishii
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Yoshiaki Zaizen
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Goushi Matama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Tomonori Chikasue
- Department of Radiology, Kurume University School of Medicine, Japan
| | - Kiminori Fujimoto
- Department of Radiology, Kurume University School of Medicine, Japan
| | - Kazuhiro Tabata
- Division of Pathology, Department of Oncology, Kagoshima University Graduate School of Medical and Dental Sciences, Japan
| | - Junya Fukuoka
- Department of Pathology, Nagasaki University Hospital, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Tomoaki Hoshino
- Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Japan
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12
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Sharma D, Ben Yakov G, Kapuria D, Viana Rodriguez G, Gewirtz M, Haddad J, Kleiner DE, Koh C, Bergerson JRE, Freeman AF, Heller T. Tip of the iceberg: A comprehensive review of liver disease in Inborn errors of immunity. Hepatology 2022; 76:1845-1861. [PMID: 35466407 DOI: 10.1002/hep.32539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/30/2022] [Accepted: 04/17/2022] [Indexed: 12/08/2022]
Abstract
Inborn errors of immunity (IEIs) consist of numerous rare, inherited defects of the immune system that affect about 500,000 people in the United States. As advancements in diagnosis through genetic testing and treatment with targeted immunotherapy and bone marrow transplant emerge, increasing numbers of patients survive into adulthood posing fresh clinical challenges. A large spectrum of hepatobiliary diseases now present in those with immunodeficiency diseases, leading to morbidity and mortality in this population. Awareness of these hepatobiliary diseases has lagged the improved management of the underlying disorders, leading to missed opportunities to improve clinical outcomes. This review article provides a detailed description of specific liver diseases occurring in various inborn errors of immunity. A generalized approach to diagnosis and management of hepatic complications is provided, and collaboration with hepatologists, immunologists, and pathologists is emphasized as a requirement for optimizing management and outcomes.
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Affiliation(s)
- Disha Sharma
- Department of Internal MedicineMedStar Washington Hospital Center & Georgetown UniversityWashingtonDCUSA.,Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Gil Ben Yakov
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,26744Center for Liver DiseaseSheba Medical CenterTel HaShomerIsrael
| | - Devika Kapuria
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA.,Department of GastroenterologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Gracia Viana Rodriguez
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Meital Gewirtz
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - James Haddad
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - David E Kleiner
- 3421Laboratory of PathologyNational Cancer InstituteBethesdaMarylandUSA
| | - Christopher Koh
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
| | - Jenna R E Bergerson
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and MicrobiologyNIAID, NIHBethesdaMarylandUSA
| | - Theo Heller
- Liver Diseases Branch, Translational Hepatology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, NIHBethesdaMarylandUSA
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13
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Yazdanpanah N, Rezaei N. Autoimmune disorders associated with common variable immunodeficiency: prediction, diagnosis, and treatment. Expert Rev Clin Immunol 2022; 18:1265-1283. [PMID: 36197300 DOI: 10.1080/1744666x.2022.2132938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency. Due to the wide spectrum of the CVID manifestations, the differential diagnosis becomes complicated, ends in a diagnostic delay and increased morbidity and mortality rates. Autoimmunity is one of the important complications associated with CVID. While immunoglobulin replacement therapy has considerably decreased the mortality rate in CVID patients, mainly infection-related mortality, other complications such as autoimmunity appeared prevalent and, in some cases, life threatening. AREAS COVERED In this article, genetics, responsible immune defects, autoimmune manifestations in different organs, and the diagnosis and treatment processes in CVID patients are reviewed, after searching the literature about these topics. EXPERT OPINION Considering the many phenotypes of CVID and the fact that it remained undiagnosed until older ages, it is important to include various manifestations of CVID in the differential diagnosis. Due to the different manifestations of CVID, including autoimmune diseases, interdisciplinary collaboration of physicians from different fields is highly recommended, as discussed in the manuscript. Meanwhile, it is important to determine which patients could benefit from genetic diagnostic studies since such studies are not necessary for establishing the diagnosis of CVID.
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Affiliation(s)
- Niloufar Yazdanpanah
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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14
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An Expert Opinion/Approach: Clinical Presentations, Diagnostic Considerations, and Therapeutic Options for Gastrointestinal Manifestations of Common Variable Immune Deficiency. Am J Gastroenterol 2022; 117:1743-1752. [PMID: 36148549 DOI: 10.14309/ajg.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/16/2022] [Indexed: 01/11/2023]
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency. It is characterized by impaired B-cell differentiation. Although patients can be diagnosed with CVID anytime during their lifetime, most patients have symptoms for 5-9 years before their diagnosis. The diagnosis of CVID starts with a detailed history focusing on the infectious and noninfectious manifestations of the disease. In patients who are suspected to experience CVID, quantitative immunoglobulins (Ig) should be checked to confirm the diagnosis. IgG should be at least 2 times less than the age-specific SD along with either a low IgA or IgM and with evidence of impaired vaccine response. CVID is usually associated with infectious and/or noninfectious conditions, the latter of which can be inflammatory, autoimmune, lymphoproliferative, or malignant, among other manifestations. Ig therapy has positively affected the disease course of patients with infectious complications but has limited effect on the noninfectious manifestations because the noninfectious complications are related to immune dysregulation involving B cells and T cells rather than primarily due to antibody deficiency. When the gastrointestinal (GI) system is involved, patients with CVID may display signs and symptoms that mimic several GI conditions such as celiac disease, pernicious anemia, or inflammatory bowel diseases. The inflammatory bowel disease-like condition is usually treated with steroids, 5-aminosalicylates, thiopurines, or biologic agents to control the inflammation. In this review, the clinical presentations, diagnostic considerations, and therapeutic options for GI manifestations of CVID will be discussed to facilitate the individualized management of these often-complex patients.
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15
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Bintalib HM, Lowe DM, Mancuso G, Gkrepi G, Seneviratne SL, Burns SO, Hurst JR. Corticosteroid-induced remission and mycophenolate maintenance therapy in granulomatous lymphocytic interstitial lung disease: long-term, longitudinal change in lung function in a single-centre cohort. ERJ Open Res 2022; 8:00024-2022. [PMID: 36267899 PMCID: PMC9574553 DOI: 10.1183/23120541.00024-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/27/2022] [Indexed: 11/11/2022] Open
Abstract
Aim The aim of the study was to evaluate the response in lung function to different treatment regimens for common variable immunodeficiency patients with granulomatous lymphocytic interstitial lung disease (GLILD). Method A longitudinal retrospective cohort study was carried out. Patients were divided into three groups. To assess the response to different treatments, we compared baseline lung function with post-treatment tests. Results 14 patients with GLILD were included, seven of whom were treated with acute corticosteroids for a mean duration of 132±65 days. Spirometry results were unchanged, but there was a significant improvement in diffusing capacity of the lung for carbon monoxide (D LCO)% and transfer coefficient of the lung for carbon monoxide (K CO)% (median change in D LCO%=7%, p=0.04, and K CO%=13%, p=0.02). Relapse occurred in three out of seven patients. Five patients were treated with long-term mycophenolate mofetil (MMF) with/without corticosteroids for a mean duration of 1277±917 days. No changes were found in spirometry; however, there was a significant increase in D LCO% and K CO% (median change in each of D LCO% and K CO%=10%, p=0.04). Four patients on steroids with MMF successfully weaned the prednisone dose over 12 months. Four patients never received immunosuppression therapy. A significant decline was found in their lung function assessed over 7.5 years. The median reduction in the forced vital capacity (FVC)%, forced expiratory volume in 1 s (FEV1)% and D LCO% was 15%, 7% and 15%, equivalent to 2%, 1% and 2% per year, respectively. Conclusion Corticosteroids improve gas transfer in GLILD, but patients often relapse. The use of MMF was associated with long-term effectiveness in GLILD and permits weaning of corticosteroids. A delay in initiating and continuing maintenance treatment could lead to disease progression.
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Affiliation(s)
- Heba M. Bintalib
- UCL Respiratory, University College London, London, UK,Department of Respiratory Care, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia,Corresponding author: Heba M. Bintalib ()
| | - David M. Lowe
- Institute of Immunity and Transplantation, University College London, London, UK,Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - Gaia Mancuso
- Unit of Immunology, Rheumatology, Allergy, and Rare Diseases (UnIRAR), Vita-Salute San Raffaele University, Milan, Italy
| | - Georgia Gkrepi
- Respiratory Medicine Department, University Hospital of Ioannina, Ioannina, Greece
| | | | - Siobhan O. Burns
- Institute of Immunity and Transplantation, University College London, London, UK,Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - John R. Hurst
- UCL Respiratory, University College London, London, UK
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16
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Common variable immunodeficiency and its inflammatory neurological manifestations: a case report and literature review. Mult Scler Relat Disord 2022; 67:104086. [DOI: 10.1016/j.msard.2022.104086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/26/2022] [Accepted: 07/31/2022] [Indexed: 11/19/2022]
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17
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Joshi TP, Wang HY, Athukuri P, Bohac S, Farr MA, Hinson D, Kahla JA, Khalfe N, McBee DB, Stroh R, Walters N, Ren V. Biologic Therapies for the Management of Cutaneous Findings in Genodermatoses: A Review. Am J Clin Dermatol 2022; 23:673-688. [PMID: 35606649 DOI: 10.1007/s40257-022-00700-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 01/17/2023]
Abstract
Genodermatoses are genetically inherited dermatologic conditions. The management of cutaneous findings in genodermatoses is challenging, and first-line therapies, such as steroids and/or retinoids, are often inadequate. In recent years, research on the molecular basis of genodermatoses has led to the use of biologic therapies for intractable disease. Here, we review the evidence regarding the use of available biologic therapies for the management of dermatologic findings in genodermatoses. Biologic therapies appear to be promising therapeutic options for several recalcitrant genodermatoses, especially those with underlying immune dysregulation. However, not all genodermatoses are amenable to biologic therapies, and some have been shown to paradoxically worsen under treatment. Biologic therapies offer a novel avenue to target refractory genodermatoses. However, evidence supporting the use of biologic therapies in the management of genodermatoses is mostly limited to case reports and case series. Further studies are warranted to determine the safety and efficacy of biologic therapies for the management of cutaneous findings in genodermatoses.
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18
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Pulmonary Manifestations of Primary Humoral Deficiencies. Can Respir J 2022; 2022:7140919. [PMID: 35440951 PMCID: PMC9013573 DOI: 10.1155/2022/7140919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/16/2022] [Accepted: 03/25/2022] [Indexed: 01/13/2023] Open
Abstract
Primary immunodeficiencies are a group of conditions characterized by developmental or functional alterations in the immune system caused by hereditary genetic defects. Primary immunodeficiencies may affect either the innate or the adaptive (humoral and cellular) immune system. Pulmonary complications in primary humoral deficiencies are frequent and varied and are associated with high morbidity and mortality rates. The types of complications include bronchiectasis secondary to recurrent respiratory infections and interstitial pulmonary involvement, which can be associated with autoimmune cytopenias, lymphoproliferation, and a range of immunological manifestations. Early detection is key to timely management. Immunoglobulin replacement therapy reduces the severity of disease, the frequency of exacerbations, and hospital admissions in some primary humoral deficiencies. Therefore, the presence of pulmonary disease with concomitant infectious and/or autoimmune complications should raise suspicion of primary humoral deficiencies and warrants a request for immunoglobulin determination in blood. Once diagnosis is confirmed; early immunoglobulin replacement therapy will improve the course of the disease. Further studies are needed to better understand the pathogenesis of pulmonary disease related to primary humoral deficiencies and favor the development of targeted therapies that improve the prognosis of patients.
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19
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Abstract
INTRODUCTION There is a wide spectrum of noninfectious gastrointestinal pathology, causing considerable morbidity and mortality in CVID, where both etiology and effective therapy are under debate. AREAS COVERED This review will focus on the noninfectious inflammation in the GI tract in CVID patients, covering the both the upper and lower GI tract inflammation, including the liver. The controversy of the CVID enteropathy definition and that of gluten-free diet for celiac-like disease in CVID will be discussed. Furthermore, the review will cover the link between GI inflammation and GI cancer. Finally, the role of gut microbiota, IgA, and genetics and its relationship with CVID enteropathy is scrutinized. The authors reviewed literature from PubMed. EXPERT OPINION The heterogeneity and the unknown mechanism behind CVID enteropathy, and thereby the lack of effective treatment, is one of the key challenges in the field of CVID. Celiac-like disease in CVID is due to immune dysregulation, and a gluten-free diet is therefore not indicated. Gut microbial dysbiosis and mucosal IgA can initiate systemic and local inflammation and is involved in the immune dysregulation in CVID. Considering the heterogeneity of CVID enteropathy, personalized medicine is probably the future for these patients.
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Affiliation(s)
- I M Andersen
- Section of Clinical Immunology and Infectious Diseases, Department of Rheumatology, Dermatology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway
| | - S F Jørgensen
- Section of Clinical Immunology and Infectious Diseases, Department of Rheumatology, Dermatology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway.,Research Institute of Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Norway
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20
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Perlman DM, Sudheendra MT, Racilla E, Allen TL, Joshi A, Bhargava M. Granulomatous-Lymphocytic Interstitial Lung Disease Mimicking Sarcoidosis. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2021; 38:e2021025. [PMID: 34744421 PMCID: PMC8552568 DOI: 10.36141/svdld.v38i3.11114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/12/2021] [Indexed: 11/07/2022]
Abstract
Common variable immunodeficiency (CVID) is one of the most common primary immunodeficiency disorders characterized by hypogammaglobulinemia and inadequate antibody response to immunizations. The impaired antibody response occurs due to the failure of B cells to differentiate into plasma cells resulting in low immunoglobulins levels and increased frequency of infections. Granulomatous and Lymphocytic Interstitial Lung Disease (GLILD) is a non-infectious complication of CVID that is seen in 10-30% of cases. GLILD is a multisystem inflammatory disease involving the lungs, lymph node, liver, spleen and gastrointestinal tract that mimics sarcoidosis. This report describes a series of cases who presented with dyspnea, recurrent respiratory infections or autoimmunity and on further evaluation revealed features suggestive of GLILD. There is very limited understanding of GLILD in terms of clinical presentation, the histo-pathological logical findings, and the diagnostic criteria by itself are limited. A diagnosis of GLILD is established in cases of CVID when there is evidence of lymphoproliferation, cytopenia, autoimmune processes and a lung biopsy demonstrating lymphocytic interstitial pneumonia, follicular bronchiolitis, lymphoid hyperplasia, and/or non-necrotizing granulomas. We review the treatment strategies, including replacement of immunoglobulin and agents targeting B and T lymphocytes. Systematic characterization of GLILD cases and long term follow up studies are sorely needed to understand the natural history of GLILD.
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Affiliation(s)
- David M Perlman
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine University of Minnesota Medical School, Minneapolis, MN, USA
| | - Muthya Tejasvini Sudheendra
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine University of Minnesota Medical School, Minneapolis, MN, USA
| | - Emilian Racilla
- Department of Lab Medicine and Pathology, University of Minnesota Medical School, Minneapolis MN, USA
| | - Tadashi L Allen
- Department of Radiology, University of Minnesota Medical School, Minneapolis MN, USA
| | - Avni Joshi
- Division of Allergy and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Maneesh Bhargava
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine University of Minnesota Medical School, Minneapolis, MN, USA
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21
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Rodina Y, Deripapa E, Shvets O, Mukhina A, Roppelt A, Yuhacheva D, Laberko A, Burlakov V, Abramov D, Tereshchenko G, Novichkova G, Shcherbina A. Rituximab and Abatacept Are Effective in Differential Treatment of Interstitial Lymphocytic Lung Disease in Children With Primary Immunodeficiencies. Front Immunol 2021; 12:704261. [PMID: 34566961 PMCID: PMC8458825 DOI: 10.3389/fimmu.2021.704261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022] Open
Abstract
Background Interstitial lymphocytic lung disease (ILLD), a recently recognized complication of primary immunodeficiencies (PID), is caused by immune dysregulation, abnormal bronchus-associated lymphoid tissue (BALT) hyperplasia, with subsequent progressive loss of pulmonary function. Various modes of standard immunosuppressive therapy for ILLD have been shown as only partially effective. Objectives To retrospectively evaluate the safety and efficacy of abatacept or rituximab in treatment of ILLD in children with PID. Methods 29 children (median age 11 years) with various forms of PID received one of the two therapy regimens predominantly based on the lesions’ immunohistopathology: children with prevalent B-cell lung infiltration received rituximab (n = 16), and those with predominantly T-cell infiltration received abatacept (n = 17). Clinical and radiological symptoms were assessed using a severity scale developed for the study. Results The targeted therapy with abatacept (A) or rituximab (R) enabled long-term control of clinical (A 3.4 ± 1.3 vs. 0.6 ± 0.1; R 2.8 ± 1 vs. 0.7 ± 0.05, p < 0.01) and radiological (A 18.4 ± 3.1 vs. 6.0 ± 2.0; R 30 ± 7.1 vs. 10 ± 1.7, p < 0.01) symptoms of ILLD in both groups and significantly improved patients’ quality of life, as measured by the total scale (TS) score of 57 ± 2.1 in treatment recipients vs. 31.2 ± 1.9 before therapy (p < 0.01). Conclusions ILLD histopathology should be considered when selecting treatment. Abatacept and rituximab are effective and safe in differential treatment of ILLD in children.
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Affiliation(s)
- Yulia Rodina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - E Deripapa
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - O Shvets
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - A Mukhina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - A Roppelt
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - D Yuhacheva
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - A Laberko
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - V Burlakov
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - D Abramov
- Department of Pathology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - G Tereshchenko
- Department of Radiology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - G Novichkova
- Department of Hematology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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22
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Crohn's-like Enteritis in X-Linked Agammaglobulinemia: A Case Series and Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3466-3478. [PMID: 34029777 DOI: 10.1016/j.jaip.2021.04.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND X-linked agammaglobulinemia (XLA) is an inherited primary immunodeficiency that usually manifests clinically with recurrent sinopulmonary infections. Gastrointestinal manifestations are mostly driven by acute infections and disturbed mucosal immunity, but there is a notable prevalence of inflammatory bowel disease (IBD). Differentiating between XLA-associated enteritis, which can originate from recurrent infections, and IBD can be diagnostically and therapeutically challenging. OBJECTIVE This study presents a critical appraisal of the clinical, radiological, endoscopic, and histological features associated with XLA-associated Crohn disease (CD)-like enteritis. METHODS We report 3 cases and performed a systematic review of the literature describing the diagnoses and outcomes. RESULTS An XLA-related enteropathy presented in adolescence with an ileocolonic CD-like phenotype without perianal disease. Abdominal pain, noninfectious diarrhea, and weight loss were the most common symptoms. Imaging and endoscopic findings closely resemble CD. However, histologically, it presents without nodular lymphoid hyperplasia and only 2 studies reported the presence of granulomas. In addition, in XLA-associated enteritis, immunohistochemistry showed the absence or marked reduction in B cells and plasma cells. CONCLUSIONS An XLA-associated enteritis is a distinct pathological process that presents clinically in a manner similar to ileocolonic CD. It is important to evaluate for infectious diarrhea, which is common in XLA and can mimic IBD clinically. Complete multidisciplinary evaluation is, therefore, recommended for XLA patients with persistent gastrointestinal symptoms. Although more research is needed, therapeutic selection for XLA-associated enteritis is like that of IBD, and the possible risk of drug interactions and complications from increasing immunosuppression should be considered.
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23
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Lamers OAC, Smits BM, Leavis HL, de Bree GJ, Cunningham-Rundles C, Dalm VASH, Ho HE, Hurst JR, IJspeert H, Prevaes SMPJ, Robinson A, van Stigt AC, Terheggen-Lagro S, van de Ven AAJM, Warnatz K, van de Wijgert JHHM, van Montfrans J. Treatment Strategies for GLILD in Common Variable Immunodeficiency: A Systematic Review. Front Immunol 2021; 12:606099. [PMID: 33936030 PMCID: PMC8086379 DOI: 10.3389/fimmu.2021.606099] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/24/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Besides recurrent infections, a proportion of patients with Common Variable Immunodeficiency Disorders (CVID) may suffer from immune dysregulation such as granulomatous-lymphocytic interstitial lung disease (GLILD). The optimal treatment of this complication is currently unknown. Experienced-based expert opinions have been produced, but a systematic review of published treatment studies is lacking. Goals To summarize and synthesize the published literature on the efficacy of treatments for GLILD in CVID. Methods We performed a systematic review using the PRISMA guidelines. Papers describing treatment and outcomes in CVID patients with radiographic and/or histologic evidence of GLILD were included. Treatment regimens and outcomes of treatment were summarized. Results 6124 papers were identified and 42, reporting information about 233 patients in total, were included for review. These papers described case series or small, uncontrolled studies of monotherapy with glucocorticoids or other immunosuppressants, rituximab monotherapy or rituximab plus azathioprine, abatacept, or hematopoietic stem cell transplantation (HSCT). Treatment response rates varied widely. Cross-study comparisons were complicated because different treatment regimens, follow-up periods, and outcome measures were used. There was a trend towards more frequent GLILD relapses in patients treated with corticosteroid monotherapy when compared to rituximab-containing treatment regimens based on qualitative endpoints. HSCT is a promising alternative to pharmacological treatment of GLILD, because it has the potential to not only contain symptoms, but also to resolve the underlying pathology. However, mortality, especially among immunocompromised patients, is high. Conclusions We could not draw definitive conclusions regarding optimal pharmacological treatment for GLILD in CVID from the current literature since quantitative, well-controlled evidence was lacking. While HSCT might be considered a treatment option for GLILD in CVID, the risks related to the procedure are high. Our findings highlight the need for further research with uniform, objective and quantifiable endpoints. This should include international registries with standardized data collection including regular pulmonary function tests (with carbon monoxide-diffusion), uniform high-resolution chest CT radiographic scoring, and uniform treatment regimens, to facilitate comparison of treatment outcomes and ultimately randomized clinical trials.
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Affiliation(s)
- Olivia A C Lamers
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Bas M Smits
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, Netherlands.,Department of Immunology and Rheumatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Helen Louisa Leavis
- Department of Immunology and Rheumatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Godelieve J de Bree
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Charlotte Cunningham-Rundles
- Department of Medicine, Division of Clinical Immunology and Department of Pediatrics, Mount Sinai Hospital, New York, NY, United States
| | - Virgil A S H Dalm
- Department of Internal Medicine, Division of Clinical Immunology and Department of Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hsi-En Ho
- Department of Medicine, Division of Clinical Immunology and Department of Pediatrics, Mount Sinai Hospital, New York, NY, United States
| | - John R Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Hanna IJspeert
- Department of Internal Medicine, Division of Clinical Immunology and Department of Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sabine M P J Prevaes
- Wilhelmina Children's Hospital, Department of Pediatric Pulmonology, Utrecht, Netherlands
| | - Alex Robinson
- UCL Respiratory, University College London, London, United Kingdom
| | - Astrid C van Stigt
- Department of Internal Medicine, Division of Clinical Immunology and Department of Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Terheggen-Lagro
- Department of Pediatric Pulmonology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Annick A J M van de Ven
- Departments of Rheumatology and Clinical Immunology, Internal Medicine and Allergology, University Medical Center Groningen, Groningen, Netherlands
| | - Klaus Warnatz
- Department of Immunology, Universitätsklinikum Freiburg, Freiburg, Germany.,Department of Rheumatology and Clinical Immunology, Division of Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Janneke H H M van de Wijgert
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Joris van Montfrans
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, Netherlands
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24
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Strunz PP, Fröhlich M, Gernert M, Schwaneck EC, Nagler LK, Kroiss A, Tony HP, Schmalzing M. Rituximab for the Treatment of Common Variable Immunodeficiency (CVID) with Pulmonary and Central Nervous System Involvement. Open Rheumatol J 2021. [DOI: 10.2174/1874312902115010009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background:
Granulomatous and lymphocytic interstitial lung disease (GLILD) represents a typical form of pulmonary manifestation of CVID. Except for glucocorticoid- and immunoglobulin-administration, no standardized treatment recommendations exist.
Objective:
To investigate our CVID-patients with GLILD for the applied immunosuppressive regimen, with a focus on rituximab.
Methods:
A retrospective analysis of all CVID-patients for the manifestation and treatment of GLILD at a single German center was performed in this study. For the evaluation of treatment-response, CT-imaging and pulmonary function testing were used.
Results:
50 patients were identified for the diagnosis of a CVID. 12% (n = 6) have radiological and/or histological confirmed diagnosis of a GLILD. Three patients received rituximab in a dose of 2 x 1000mg, separated by 2 weeks repeatedly. All patients showed radiological response and stabilization or improvement of the pulmonary function. Rituximab was used in one patient over 13 years with repeated treatment-response. Furthermore, the synchronic central nervous system-involvement of a GLILD-patient also responded to rituximab-treatment. With sufficient immunoglobulin-replacement-therapy, the occurring infections were manageable without the necessity of intensive care treatment.
Conclusion:
Rituximab might be considered as an effective and relatively safe treatment for CVID-patients with GLILD.
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25
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Rubella Vaccine Persistence Within Cutaneous Granulomas in Common Variable Immunodeficiency Disorder. Am J Dermatopathol 2021; 42:455-457. [PMID: 31899704 DOI: 10.1097/dad.0000000000001598] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Common variable immunodeficiency disorder is a primary immunodeficiency disorder characterized by reduced levels of serum immunoglobulins and impaired antibody response. This condition may be associated with development of noninfectious granulomatous dermatitis of the skin which may be disfiguring and destructive. There are no published guidelines for the treatment of cutaneous granulomas in this patient population. In recent studies, rubella virus-positive cells in granulomas were localized to M2 macrophages which have an important role in wound healing and the secretion of immunoregulatory cytokines. We present a case of treatment-refractory, disfiguring common variable immunodeficiency disorder-associated granulomatous dermatitis. Immunofluorescence microscopy of the biopsy specimen confirmed the presence of rubella vaccine capsid proteins in M2 macrophages within the granuloma, a newly recognized phenomenon in this patient population. This knowledge may serve to identify future therapeutic targets or preventative strategies for granulomatous dermatitis in patients with primary immunodeficiency disorder.
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26
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Janssen LMA, van der Flier M, de Vries E. Lessons Learned From the Clinical Presentation of Common Variable Immunodeficiency Disorders: A Systematic Review and Meta-Analysis. Front Immunol 2021; 12:620709. [PMID: 33833753 PMCID: PMC8021796 DOI: 10.3389/fimmu.2021.620709] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/24/2021] [Indexed: 12/22/2022] Open
Abstract
Background Diagnostic delay in common variable immunodeficiency disorders (CVID) is considerable. There is no generally accepted symptom-recognition framework for its early detection. Objective To systematically review all existing data on the clinical presentation of CVID. Methods PubMed, EMBASE and Cochrane were searched for cohort studies, published January/1999-December/2019, detailing the clinical manifestations before, at and after the CVID-diagnosis. Results In 51 studies (n=8521 patients) 134 presenting and 270 total clinical manifestations were identified. Recurrent upper and/or lower respiratory infections were present at diagnosis in 75%. Many patients had suffered severe bacterial infections (osteomyelitis 4%, meningitis 6%, septicemia 8%, mastoiditis 8%). Bronchiectasis (28%), lymphadenopathy (27%), splenomegaly (13%), inflammatory bowel disease (11%), autoimmune cytopenia (10%) and idiopathic thrombocytopenia (6%) were also frequently reported. A bimodal sex distribution was found, with male predominance in children (62%) and female predominance in adults (58%). 25% of CVID-patients developed other manifestations besides infections in childhood, this percentage was much higher in adults (62%). Immune-dysregulation features, such as granulomatous-lymphocytic interstitial lung disease and inflammatory bowel disease, were more prominent in adults. Conclusions The shift from male predominance in childhood to female predominance in adults suggests differences in genetic and environmental etiology in CVID and has consequences for pathophysiologic studies. We confirm the high frequency of respiratory infections at presentation, but also show a high incidence of severe bacterial infections such as sepsis and meningitis, and immune dysregulation features including lymphoproliferative, gastrointestinal and autoimmune manifestations. Early detection of CVID may be improved by screening for antibody deficiency in patients with these manifestations.
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Affiliation(s)
- Lisanne M A Janssen
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Department of Pediatrics, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Michiel van der Flier
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Esther de Vries
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Laboratory of Medical Microbiology and Immunology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
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27
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Matson EM, Abyazi ML, Bell KA, Hayes KM, Maglione PJ. B Cell Dysregulation in Common Variable Immunodeficiency Interstitial Lung Disease. Front Immunol 2021; 11:622114. [PMID: 33613556 PMCID: PMC7892472 DOI: 10.3389/fimmu.2020.622114] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/23/2020] [Indexed: 12/16/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequently diagnosed primary antibody deficiency. About half of CVID patients develop chronic non-infectious complications thought to be due to intrinsic immune dysregulation, including autoimmunity, gastrointestinal disease, and interstitial lung disease (ILD). Multiple studies have found ILD to be a significant cause of morbidity and mortality in CVID. Yet, the precise mechanisms underlying this complication in CVID are poorly understood. CVID ILD is marked by profound pulmonary infiltration of both T and B cells as well as granulomatous inflammation in many cases. B cell depletive therapy, whether done as a monotherapy or in combination with another immunosuppressive agent, has become a standard of therapy for CVID ILD. However, CVID is a heterogeneous disorder, as is its lung pathology, and the precise patients that would benefit from B cell depletive therapy, when it should administered, and how long it should be repeated all remain gaps in our knowledge. Moreover, some have ILD recurrence after B cell depletive therapy and the relative importance of B cell biology remains incompletely defined. Developmental and functional abnormalities of B cell compartments observed in CVID ILD and related conditions suggest that imbalance of B cell signaling networks may promote lung disease. Included within these potential mechanisms of disease is B cell activating factor (BAFF), a cytokine that is upregulated by the interferon gamma (IFN-γ):STAT1 signaling axis to potently influence B cell activation and survival. B cell responses to BAFF are shaped by the divergent effects and expression patterns of its three receptors: BAFF receptor (BAFF-R), transmembrane activator and CAML interactor (TACI), and B cell maturation antigen (BCMA). Moreover, soluble forms of BAFF-R, TACI, and BCMA exist and may further influence the pathogenesis of ILD. Continued efforts to understand how dysregulated B cell biology promotes ILD development and progression will help close the gap in our understanding of how to best diagnose, define, and manage ILD in CVID.
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Affiliation(s)
- Erik M Matson
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Miranda L Abyazi
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Kayla A Bell
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Kevin M Hayes
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Paul J Maglione
- Pulmonary Center, Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
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28
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von Spee-Mayer C, Echternach C, Agarwal P, Gutenberger S, Soetedjo V, Goldacker S, Warnatz K. Abatacept Use Is Associated with Steroid Dose Reduction and Improvement in Fatigue and CD4-Dysregulation in CVID Patients with Interstitial Lung Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:760-770.e10. [DOI: 10.1016/j.jaip.2020.10.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 10/10/2020] [Accepted: 10/12/2020] [Indexed: 11/29/2022]
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29
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Viallard JF, Lebail B, Begueret H, Fieschi C. [Common variable immunodeficiency disorders: Part 2. Updated clinical manifestations and therapeutic management]. Rev Med Interne 2021; 42:473-481. [PMID: 33516581 DOI: 10.1016/j.revmed.2020.12.015] [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: 07/03/2020] [Revised: 12/04/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are the most common symptomatic primary antibody deficiency in adults with an estimated prevalence of 1/25,000. The most frequent clinical manifestations are upper respiratory tract infections (including pneumonia, bronchitis, and sinusitis) predominantly with Streptococcus pneumoniae or H. influenzae. However, CVID are complicated in 20 to 30 % of cases of non-infectious manifestations which have been well characterized in recent years. Several complications can be observed including autoimmune, lymphoproliferative, granulomatous or cancerous manifestations involving one or more organs. These complications, mostly antibody-mediated cytopenias, are correlated with a decrease in the number of circulating switched memory B cells. Replacement therapy with polyvalent gammaglobulins has greatly improved the prognosis of these patients but it remains poor in the presence of digestive complications (especially in the case of chronic enteropathy and/or porto-sinusoidal vascular disease), pulmonary complications (bronchiectasis and/or granulomatous lymphocytic interstitial lung disease) and when progression to lymphoma. Much progress is still to be made, in particular on the therapeutic management of non-infectious complications which should benefit in the future from targeted treatments based on knowledge of genetics and immunology.
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Affiliation(s)
- J F Viallard
- Service de médecine interne et maladies infectieuses, hôpital Haut-Lévêque, CHU de Bordeaux, 5, avenue de Magellan, 33604 Pessac, France; Université de Bordeaux, Bordeaux, France.
| | - B Lebail
- Université de Bordeaux, Bordeaux, France; Service d'anatomopathologie, hôpital Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
| | - H Begueret
- Service d'anatomopathologie, CHU Bordeaux, hôpital Haut-Lévêque, 5, avenue de Magellan, 33604 Pessac, France
| | - C Fieschi
- Département d'immunologie, université de Paris, AP-HP, France; INSERM U1126, centre Hayem, hôpital Saint-Louis, Paris, France
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30
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Fraz MSA, Moe N, Revheim ME, Stavrinou ML, Durheim MT, Nordøy I, Macpherson ME, Aukrust P, Jørgensen SF, Aaløkken TM, Fevang B. Granulomatous-Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency-Features of CT and 18F-FDG Positron Emission Tomography/CT in Clinically Progressive Disease. Front Immunol 2021; 11:617985. [PMID: 33584710 PMCID: PMC7874137 DOI: 10.3389/fimmu.2020.617985] [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: 10/15/2020] [Accepted: 12/08/2020] [Indexed: 11/13/2022] Open
Abstract
Common variable immunodeficiency (CVID) is characterized not only by recurrent bacterial infections, but also autoimmune and inflammatory complications including interstitial lung disease (ILD), referred to as granulomatous-lymphocytic interstitial lung disease (GLILD). Some patients with GLILD have waxing and waning radiologic findings, but preserved pulmonary function, while others progress to end-stage respiratory failure. We reviewed 32 patients with radiological features of GLILD from our Norwegian cohort of CVID patients, including four patients with possible monogenic defects. Nineteen had deteriorating lung function over time, and 13 had stable lung function, as determined by pulmonary function testing of forced vital capacity (FVC), and diffusion capacity of carbon monoxide (DLCO). The overall co-existence of other non-infectious complications was high in our cohort, but the prevalence of these was similar in the two groups. Laboratory findings such as immunoglobulin levels and T- and B-cell subpopulations were also similar in the progressive and stable GLILD patients. Thoracic computer tomography (CT) scans were systematically evaluated and scored for radiologic features of GLILD in all pulmonary segments. Pathologic features were seen in all pulmonary segments, with traction bronchiectasis as the most prominent finding. Patients with progressive disease had significantly higher overall score of pathologic features compared to patients with stable disease, most notably traction bronchiectasis and interlobular septal thickening. 18F-2-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/CT (PET/CT) was performed in 17 (11 with progressive and six with stable clinical disease) of the 32 patients and analyzed by quantitative evaluation. Patients with progressive disease had significantly higher mean standardized uptake value (SUVmean), metabolic lung volume (MLV) and total lung glycolysis (TLG) as compared to patients with stable disease. Nine patients had received treatment with rituximab for GLILD. There was significant improvement in pathologic features on CT-scans after treatment while there was a variable effect on FVC and DLCO. Conclusion Patients with progressive GLILD as defined by deteriorating pulmonary function had significantly greater pathology on pulmonary CT and FDG-PET CT scans as compared to patients with stable disease, with traction bronchiectasis and interlobular septal thickening as prominent features.
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Affiliation(s)
| | - Natasha Moe
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Mona-Elisabeth Revheim
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maria L Stavrinou
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Michael T Durheim
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Respiratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Ingvild Nordøy
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Magnhild Eide Macpherson
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Pål Aukrust
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Silje Fjellgård Jørgensen
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Trond Mogens Aaløkken
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Børre Fevang
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Centre for Rare Diseases, Oslo University Hospital, Oslo, Norway
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31
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Narula N, Iannuzzi M. Sarcoidosis: Pitfalls and Challenging Mimickers. Front Med (Lausanne) 2021; 7:594275. [PMID: 33505980 PMCID: PMC7829200 DOI: 10.3389/fmed.2020.594275] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.
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Affiliation(s)
- Naureen Narula
- Staten Island University Hospital, New York, NY, United States
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32
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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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van de Ven AAJM, Alfaro TM, Robinson A, Baumann U, Bergeron A, Burns SO, Condliffe AM, Fevang B, Gennery AR, Haerynck F, Jacob J, Jolles S, Malphettes M, Meignin V, Milota T, van Montfrans J, Prasse A, Quinti I, Renzoni E, Stolz D, Warnatz K, Hurst JR. Managing Granulomatous-Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency Disorders: e-GLILDnet International Clinicians Survey. Front Immunol 2020; 11:606333. [PMID: 33324422 PMCID: PMC7726128 DOI: 10.3389/fimmu.2020.606333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/27/2020] [Indexed: 12/15/2022] Open
Abstract
Background Granulomatous-lymphocytic interstitial lung disease (GLILD) is a rare, potentially severe pulmonary complication of common variable immunodeficiency disorders (CVID). Informative clinical trials and consensus on management are lacking. Aims The European GLILD network (e-GLILDnet) aims to describe how GLILD is currently managed in clinical practice and to determine the main uncertainties and unmet needs regarding diagnosis, treatment and follow-up. Methods The e-GLILDnet collaborators developed and conducted an online survey facilitated by the European Society for Immunodeficiencies (ESID) and the European Respiratory Society (ERS) between February-April 2020. Results were analyzed using SPSS. Results One hundred and sixty-one responses from adult and pediatric pulmonologists and immunologists from 47 countries were analyzed. Respondents treated a median of 27 (interquartile range, IQR 82-maximum 500) CVID patients, of which a median of 5 (IQR 8-max 200) had GLILD. Most respondents experienced difficulties in establishing the diagnosis of GLILD and only 31 (19%) had access to a standardized protocol. There was little uniformity in diagnostic or therapeutic interventions. Fewer than 40% of respondents saw a definite need for biopsy in all cases or performed bronchoalveolar lavage for diagnostics. Sixty-six percent used glucocorticosteroids for remission-induction and 47% for maintenance therapy; azathioprine, rituximab and mycophenolate mofetil were the most frequently prescribed steroid-sparing agents. Pulmonary function tests were the preferred modality for monitoring patients during follow-up. Conclusions These data demonstrate an urgent need for clinical studies to provide more evidence for an international consensus regarding management of GLILD. These studies will need to address optimal procedures for definite diagnosis and a better understanding of the pathogenesis of GLILD in order to provide individualized treatment options. Non-availability of well-established standardized protocols risks endangering patients.
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Affiliation(s)
- Annick A. J. M. van de Ven
- Departments of Internal Medicine and Allergology, Rheumatology and Clinical Immunology, University Medical Center Groningen, Netherlands
| | - Tiago M. Alfaro
- Pneumology Unit, Centro Hospital e Universitário de Coimbra, Coimbra, Portugal and Centre of Pneumology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | | | - Ulrich Baumann
- Department of Paediatric Pulmonology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Anne Bergeron
- Université de Paris, Assistance Publique Hôpitaux de Paris (APHP), Hôpital Saint Louis, Paris, France
| | - Siobhan O. Burns
- Institute of Immunity and Transplantation, University College London, Dept of Immunology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Alison M. Condliffe
- Department of Infection, Immunity and Cardiovascular Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Børre Fevang
- Centre for Rare Disorders and Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Andrew R. Gennery
- Translational and Clinical Research Institute, Newcastle University and Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
| | - Filomeen Haerynck
- Department of Pediatric Pulmonology and Immunology, Centre for Primary Immune deficiency Ghent, PID research lab, Ghent University Hospital, Belgium
| | - Joseph Jacob
- UCL Respiratory, University College London, London, United Kingdom
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
| | - Marion Malphettes
- Department of Clinical Immunology, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Université Paris Diderot, Paris, France
| | - Véronique Meignin
- Department of Pathology, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Tomas Milota
- Department of Immunology, Second Faculty of Medicine Charles University and Motol University Hospital, Prague, Czech Republic
| | - Joris van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antje Prasse
- Department of Pulmonology, Hannover Medical School and DZL BREATH, and Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Elisabetta Renzoni
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, United Kingdom
| | - Daiana Stolz
- Clinic for Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - John R. Hurst
- UCL Respiratory, University College London, London, United Kingdom
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Dhalla F, Lochlainn DJM, Chapel H, Patel SY. Histology of Interstitial Lung Disease in Common Variable Immune Deficiency. Front Immunol 2020; 11:605187. [PMID: 33329602 PMCID: PMC7718002 DOI: 10.3389/fimmu.2020.605187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Abstract
Interstitial lung disease (ILD) is an important non-infectious complication in several primary immune deficiencies. In common variable immune deficiency (CVID) it is associated with complex clinical phenotypes and adverse outcomes. The histology of ILD in CVID is heterogeneous and mixed patterns are frequently observed within a single biopsy, including non-necrotising granulomatous inflammation, lymphoid interstitial pneumonitis, lymphoid hyperplasia, follicular bronchiolitis, organizing pneumonia, and interstitial fibrosis; ILD has to be differentiated from lymphoma. The term granulomatous-lymphocytic interstitial lung disease (GLILD), coined to describe the histopathological findings within the lungs of patients with CVID with or without multisystem granulomata, is somewhat controversial as pulmonary granulomata are not always present on histology and the nature of infiltrating lymphocytes is variable. In this mini review we summarize the literature on the histology of CVID-related ILD and discuss some of the factors that may contribute to the inter- and intra- patient variability in the histological patterns reported. Finally, we highlight areas for future development. In particular, there is a need for standardization of histological assessments and reporting, together with a better understanding of the immunopathogenesis of CVID-related ILD to resolve the apparent heterogeneity of ILD in this setting and guide the selection of rational targeted therapies in different patients.
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Affiliation(s)
- Fatima Dhalla
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Developmental Immunology, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Dylan J Mac Lochlainn
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Helen Chapel
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Primary Immunodeficiency Unit, Nuffield Department of Medicine and National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Smita Y Patel
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Primary Immunodeficiency Unit, Nuffield Department of Medicine and National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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López A, Paolini M, Fernández Romero D. Lung disease in patients with common variable immunodeficiency. Allergol Immunopathol (Madr) 2020; 48:720-728. [PMID: 32446785 DOI: 10.1016/j.aller.2020.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Common Variable Immunodeficiency (CVID) is characterized by an impaired antibody production and a higher susceptibility to encapsulated bacterial infections. Lung disease is considered to be the most important cause of morbidity and mortality. METHODS We analyzed clinical, radiological and functional characteristics in 80 patients with CVID assisted in the Unidad Inmunologia e Histocompatibilidad at Durand Hospital from 1982 to 2018. RESULTS Of the 80 patients, 55 showed pathologic lung Computed Tomography (CT). Twenty of them (36.4%) showed bronchiectasis; 26 (47.3%) interstitial involvement associated with nodules and adenopathies called GLILD (granulomatous-lymphocytic interstitial lung disease); and nine patients (16.3%) showed other lesions. Nine percent of patients with lung disease showed CT progression; none of them had spirometry worsening. GLILD patients had normal and restrictive patterns in lung function tests, in equal proportions. Two patients - one with GLILD and the other one with bronchiectasis - had an increase in spirometric pattern severity without CT progression. Lung biopsy was performed in 19% of GLILD patients, all of whom had histopathologic diagnosis of Lymphoid Interstitial Pneumonia (LIP). CONCLUSIONS GLILD is the major cause of lung disease in CVID. Computed tomography is useful for diagnosis but not necessary in follow-up, in which functional tests should have better correlation with clinical evolution, reducing radiation exposure. Biopsy should be indicated when the clinical diagnosis is unclear. Treatment should be considered whenever there is clear evidence of disease progression.
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Rubella virus-associated chronic inflammation in primary immunodeficiency diseases. Curr Opin Allergy Clin Immunol 2020; 20:574-581. [PMID: 33044342 DOI: 10.1097/aci.0000000000000694] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF THE REVIEW The aim of this article is to summarize recent data on rubella virus (RuV) vaccine in chronic inflammation focusing on granulomas in individuals with primary immunodeficiencies (PIDs). RECENT FINDINGS The live attenuated RuV vaccine has been recently associated with cutaneous and visceral granulomas in children with various PIDs. RuV vaccine strain can persist for decades subclinically in currently unknown body site(s) before emerging in granulomas. Histologically, RuV is predominately localized in M2 macrophages in the granuloma centers. Multiple mutations accumulate during persistence resulting in emergence of immunodeficiency-related vaccine-derived rubella viruses (iVDRVs) with altered immunological, replication, and persistence properties. Viral RNA was detected in granuloma biopsies and nasopharyngeal secretions and infectious virus were isolated from the granuloma lesions. The risk of iVDRV transmissibility to contacts needs to be evaluated. Several broad-spectrum antiviral drugs have been tested recently but did not provide significant clinical improvement. Hematopoietic stem cell transplantation remains the only reliable option for curing chronic RuV-associated granulomas in PIDs. SUMMARY Persistence of vaccine-derived RuVs appears to be a crucial factor in a significant proportion of granulomatous disease in PIDs. RuV testing of granulomas in PID individuals might help with case management.
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Hanitsch L, Baumann U, Boztug K, Burkhard-Meier U, Fasshauer M, Habermehl P, Hauck F, Klock G, Liese J, Meyer O, Müller R, Pachlopnik-Schmid J, Pfeiffer-Kascha D, Warnatz K, Wehr C, Wittke K, Niehues T, von Bernuth H. Treatment and management of primary antibody deficiency: German interdisciplinary evidence-based consensus guideline. Eur J Immunol 2020; 50:1432-1446. [PMID: 32845010 DOI: 10.1002/eji.202048713] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/25/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022]
Abstract
This evidence-based clinical guideline provides consensus-recommendations for the treatment and care of patients with primary antibody deficiencies (PADs). The guideline group comprised 20 clinical and scientific expert associations of the German, Swiss, and Austrian healthcare system and representatives of patients. Recommendations were based on results of a systematic literature search, data extraction, and evaluation of methodology and study quality in combination with the clinical expertise of the respective representatives. Consensus-based recommendations were determined via nominal group technique. PADs are the largest clinically relevant group of primary immunodeficiencies. Most patients with PADs present with increased susceptibility to infections, however immune dysregulation, autoimmunity, and cancer affect a significant number of patients and may precede infections. This guideline therefore covers interdisciplinary clinical and therapeutic aspects of infectious (e.g., antibiotic prophylaxis, management of bronchiectasis) and non-infectious manifestations (e.g., management of granulomatous disease, immune cytopenia). PADs are grouped into disease entities with definitive, probable, possible, or unlikely benefit of IgG-replacement therapy. Summary and consensus-recommendations are provided for treatment indication, dosing, routes of administration, and adverse events of IgG-replacement therapy. Special aspects of concomitant impaired T-cell function are highlighted as well as clinical data on selected monogenetic inborn errors of immunity formerly classified into PADs (APDS, CTLA-4-, and LRBA-deficiency).
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Affiliation(s)
- Leif Hanitsch
- Institute for Medical Immunology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Ulrich Baumann
- Department of Paediatric Pulmonology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Kaan Boztug
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Department of Pediatrics and Adolescent Medicine and St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | | | - Maria Fasshauer
- ImmunoDeficiencyCenter Leipzig (IDCL), Hospital St. Georg gGmbH Leipzig, Academic Teaching Hospital of the University of Leipzig, Leipzig, Germany
| | | | - Fabian Hauck
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerd Klock
- Technische Universität Darmstadt, Clemens-Schöpf-Institut für Organische Chemie & Biochemie, Darmstadt, Germany
| | - Johannes Liese
- Pediatric Immunology, Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Oliver Meyer
- Institute of Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Rainer Müller
- Klinik und Poliklinik für HNO-Heilkunde, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jana Pachlopnik-Schmid
- Division of Immunology, University Children's Hospital Zurich and University of Zurich, Switzerland
| | | | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Wehr
- Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kirsten Wittke
- Institute for Medical Immunology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Tim Niehues
- Department of Pediatrics, Helios Klinikum Krefeld, Krefeld, Germany
| | - Horst von Bernuth
- Department of Immunology, Labor Berlin Charité - Vivantes GmbH, Berlin, Germany.,Berlin Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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Verbsky JW, Hintermeyer MK, Simpson PM, Feng M, Barbeau J, Rao N, Cool CD, Sosa-Lozano LA, Baruah D, Hammelev E, Busalacchi A, Rymaszewski A, Woodliff J, Chen S, Bausch-Jurken M, Routes JM. Rituximab and antimetabolite treatment of granulomatous and lymphocytic interstitial lung disease in common variable immunodeficiency. J Allergy Clin Immunol 2020; 147:704-712.e17. [PMID: 32745555 DOI: 10.1016/j.jaci.2020.07.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/08/2020] [Accepted: 07/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Granulomatous and lymphocytic interstitial lung disease (GLILD) is a life-threatening complication in patients with common variable immunodeficiency (CVID), but the optimal treatment is unknown. OBJECTIVE Our aim was to determine whether rituximab with azathioprine or mycophenolate mofetil improves the high-resolution computed tomography (HRCT) chest scans and/or pulmonary function test results in patients with CVID and GLILD. METHODS A retrospective chart review of clinical and laboratory data on 39 patients with CVID and GLILD who completed immunosuppressive therapy was performed. Chest HRCT scans, performed before therapy and after the conclusion of therapy, were blinded, randomized, and scored independently by 2 radiologists. Differences between pretreatment and posttreatment HRCT scan scores, pulmonary function test results, and lymphocyte subsets were analyzed. Whole exome sequencing was performed on all patients. RESULTS Immunosuppressive therapy improved patients' HRCT scan scores (P < .0001), forced vital capacity (P = .0017), FEV1 (P = .037), and total lung capacity (P = .013) but not their lung carbon monoxide diffusion capacity (P = .12). Nine patients relapsed and 6 completed retreatment, with 5 of 6 of these patients (83%) having improved HRCT scan scores (P = .063). Relapse was associated with an increased number of B cells (P = .016) and activated CD4 T cells (P = .016). Four patients (10%) had pneumonia while undergoing active treatment, and 2 patients (5%) died after completion of therapy. Eight patients (21%) had a damaging mutation in a gene known to predispose (TNFRSF13B [n = 3]) or cause a CVID-like primary immunodeficiency (CTLA4 [n = 2], KMT2D [n = 2], or BIRC4 [n = 1]). Immunosuppression improved the HRCT scan scores in patients with (P = .0078) and without (P < .0001) a damaging mutation. CONCLUSIONS Immunosuppressive therapy improved the radiographic abnormalities and pulmonary function of patients with GLILD. A majority of patients had sustained remissions.
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Affiliation(s)
- James W Verbsky
- Division of Pediatric Rheumatology, Medical College Wisconsin, Milwaukee, Wis; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Mary K Hintermeyer
- Asthma, Allergy and Clinical Immunology, Children's Wisconsin, Milwaukee, Wis
| | - Pippa M Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Department of Quantitative Health Sciences, Medical College Wisconsin, Milwaukee, Wis
| | - Mingen Feng
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Department of Quantitative Health Sciences, Medical College Wisconsin, Milwaukee, Wis
| | - Jody Barbeau
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Department of Quantitative Health Sciences, Medical College Wisconsin, Milwaukee, Wis
| | - Nagarjun Rao
- Department of Pathology, Aurora Clinical Laboratories/Great Lakes Pathologists, Aurora West Allis Medical Center, West Allis, Wis
| | - Carlyne D Cool
- Department of Pathology and Division of Pulmonary and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo; National Jewish Health, Denver, Colo
| | - Luis A Sosa-Lozano
- Division of Diagnostic Radiology, Medical College of Wisconsin, Milwaukee, Wis
| | - Dhiraj Baruah
- Division of Thoracic Radiology, Medical University of South Carolina, Charleston, SC
| | - Erin Hammelev
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Asthma, Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wis
| | - Alyssa Busalacchi
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Asthma, Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wis
| | - Amy Rymaszewski
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Asthma, Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wis
| | - Jeff Woodliff
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Asthma, Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wis
| | - Shaoying Chen
- Division of Pediatric Rheumatology, Medical College Wisconsin, Milwaukee, Wis; Division of Asthma, Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wis
| | - Mary Bausch-Jurken
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Asthma, Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wis
| | - John M Routes
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Asthma, Allergy and Clinical Immunology, Medical College of Wisconsin, Milwaukee, Wis.
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Primary Humoral Immune Deficiencies: Overlooked Mimickers of Chronic Immune-Mediated Gastrointestinal Diseases in Adults. Int J Mol Sci 2020; 21:ijms21155223. [PMID: 32718006 PMCID: PMC7432083 DOI: 10.3390/ijms21155223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022] Open
Abstract
In recent years, the incidence of immune-mediated gastrointestinal disorders, including celiac disease (CeD) and inflammatory bowel disease (IBD), is increasingly growing worldwide. This generates a need to elucidate the conditions that may compromise the diagnosis and treatment of such gastrointestinal disorders. It is well established that primary immunodeficiencies (PIDs) exhibit gastrointestinal manifestations and mimic other diseases, including CeD and IBD. PIDs are often considered pediatric ailments, whereas between 25 and 45% of PIDs are diagnosed in adults. The most common PIDs in adults are the selective immunoglobulin A deficiency (SIgAD) and the common variable immunodeficiency (CVID). A trend to autoimmunity occurs, while gastrointestinal disorders are common in both diseases. Besides, the occurrence of CeD and IBD in SIgAD/CVID patients is significantly higher than in the general population. However, some differences concerning diagnostics and management between enteropathy/colitis in PIDs, as compared to idiopathic forms of CeD/IBD, have been described. There is an ongoing discussion whether CeD and IBD in CVID patients should be considered a true CeD and IBD or just CeD-like and IBD-like diseases. This review addresses the current state of the art of the most common primary immunodeficiencies in adults and co-occurring CeD and IBD.
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Beaton TJ, Gillis D, Morwood K, Bint M. Granulomatous lymphocytic interstitial lung disease: limiting immunosuppressive therapy-a single-centre experience. Respirol Case Rep 2020; 8:e00565. [PMID: 32377343 PMCID: PMC7199072 DOI: 10.1002/rcr2.565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 01/09/2023] Open
Abstract
Granulomatous lymphocytic interstitial lung disease (GLILD) is characterized by lymphocytic and granulomatous pulmonary infiltration occurring in common variable immunodeficiency (CVID). It is associated with increased mortality compared with CVID patients without GLILD. There are no treatment guidelines due to the low prevalence and the heterogeneity of the condition. A case review of three patients diagnosed with GLILD was performed from a single Australian centre. Patients met the European Society of Immunodeficiency criteria for CVID and a diagnosis of GLILD was confirmed by a multidisciplinary team. Patients were managed with immunoglobulin (Ig) replacement and immunosuppressive agents if required: the decision for immunosuppression was made on the basis of symptoms and declining pulmonary function. All patients clinically improved. One patient had immunosuppressive treatment ceased. GLILD responds to varying immunosuppressive regimes when IgG monotherapy fails. Immunosuppressive therapy can be discontinued following improvement, but patients require close observation. This series helps inform future GLILD treatment guidelines.
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Affiliation(s)
- Thomas J. Beaton
- Department of Clinical Immunology and AllergySunshine Coast University HospitalBirtinyaQLDAustralia
| | - David Gillis
- Department of Clinical Immunology and AllergySunshine Coast University HospitalBirtinyaQLDAustralia
| | - Karen Morwood
- Department of Clinical Immunology and AllergySunshine Coast University HospitalBirtinyaQLDAustralia
| | - Michael Bint
- Department of Respiratory MedicineSunshine Coast University HospitalBirtinyaQLDAustralia
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Froehlich M, Schwaneck EC, Gernert M, Gadeholt O, Strunz PP, Morbach H, Tony HP, Schmalzing M. Autologous Stem Cell Transplantation in Common Variable Immunodeficiency: A Case of Successful Treatment of Severe Refractory Autoimmune Encephalitis. Front Immunol 2020; 11:1317. [PMID: 32670291 PMCID: PMC7330058 DOI: 10.3389/fimmu.2020.01317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most common primary immunodeficiency in adults. It is associated with hypogammaglobulinemia, recurring infections and autoimmune phenomena. Treatment includes immunoglobulin substitution and immunosuppressants. Autoimmune neurological manifestations of CVID are rare and occur predominantly as granulomatous disease. We report the case of a 35-year-old woman with CVID who developed autoimmune encephalitis as demonstrated by double cerebral biopsy. Infectious or malignant causes could be excluded. Despite intensive immunosuppressive therapy with common regimens no significant improvement could be achieved. Ultimately, an autologous hematopoietic stem cell transplantation (HSCT) was performed, resulting in lasting complete remission of the encephalitis. To our knowledge, this is the first report of refractory autoimmune phenomena in CVID treated by autologous HSCT.
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Affiliation(s)
- Matthias Froehlich
- Schwerpunkt Rheumatologie/Klinische Immunologie, Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
| | - Eva C Schwaneck
- Schwerpunkt Rheumatologie/Klinische Immunologie, Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
| | - Michael Gernert
- Schwerpunkt Rheumatologie/Klinische Immunologie, Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
| | - Ottar Gadeholt
- Rheumatologische Schwerpunktpraxis Würzburg, Würzburg, Germany
| | - Patrick-Pascal Strunz
- Schwerpunkt Rheumatologie/Klinische Immunologie, Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
| | - Henner Morbach
- Kinderklinik und Poliklinik, Universität Würzburg, Würzburg, Germany
| | - Hans-Peter Tony
- Schwerpunkt Rheumatologie/Klinische Immunologie, Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
| | - Marc Schmalzing
- Schwerpunkt Rheumatologie/Klinische Immunologie, Medizinische Klinik und Poliklinik II, Universität Würzburg, Würzburg, Germany
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Maglione PJ. Chronic Lung Disease in Primary Antibody Deficiency: Diagnosis and Management. Immunol Allergy Clin North Am 2020; 40:437-459. [PMID: 32654691 DOI: 10.1016/j.iac.2020.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic lung disease is a complication of primary antibody deficiency (PAD) associated with significant morbidity and mortality. Manifestations of lung disease in PAD are numerous. Thoughtful application of diagnostic approaches is imperative to accurately identify the form of disease. Much of the treatment used is adapted from immunocompetent populations. Recent genomic and translational medicine advances have led to specific treatments. As chronic lung disease has continued to affect patients with PAD, we hope that continued advancements in our understanding of pulmonary pathology will ultimately lead to effective methods that alleviate impact on quality of life and survival.
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Affiliation(s)
- Paul J Maglione
- Pulmonary Center, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA 02118, USA.
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43
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Ho HE, Cunningham-Rundles C. Non-infectious Complications of Common Variable Immunodeficiency: Updated Clinical Spectrum, Sequelae, and Insights to Pathogenesis. Front Immunol 2020; 11:149. [PMID: 32117289 PMCID: PMC7025475 DOI: 10.3389/fimmu.2020.00149] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/20/2020] [Indexed: 12/12/2022] Open
Abstract
Non-infectious complications in common variable immunodeficiency (CVID) have emerged as a major clinical challenge. Detailed clinical spectrum, organ-specific pathologies and associated sequelae from 623 CVID patients followed in New York since 1974 were analyzed, and recent insights to pathogenesis were reviewed. Non-infectious manifestations were present in 68.1% of patients, and they do not tend to be present in isolation. They include autoimmunity (33.2%), chronic lung disease (30.3%), lymphoid hyperplasia/splenomegaly (20.9%), liver disease (12.7%), granulomas (9.3%), gastrointestinal disease (7.3%), lymphoma (6.7%), and other malignancies (6.4%). In the lungs, interstitial disease and bronchiectasis were the most common findings, with lymphoma at this site being a rare (n = 6), but serious, manifestation. Bronchiectasis was not a prerequisite for the development of interstitial disease. In the liver, granulomas and nodular regenerative hyperplasia were the most common. Gastrointestinal disease may affect any segment of the intestinal tract, with lymphoid infiltrations and villous blunting being the leading histologic findings. With progression of organ-specific diseases, a wide spectrum of associated sequelae was observed. Lymphoma was more common in females (P = 0.036)—all B cell types except in one subject. Solid organ transplantations (liver, n = 5; lung, n = 4; combined lung and heart, n = 2) and hematopoietic stem cell transplantations (for B cell lymphoma, n = 1) have rarely been performed in this cohort, with mixed outcomes. Recent identification of monogenic defects, in ~10–30% of various CVID cohorts, has highlighted the molecular pathways that can affect both antibody production and broader immune regulation. In addition, cellular defects in both innate and adaptive immune systems are increasingly recognized in this syndrome.
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Affiliation(s)
- Hsi-En Ho
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Charlotte Cunningham-Rundles
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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van de Ven A, Mader I, Wolff D, Goldacker S, Fuhrer H, Rauer S, Grimbacher B, Warnatz K. Structural Noninfectious Manifestations of the Central Nervous System in Common Variable Immunodeficiency Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1047-1062.e6. [PMID: 31857261 DOI: 10.1016/j.jaip.2019.11.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/02/2019] [Accepted: 11/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Central nervous system (CNS) disease in adult common variable immunodeficiency (CVID) is rare, and therefore diagnostic and therapeutic protocols are lacking. OBJECTIVE To provide clinical information aiming to establish awareness and first experience-based recommendations. METHODS We reviewed clinical manifestations, genetic and immunological characteristics, diagnostic evaluation, and treatment of patients with CVID with abnormal magnetic resonance imaging (MRI) of the CNS disease in our cohort. RESULTS Seventeen patients with CNS manifestation and a previous diagnosis of CVID were identified. Presenting symptoms of the CNS disease included loss of sensory or motoric function, headache, or epilepsy. Contrast-enhancing lesions of the brain or solely the spinal cord were the most common findings on MRI. The prevalence of splenomegaly, lymphadenopathy, interstitial lung disease, and autoimmune cytopenia was significantly increased compared with control CVID patients. In 8 patients, a molecular defect was identified, including mutations in CTLA4, NFKB1, and CECR1. Patients with CVID with CNS involvement generally displayed lymphopenia, skewed CD4+ T-cell subsets, and increased proportions of CD21low B cells in the peripheral blood. CNS involvement usually responded well to high-dose steroids, but regularly required maintenance therapy to prevent relapse. CONCLUSION CNS disease is a severe but rare complication in CVID disorders, particularly affecting patients with other noninfectious disease symptoms. Diagnostic evaluation needs to rule out infectious causes by all means; a genetic evaluation is recommended given the high probability of an underlying monogenic disorder. Possible treatment consists of steroids with yet to be determined optimal maintenance therapy in case of relapse.
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Affiliation(s)
- Annick van de Ven
- Departments of Internal Medicine and Allergology, Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, the Netherlands; Department of Rheumatology and Clinical Immunology, Division of Immunodeficiency, Medical Center of the University Hospital, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Irina Mader
- Department of Radiology, Schön Klinik, Vogtareuth, Germany; Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Sigune Goldacker
- Department of Rheumatology and Clinical Immunology, Division of Immunodeficiency, Medical Center of the University Hospital, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hannah Fuhrer
- Department of Neurology and Neurophysiology, University Hospital Freiburg, Freiburg, Germany
| | - Sebastian Rauer
- Department of Neurology and Neurophysiology, University Hospital Freiburg, Freiburg, Germany
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany; DZIF - German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany; CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany; RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
| | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Division of Immunodeficiency, Medical Center of the University Hospital, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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45
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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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Agarwal S, Cunningham-Rundles C. Gastrointestinal Manifestations and Complications of Primary Immunodeficiency Disorders. Immunol Allergy Clin North Am 2019; 39:81-94. [PMID: 30466774 DOI: 10.1016/j.iac.2018.08.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastrointestinal (GI) involvement can be the presenting disease manifestation in patients with primary immunodeficiency disorders (PIDs). Infections and noninfectious diarrhea are frequent manifestations; however, malignancy and inflammatory and autoimmune-related GI diseases are also described. GI symptoms and disease seen in association with PIDs can mimic other diseases but are often resistant to conventional treatments owing to alternate disease mechanisms. Despite the advances in treatments for these conditions, therapy for immunodeficiency-related GI disease is often empiric.
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Affiliation(s)
- Shradha Agarwal
- Division of Allergy and Clinical Immunology after the Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1089, New York, NY 10029, USA.
| | - Charlotte Cunningham-Rundles
- Division of Allergy and Clinical Immunology after the Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1089, New York, NY 10029, USA
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Gupta A, Wang B, Gupta S. Granuloma-like lesion at subcutaneous immunoglobulin site in a common variable immunodeficiency patient. Immunotherapy 2019; 11:1177-1180. [PMID: 31478429 DOI: 10.2217/imt-2019-0109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Immunoglobulin therapy is the main stay in the treatment of primary antibody deficiencies. Granulomatous lesions are common complication in patients with common variable immunodeficiency (CVID). We present the first case of cutaneous granuloma-like lesion at site of subcutaneous immunoglobulin injections in a patient with CVID. These lesions resolve overtime following switching treatment to intravenous immunoglobulin. Unlike granulomas associated with CVID, granulomatous lesion in this patient did not require any specific therapy, and resolved over a period of 4 weeks following switching subcutaneous immunoglobulin to intravenous immunoglobulin.
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Affiliation(s)
- Ankmalika Gupta
- Department of Medicine, Division of Basic & Clinical Immunology, CA 92663, USA.,Department of Medicine, Hoag Medical Group, Newport Beach, CA 92697, USA
| | - Beverly Wang
- Department of Pathology, University of California, Irvine, CA 92697, USA
| | - Sudhir Gupta
- Department of Medicine, Division of Basic & Clinical Immunology, CA 92663, USA
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48
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Cinetto F, Scarpa R, Pulvirenti F, Quinti I, Agostini C, Milito C. Appropriate lung management in patients with primary antibody deficiencies. Expert Rev Respir Med 2019; 13:823-838. [PMID: 31361157 DOI: 10.1080/17476348.2019.1641085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Human primary immunodeficiency diseases (PIDs) include a broad spectrum of more than 350 disorders, involving different branches of the immune system and classified as 'rare diseases.' Predominantly antibody deficiencies (PADs) represent more than half of the PIDs diagnosed in Europe and are often diagnosed in the adulthood. Areas covered: Although PAD could first present with autoimmune or neoplastic features, respiratory infections are frequent and respiratory disease represents a relevant cause of morbidity and mortality. Pulmonary complications may be classified as infection-related (acute and chronic), immune-mediated, and neoplastic. Expert opinion: At present, no consensus guidelines are available on how to monitor and manage lung complications in PAD patients. In this review, we will discuss the available diagnostic, prognostic and therapeutic instruments and we will suggest an appropriate and evidence-based approach to lung diseases in primary antibody deficiencies. We will also highlight the possible role of promising new tools and strategies in the management of pulmonary complications. However, future studies are needed to reduce of diagnostic delay of PAD and to better understand lung diseases mechanisms, with the final aim to ameliorate therapeutic options that will have a strong impact on Quality of Life and long-term prognosis of PAD patients.
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Affiliation(s)
- Francesco Cinetto
- Department of Medicine - DIMED, University of Padova , Padova , Italy.,Internal Medicine I, Ca' Foncello Hospital , Treviso , Italy
| | - Riccardo Scarpa
- Department of Medicine - DIMED, University of Padova , Padova , Italy.,Internal Medicine I, Ca' Foncello Hospital , Treviso , Italy
| | - Federica Pulvirenti
- Department of Molecular Medicine, "Sapienza" University of Roma , Roma , Italy
| | - Isabella Quinti
- Department of Molecular Medicine, "Sapienza" University of Roma , Roma , Italy
| | - Carlo Agostini
- Department of Medicine - DIMED, University of Padova , Padova , Italy.,Internal Medicine I, Ca' Foncello Hospital , Treviso , Italy
| | - Cinzia Milito
- Department of Molecular Medicine, "Sapienza" University of Roma , Roma , Italy
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49
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Agarwal S, Cunningham-Rundles C. Autoimmunity in common variable immunodeficiency. Ann Allergy Asthma Immunol 2019; 123:454-460. [PMID: 31349011 DOI: 10.1016/j.anai.2019.07.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Common variable immunodeficiency (CVID) is a primary immunodeficiency that is clinically heterogeneous, characterized by both infectious and noninfectious complications. Although the hallmark of disease presentation is commonly a history of recurrent sinopulmonary infections, autoimmunity and noninfectious inflammatory conditions are increasingly associated with CVID. DATA SOURCES A comprehensive literature search using PubMed of basic science and clinical articles was performed. STUDY SELECTIONS Articles discussing the association of autoimmunity with primary immunodeficiency, specifically CVID, were selected. RESULTS The most common autoimmune conditions are cytopenias, including immune thrombocytopenia purpura and hemolytic anemia, but organ-specific autoimmune/inflammatory complications involving the gastrointestinal, skin, joints, connective tissue, and respiratory tract. In most cases, immunoglobulin replacement therapy does not ameliorate or treat these inflammatory complications, and additional immunomodulatory treatments are needed. CONCLUSION Mechanisms producing these conditions are poorly understood but include cytokine and cellular inflammatory pathways, and loss of tolerance to self-antigens through the multiple signaling molecules and pathways common to tolerance and immune deficiency.
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Affiliation(s)
- Shradha Agarwal
- Icahn School of Medicine at Mount Sinai, Division of Allergy and Clinical Immunology, Department of Medicine, New York, New York.
| | - Charlotte Cunningham-Rundles
- Icahn School of Medicine at Mount Sinai, Division of Allergy and Clinical Immunology, Department of Medicine, New York, New York
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50
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Patel S, Anzilotti C, Lucas M, Moore N, Chapel H. Interstitial lung disease in patients with common variable immunodeficiency disorders: several different pathologies? Clin Exp Immunol 2019; 198:212-223. [PMID: 31216049 DOI: 10.1111/cei.13343] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 12/30/2022] Open
Abstract
Various reports of disease-related lung pathologies in common variable immunodeficiency disorder (CVID) patients have been published, with differing histological and high-resolution computed tomography (HRCT) findings. Data were extracted from the validated Oxford Primary Immune Deficiencies Database (PID) database (1986-2016) on adult, sporadic CVID patients with suspected interstitial lung disease (ILD). Histology of lung biopsies was studied in relation to length of follow-up, clinical outcomes, HRCT findings and chest symptoms, to look for evidence for different pathological processes. Twenty-nine CVID patients with lung histology and/or radiological evidence of ILD were followed. After exclusions, lung biopsies from 16 patients were reanalysed for ILD. There were no well-formed granulomata, even though 10 patients had systemic, biopsy-proven granulomata in other organs. Lymphocytic infiltration without recognizable histological pattern was the most common finding, usually with another feature. On immunochemistry (n = 5), lymphocytic infiltration was due to T cells (CD4 or CD8). Only one patient showed B cell follicles with germinal centres. Interstitial inflammation was common; only four of 11 such biopsies also showed interstitial fibrosis. Outcomes were variable and not related to histology, suggesting possible different pathologies. The frequent nodules on HRCT were not correlated with histology, as there were no well-formed granulomata. Five patients were asymptomatic, so it is essential for all patients to undergo HRCT, and to biopsy if abnormal HRCT findings are seen. Internationally standardized pathology and immunochemical data are needed for longitudinal studies to determine the precise pathologies and prognoses in this severe complication of CVIDs, so that appropriate therapies may be found.
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Affiliation(s)
- S Patel
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Clinical Immunology, Oxford University Hospitals, John Radcliffe Site, Oxford, UK
| | - C Anzilotti
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Clinical Immunology, Oxford University Hospitals, John Radcliffe Site, Oxford, UK
| | - M Lucas
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - N Moore
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H Chapel
- Primary Immunodeficiency Unit, Department of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Clinical Immunology, Oxford University Hospitals, John Radcliffe Site, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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