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Díaz-Alberola I, Espuch-Oliver A, Fernández-Segovia F, López-Nevot MÁ. Possible Role of Cytomegalovirus in Gastric Cancer Development and Recurrent Macrolide-Resistant Campylobacter jejuni Infection in Common Variable Immunodeficiency: A Case Report and Literature Discussion. Microorganisms 2024; 12:1078. [PMID: 38930460 PMCID: PMC11205354 DOI: 10.3390/microorganisms12061078] [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: 04/18/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic immunodeficiency in adults. It comprises a group of syndromes whose etiology involves genetic, epigenetic, microbiota, and environmental factors. We present the case of a 46-year-old Caucasian male patient with CVID and an immune dysregulation phenotype. The particular elements of the case consisted of an atypical clinical course, which undoubtedly demonstrates the great variability of clinical manifestations that these types of patients can suffer from, including bacterial and viral infections, autoimmune phenomena, and neoplasia. Notably, the patient suffered from recurrent gastrointestinal infection with macrolide-resistant Campylobacter jejuni and gastroduodenal disease and viraemia by cytomegalovirus (CMV). In addition, CMV was postulated as the main pro-oncogenic factor contributing to the development of early-onset intestinal-type gastric adenocarcinoma, for which the patient underwent gastrectomy. The patient's evolution was difficult, but finally, as a result of the multidisciplinary approach, clinical stabilization and improvement in his quality of life were achieved. Based on our brief literature review, this is the first reported case of this clinical complexity. Our experience could help with the management of future patients with CVID and may also update current epidemiological data on CVID.
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Affiliation(s)
- Irene Díaz-Alberola
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18016 Granada, Spain
| | - Andrea Espuch-Oliver
- Servicio de Análisis Clínicos, Hospital Universitario de Torrecárdenas, 04009 Almeria, Spain
| | - Francisco Fernández-Segovia
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18016 Granada, Spain
- Servicio de Anatomía Patológica, Hospital Universitario Clínico San Cecilio, 18016 Granada, Spain
| | - Miguel Ángel López-Nevot
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18016 Granada, Spain
- Departamento de Bioquímica, Biología Molecular e Inmunología III, University of Granada, 18012 Granada, Spain
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Milito C, Pulvirenti F, Garzi G, Sculco E, Cinetto F, Firinu D, Lagnese G, Punziano A, Discardi C, Costanzo G, Felice C, Spadaro G, Ferrari S, Quinti I. Decline of gastric cancer mortality in common variable immunodeficiency in the years 2018-2022. Front Immunol 2023; 14:1231242. [PMID: 37868983 PMCID: PMC10587402 DOI: 10.3389/fimmu.2023.1231242] [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: 05/30/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction In patients with Common Variable Immunodeficiency, malignancy has been reported as the leading cause of death in adults, with a high risk of B-cell lymphomas and gastric cancer. Methods We conducted a five-year prospective study aiming to update the incidence and mortality of gastric cancer and the incidence of gastric precancerous lesions in 512 CVID patients who underwent a total of 400 upper gastrointestinal endoscopies. Results In the pre-pandemic period, 0.58 endoscopies were performed per patient/year and in the COVID-19 period, 0.39 endoscopies were performed per patient/year. Histology revealed areas with precancerous lesions in about a third of patients. Patients who had more than one gastroscopy during the study period were more likely to have precancerous lesions. Two patients received a diagnosis of gastric cancer in the absence of Helicobacter pylori infection. The overall prevalence of Helicobacter pylori infection in biopsy specimens was 19.8% and related only to active gastritis. Among patients who had repeated gastroscopies, about 20% progressed to precancerous lesions, mostly independent of Helicobacter pylori. Discussion While gastric cancer accounted for one in five deaths from CVID in our previous survey, no gastric cancer deaths were recorded in the past five years, likely consistent with the decline in stomach cancer mortality observed in the general population. However, during the COVID-19 pandemic, cancer screening has been delayed. Whether such a delay or true decline could be the reason for the lack of gastric cancer detection seen in CVID may become clear in the coming years. Due to the high incidence of precancerous lesions, we cannot rely on observed and predicted trends in gastric cancer mortality and strongly recommend tailored surveillance programs.
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Affiliation(s)
- Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Federica Pulvirenti
- Reference Center for Primary Immune Deficiencies, AOU Policlinico Umberto I, Rome, Italy
| | - Giulia Garzi
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Eleonora Sculco
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Ca’ Foncello Hospital, AULSS2 Marca Trevigiana, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Gianluca Lagnese
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Alessandra Punziano
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Claudia Discardi
- Rare Diseases Referral Center, Internal Medicine 1, Ca’ Foncello Hospital, AULSS2 Marca Trevigiana, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Giulia Costanzo
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Carla Felice
- Rare Diseases Referral Center, Internal Medicine 1, Ca’ Foncello Hospital, AULSS2 Marca Trevigiana, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Simona Ferrari
- Medical Genetics Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
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Napiórkowska-Baran K, Ziętkiewicz M, Więsik-Szewczyk E, Matyja-Bednarczyk A, Tykwińska M, Alska E, Rosada T, Szynkiewicz E, Lubański J, Schmidt O, Szymczak B, Koperska K, Bartuzi Z. Points to Consider in Health Assessment of Adult Patients with Primary Antibody Deficiencies. J Clin Med 2023; 12:6018. [PMID: 37762958 PMCID: PMC10532356 DOI: 10.3390/jcm12186018] [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: 06/08/2023] [Revised: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
An improved recognition of inborn errors of immunity (IEI) is associated with an increase in life expectancy and a higher incidence of complications and related conditions. The aim of the study was to analyze factors enabling the primary prevention: BMI, smoking and selected laboratory tests (morphology with smear, creatinine, eGFR, total protein, albumin, ferritin, folic acid, vitamin B12, vitamin D3) included in the protocols of standard of care for adult patients with primary antibody deficiencies (PADs). The study included 94 participants ≥ 18 years old, diagnosed with PADs. Overweight was found in 17%, obesity in 14% and underweight in 15% of patients; 11.5% of patients smoked. Leukopenia was diagnosed in 16%, neutropenia in 8.5%, lymphopenia in 22.5% and thrombocytopenia in 14% of patients. A decreased concentration of hemoglobin was found in 32%, total protein in 19%, albumin in 17%, vitamin D3 in 52%, vitamin B12 in 6.5%, folic acid in 34% and ferritin in 26% of patients. Creatinine concentrations were elevated in 16% of patients, while in 20%, eGFR was reduced. Only a holistic assessment of comorbidities and complications of deficiency, as well as regular follow-up and lifestyle changes, can yield the best results in the long-term care of patients.
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Affiliation(s)
- Katarzyna Napiórkowska-Baran
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (M.T.); (E.A.); (T.R.); (Z.B.)
| | - Marcin Ziętkiewicz
- Department of Rheumatology, Clinical Immunology, Geriatrics and Internal Medicine, Medical University of Gdansk, 80-210 Gdansk, Poland;
| | - Ewa Więsik-Szewczyk
- Department of Internal Medicine, Pulmonology, Allergy and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | | | - Marta Tykwińska
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (M.T.); (E.A.); (T.R.); (Z.B.)
| | - Ewa Alska
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (M.T.); (E.A.); (T.R.); (Z.B.)
| | - Tomasz Rosada
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (M.T.); (E.A.); (T.R.); (Z.B.)
| | - Ewa Szynkiewicz
- Department of Nursing in Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland;
| | - Jakub Lubański
- Student Research Club of Clinical Immunology, Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (J.L.); (O.S.); (B.S.); (K.K.)
| | - Oskar Schmidt
- Student Research Club of Clinical Immunology, Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (J.L.); (O.S.); (B.S.); (K.K.)
| | - Bartłomiej Szymczak
- Student Research Club of Clinical Immunology, Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (J.L.); (O.S.); (B.S.); (K.K.)
| | - Kinga Koperska
- Student Research Club of Clinical Immunology, Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (J.L.); (O.S.); (B.S.); (K.K.)
| | - Zbigniew Bartuzi
- Department of Allergology, Clinical Immunology and Internal Diseases, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, 85-067 Bydgoszcz, Poland; (M.T.); (E.A.); (T.R.); (Z.B.)
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Krick D, Hauptmann K, Penndorf V, Tacke F, Krüger R, von Bernuth H, Sigal M. When malignancy hits twice – synchronous gastric carcinoma and non-Hodgkin-B-cell lymphoma in a patient with common variable immunodeficiency. ZEITSCHRIFT FÜR GASTROENTEROLOGIE 2022. [PMID: 36413990 DOI: 10.1055/a-1890-6140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
AbstractPatients with common variable immunodeficiency (CVID) generally bear a higher risk of non Hodgkin B-cell lymphomas and solid tumors, in particular gastric adenocarcinoma.Here we report a case of a 58-year-old male CVID patient who developed both malignancies within a very short period, as documented by two subsequent esophagogastroduodenoscopies performed within 4 months. While the first upper gastrointestinal endoscopy for routine surveillance purposes was uneventful, the second one after developing unexplained weight loss revealed two new neoplastic lesions in the stomach. The histological evaluation revealed a poorly differentiated adenocarcinoma infiltrating the muscularis propria forcing gastrectomy as well as a high-grade B-non-Hodgkin-lymphoma with detection of a MYC- and BCL6-translocation, necessitating chemotherapy with R-CHOP.This case emphasizes the necessity of high awareness for gastric neoplasia in patients with CVID and highlights the need of a standardized yet not established endoscopic surveillance protocol for this vulnerable group.
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Affiliation(s)
- David Krick
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kathrin Hauptmann
- Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Volker Penndorf
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Renate Krüger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Horst von Bernuth
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Sigal
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
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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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Lee EY, Betschel S, Grunebaum E. Monitoring patients with uncomplicated common variable immunodeficiency: a systematic review. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:21. [PMID: 35264237 PMCID: PMC8908590 DOI: 10.1186/s13223-022-00661-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Non-infectious complications have become a major cause of morbidity and mortality in patients with Common Variable Immunodeficiency (CVID). The monitoring of patients with CVID prior to the development of non-infectious complications is not well defined. OBJECTIVE Our objectives were to systematically review the current literature on the monitoring of CVID patients without non-infectious complications and to develop recommendations for such monitoring. METHODS MEDLINE and EMBASE were searched from January 1st, 2000 to March 25th, 2021. Studies on any aspects of CVID monitoring were included. Studies that included only children, on monitoring CVID patients with existing non-infectious complications, or in the format of case reports were excluded. RESULTS Nine studies on CVID monitoring, including 3 cohort studies, 3 experts' opinions, 2 consensus statements and a single guideline report were identified. These studies revealed that clinical assessment and bloodwork were preformed every 6 to 12 months in asymptomatic patients. Some centers performed computerized tomography scan of the chest every 2-5 years to identify chronic lung disease, although the majority did chest imaging in accordance with clinical indications. Pulmonary function tests were done annually at most centers. Most studies did not address the role of abdominal imaging to screen for liver diseases or endoscopy to screen for gastric cancer in asymptomatic patients with uncomplicated CVID. CONCLUSIONS There is paucity of evidence-based information to guide the routine monitoring of CVID patients without non-infectious complications. Prospective studies are needed to determine the best monitoring practices in this group of patients.
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Affiliation(s)
- Erika Yue Lee
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Stephen Betschel
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Eyal Grunebaum
- Division of Immunology and Allergy, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Bruns L, Panagiota V, von Hardenberg S, Schmidt G, Adriawan IR, Sogka E, Hirsch S, Ahrenstorf G, Witte T, Schmidt RE, Atschekzei F, Sogkas G. Common Variable Immunodeficiency-Associated Cancers: The Role of Clinical Phenotypes, Immunological and Genetic Factors. Front Immunol 2022; 13:742530. [PMID: 35250968 PMCID: PMC8893227 DOI: 10.3389/fimmu.2022.742530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/19/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The aim of this study was to investigate the prevalence of cancer and associating clinical, immunological, and genetic factors in a German cohort of patients with common variable immunodeficiency (CVID). Methods In this retrospective monocenter cohort study, we estimated the standardized incidence ratio (SIR) for different forms of cancer diagnosed in CVID patients. Furthermore, we evaluated the likely association of infectious and non-infectious CVID-related phenotypes with the diagnosis of cancer by calculation of the odds ratio. The genetic background of CVID in patients with cancer was evaluated with sequential targeted next-generation sequencing (tNGS) and whole-exome sequencing (WES). Patients’ family history and WES data were evaluated for genetic predisposition to cancer. Results A total of 27/219 patients (12.3%) were diagnosed with at least one type of cancer. Most common types of cancer were gastric cancer (SIR: 16.5), non-melanoma skin cancer (NMSC) (SIR: 12.7), and non-Hodgkin lymphoma (NHL) (SIR: 12.2). Immune dysregulation manifesting as arthritis, atrophic gastritis, or interstitial lung disease (ILD) was associated with the diagnosis of cancer. Furthermore, diagnosis of NMSC associated with the diagnosis of an alternative type of cancer. Studied immunological parameters did not display any significant difference between patients with cancer and those without. tNGS and/or WES yielded a definite or likely genetic diagnosis in 11.1% of CVID patients with cancer. Based on identified variants in cancer-associated genes, the types of diagnosed cancers, and family history data, 14.3% of studied patients may have a likely genetic susceptibility to cancer, falling under a known hereditary cancer syndrome. Conclusions Gastric cancer, NMSC, and NHL are the most frequent CVID-associated types of cancer. Manifestations of immune dysregulation, such as arthritis and ILD, were identified as risk factors of malignancy in CVID, whereas studied immunological parameters or the identification of a monogenic form of CVID appears to have a limited role in the evaluation of cancer risk in CVID.
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Affiliation(s)
- Luzia Bruns
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
| | - Victoria Panagiota
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Gunnar Schmidt
- Department of Human Genetics, Hannover Medical School, Hanover, Germany
| | | | - Eleni Sogka
- Department of Medical Oncology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanie Hirsch
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
| | - Gerrit Ahrenstorf
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
| | - Torsten Witte
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
- Hannover Medical School, Cluster of Excellence RESIST (EXC 2155), Hanover, Germany
| | - Reinhold Ernst Schmidt
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
- Hannover Medical School, Cluster of Excellence RESIST (EXC 2155), Hanover, Germany
| | - Faranaz Atschekzei
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
- Hannover Medical School, Cluster of Excellence RESIST (EXC 2155), Hanover, Germany
| | - Georgios Sogkas
- Department of Rheumatology and Immunology, Hannover Medical School, Hanover, Germany
- Hannover Medical School, Cluster of Excellence RESIST (EXC 2155), Hanover, Germany
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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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Krein P, Yogolare GG, Pereira MA, Grecco O, Barros MAMT, Dias AR, Marinho AKBB, Zilberstein B, Kokron CM, Ribeiro-Júnior U, Kalil J, Nahas SC, Ramos MFKP. Common variable immunodeficiency: an important but little-known risk factor for gastric cancer. Rev Col Bras Cir 2021; 48:e20213133. [PMID: 34932733 PMCID: PMC10683469 DOI: 10.1590/0100-6991e-20213133] [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: 07/23/2021] [Accepted: 09/24/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION although it is a rare disease, common variable immunodeficiency (CVID) stands out as the most frequent primary symptomatic immunodeficiency. Carriers are prone to a variety of recurrent bacterial infections, in addition to the risk of developing autoimmune diseases and neoplasms including gastric cancer (GC). Despite the recognized risk, there are no specific standardized protocols for the management of GC in these patients, so the reported oncological results are varied. Thus, this study aims to describe the clinicopathological characteristics and prognosis of patients with CVID undergoing surgical treatment of GC. METHODS all patients with GC undergoing surgical treatment between 2009 and 2020 were retrospectively evaluated. Later, patients diagnosed with CVID were identified and this group was compared with the remaining patients without any immunodeficiency. RESULTS among the 1101 patients with GC evaluated in the period, 10 had some type of immunodeficiency, and 5 were diagnosed with CVID. Patients with CVID had younger age, lower BMI, and smaller lesions compared to those without CVID. Four patients underwent curative gastrectomy and one patient underwent jejunostomy. Two patients died (1 palliative and 1 curative) and one patient had disease recurrence. There was no statistically significant difference regarding the incidence of postoperative complications and survival between the evaluated groups. CONCLUSION the CVID incidence in patients with GC undergoing surgical treatment was 0.5%, occurring at a less advanced age, but with no difference regarding surgical and oncological results.
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Affiliation(s)
- Paula Krein
- - Faculdade de Medicina, Universidade de São Paulo, Curso de Medicina - São Paulo - SP - Brasil
| | - Gustavo Gonçalves Yogolare
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Gastroenterologia - São Paulo - SP - Brasil
| | - Marina Alessandra Pereira
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Gastroenterologia - São Paulo - SP - Brasil
| | - Octavio Grecco
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Clínica Médica - Disciplina de Imunologia Clínica e Alergia - São Paulo - SP - Brasil
| | - Myrthes Anna Maragna Toledo Barros
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Clínica Médica - Disciplina de Imunologia Clínica e Alergia - São Paulo - SP - Brasil
| | - Andre Roncon Dias
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Gastroenterologia - São Paulo - SP - Brasil
| | - Ana Karolina Barreto Berselli Marinho
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Clínica Médica - Disciplina de Imunologia Clínica e Alergia - São Paulo - SP - Brasil
| | - Bruno Zilberstein
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Gastroenterologia - São Paulo - SP - Brasil
| | - Cristina Maria Kokron
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Clínica Médica - Disciplina de Imunologia Clínica e Alergia - São Paulo - SP - Brasil
| | - Ulysses Ribeiro-Júnior
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Gastroenterologia - São Paulo - SP - Brasil
| | - Jorge Kalil
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Clínica Médica - Disciplina de Imunologia Clínica e Alergia - São Paulo - SP - Brasil
| | - Sergio Carlos Nahas
- - Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Gastroenterologia - São Paulo - SP - Brasil
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Lee TK, Gereige JD, Maglione PJ. State-of-the-art diagnostic evaluation of common variable immunodeficiency. Ann Allergy Asthma Immunol 2021; 127:19-27. [PMID: 33716149 DOI: 10.1016/j.anai.2021.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To summarize the current understanding of diagnostic and postdiagnostic evaluation of common variable immunodeficiency (CVID). DATA SOURCES PubMed Central database. STUDY SELECTIONS Original research articles and review articles from 2015 to 2020 including seminal articles that shaped the diagnostic and postdiagnostic evaluation of CVID were incorporated. This work focuses on initial diagnosis of CVID, genetic evaluations, and postdiagnostic assessment of respiratory, gastrointestinal, and hepatobiliary diseases including spleen and lymph node enlargement. RESULTS CVID presents not only with frequent infections but also with noninfectious complications such as autoimmunity, gastrointestinal disease, chronic lung disease, granulomas, liver disease, lymphoid hyperplasia, splenomegaly, or malignancy. The risk of morbidity and mortality is higher in patients with CVID and noninfectious complications. Detailed diagnostic approaches, which may incorporate genetic testing, can aid characterization of individual CVID cases and shape treatment in some instances. Moreover, continued evaluation after CVID diagnosis is key to optimal management of this complex disorder. These postdiagnostic evaluations include pulmonary function testing, radiologic studies, and laboratory evaluations that may be conducted at frequencies determined by disease activity. CONCLUSION Although the diagnosis can be achieved similarly in all patients with CVID, those with noninfectious complications have distinct concerns during clinical evaluation. State-of-the-art workup of CVID with noninfectious complications typically includes genetic analysis, which may shape precision therapy, and thoughtful application of postdiagnostic tests that monitor the presence and progression of disease in the myriad of tissues that may be affected. Even with recent advancements, knowledge gaps in diagnosis, prognosis, and treatment of CVID persist, and continued research efforts are needed.
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Affiliation(s)
- Theodore K Lee
- Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Jessica D Gereige
- Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Paul J Maglione
- Section of Pulmonary, Allergy, Sleep & Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts.
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Fernando SL, Jang HSI, Li J. The Immune Dysregulation of Common Variable Immunodeficiency Disorders. Immunol Lett 2021; 230:21-26. [DOI: 10.1016/j.imlet.2020.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/27/2020] [Accepted: 12/07/2020] [Indexed: 12/19/2022]
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12
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Emerson J, van der Poorten DK, Lin MW, Chou S, McLeod D, Berglund LJ. Duodenal plasma cells correspond to serum IgA in common variable immunodeficiency. Pathology 2020; 53:503-507. [PMID: 33218739 DOI: 10.1016/j.pathol.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 08/05/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
Common variable immunodeficiency (CVID) can be associated with a range of serum IgA concentrations, from absent, to variably reduced, and in some patients classified as 'possible CVID', even normal. The aim of this study was to assess the proportion of duodenal plasma cells in patients with CVID and determine whether there was an association with serum IgA concentration. Duodenal biopsies obtained at upper endoscopy from 35 patients with CVID were assessed for the presence of plasma cells and compared with serum IgA concentrations. A reduction or absence of duodenal plasma cells in 60% of patients with CVID and an association between the proportions of duodenal plasma cells and serum IgA concentrations was demonstrated. The presence of duodenal plasma cells associated with numbers of isotype switched memory B cells in the peripheral blood. A reduction in serum IgA over time was observed in 19% of CVID patients. The gastrointestinal tract provides a window into the immune system in CVID, and these results reinforce the association between gastrointestinal plasma cells and serum IgA concentrations. Preservation of gastrointestinal plasma cells and serum IgA in some patients with CVID, and the sequential decline of both in others, highlight the heterogeneity of this disorder.
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Affiliation(s)
- Jonathan Emerson
- Departments of Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia
| | - David K van der Poorten
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; The University of Sydney, Faculty of Medicine, Sydney, NSW, Australia
| | - Ming Wei Lin
- Departments of Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia; The University of Sydney, Faculty of Medicine, Sydney, NSW, Australia
| | - Shaun Chou
- Department of Anatomical Pathology, Westmead Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia
| | - Duncan McLeod
- Department of Anatomical Pathology, Westmead Hospital, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia
| | - Lucinda J Berglund
- Departments of Immunology and Immunopathology, Westmead Hospital, Sydney, NSW, Australia; The University of Sydney, Faculty of Medicine, Sydney, NSW, Australia; NSW Health Pathology, Sydney, NSW, Australia.
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13
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Sogkas G, Dubrowinskaja N, Adriawan IR, Anim M, Witte T, Schmidt RE, Atschekzei F. High frequency of variants in genes associated with primary immunodeficiencies in patients with rheumatic diseases with secondary hypogammaglobulinaemia. Ann Rheum Dis 2020; 80:392-399. [PMID: 33046446 DOI: 10.1136/annrheumdis-2020-218280] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Treatment of rheumatic diseases requires immunomodulatory agents which can compromise antibody production. However, even in case of agents directly targeting B cells, a minority of patients develop hypogammaglobulinaemia, suggesting a genetic predisposition, which has not been investigated so far. The phenotypic overlap between primary immunodeficiency disorders (PIDs) and rheumatic diseases suggests a shared genetic basis, especially in case of patients with rheumatic diseases with hypogammaglobulinaemia. METHODS 1008 patients with rheumatic diseases visiting the outpatient clinics of the Hannover University Hospital were screened for hypogammaglobulinaemia. Those with persistent hypogammaglobulinaemia and an equal number of patients without it underwent targeted next-generation sequencing, searching for variations in genes linked with hypogammaglobulinaemia in the context of PIDs. RESULTS We identified 33 predicted pathogenic variants in 30/64 (46.9%) patients with persistent secondary hypogammaglobulinaemia. All 33 variants were monoallelic and 10 of them in 10/64 (15.6%) patients were found in genes associated with autosomal dominant PIDs. 2/64 (3.1%) patients harboured variants which were previously reported to cause PIDs. In the group without hypogammaglobulinaemia we identified seven monoallelic variants in 7/64 (10.9%), including a variant in a gene associated with an autosomal dominant PID. CONCLUSIONS Approximately half of patients with persistent secondary hypogammaglobulinaemia harboured at least a variant in a PID gene. Despite the fact that previous immunomodulatory treatment is an exclusion criterion in the diagnosis of PIDs, we identified genetic variants that can account for PID in patients with clear rheumatic phenotypes who developed hypogammaglobulinaemia after the introduction of immunomodulatory treatment. Our data suggest the common genetic causes of primary and secondary hypogammaglobulinaemia.
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Affiliation(s)
- Georgios Sogkas
- Rheumatology and Immunology, Hannover Medical University, Hannover, Germany
| | | | | | - Manfred Anim
- Rheumatology and Immunology, Hannover Medical University, Hannover, Germany
| | - Torsten Witte
- Rheumatology and Immunology, Hannover Medical University, Hannover, Germany
| | - Reinhold E Schmidt
- Rheumatology and Immunology, Hannover Medical University, Hannover, Germany
| | - Faranaz Atschekzei
- Rheumatology and Immunology, Hannover Medical University, Hannover, Germany
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Passi M, Stoleru G, Wong U. Looking Beneath the Carpet of Nodules. Gastroenterology 2020; 159:e1-e2. [PMID: 32142781 DOI: 10.1053/j.gastro.2020.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Monica Passi
- National Institute of Health, Bethesda, Maryland
| | - Gianna Stoleru
- University of Maryland Medical Center, Baltimore, Maryland.
| | - Uni Wong
- University of Maryland School of Medicine, Baltimore, Maryland
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15
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Więsik-Szewczyk E, Jahnz-Różyk K. From infections to autoimmunity: Diagnostic challenges in common variable immunodeficiency. World J Clin Cases 2020; 8:3942-3955. [PMID: 33024751 PMCID: PMC7520788 DOI: 10.12998/wjcc.v8.i18.3942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/29/2020] [Accepted: 08/26/2020] [Indexed: 02/05/2023] Open
Abstract
Common variable immunodeficiency (CVID) is the most common clinically significant primary antibody deficiency diagnosed in adults. The early symptoms are not specific. They include common infections, mainly of the respiratory tract, caused by typical microorganisms, so cases can be missed in primary care. In the majority of patients increased susceptibility to infections coexists with signs or symptoms of autoimmunity, inflammation or polyclonal lymphoproliferation, which can divert diagnosis from immune deficiency. The overall incidence of malignancy is increased in CVID and certain cancers are significantly more common. Lymphomas and gastric carcinoma are the most frequently reported malignancies in CVID, so a high index of suspicion is recommended. Diagnostic delay in CVID is seen worldwide. The main goal of this paper is to increase the awareness about CVID among health care professionals. We aim to present features which can be helpful in CVID diagnosis in order to shorten the “latency” of proper management of CVID patients. We review clinical symptoms, complications and laboratory abnormalities of CVID. Immunoglobulin replacement therapy is regarded as the cornerstone of pharmacological intervention. New modes of Ig application, mainly subcutaneously and via the hyaluronidase-facilitated subcutaneous route, help to adjust therapy to patients’ needs and preferences. Still there remain unmet needs. It remains to be seen whether CVID complications can be avoided by earlier diagnosis, treatment and thorough monitoring in the context of increased risk of malignancy. Development of patient tailored protocols depending on the clinical phenotype and risk factors might be more appropriate. The most important consideration is to diagnose suspected cases and stratify patients in a precise and timely way. Work is needed to define features predictive of unfavorable prognosis.
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Affiliation(s)
- Ewa Więsik-Szewczyk
- Department of Internal Medicine, Pulmonology, Allergy and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, Warsaw 04-141, Poland
| | - Karina Jahnz-Różyk
- Department of Internal Medicine, Pulmonology, Allergy and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, Warsaw 04-141, Poland
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Cirillo E, Giardino G, Ricci S, Moschese V, Lougaris V, Conti F, Azzari C, Barzaghi F, Canessa C, Martire B, Badolato R, Dotta L, Soresina A, Cancrini C, Finocchi A, Montin D, Romano R, Amodio D, Ferrua F, Tommasini A, Baselli LA, Dellepiane RM, Polizzi A, Chessa L, Marzollo A, Cicalese MP, Putti MC, Pession A, Aiuti A, Locatelli F, Plebani A, Pignata C. Consensus of the Italian Primary Immunodeficiency Network on transition management from pediatric to adult care in patients affected with childhood-onset inborn errors of immunity. J Allergy Clin Immunol 2020; 146:967-983. [PMID: 32827505 DOI: 10.1016/j.jaci.2020.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 02/06/2023]
Abstract
Medical advances have dramatically improved the long-term prognosis of children and adolescents with inborn errors of immunity (IEIs). Transfer of the medical care of individuals with pediatric IEIs to adult facilities is also a complex task because of the large number of distinct disorders, which requires involvement of patients and both pediatric and adult care providers. To date, there is no consensus on the optimal pathway of the transitional care process and no specific data are available in the literature regarding patients with IEIs. We aimed to develop a consensus statement on the transition process to adult health care services for patients with IEIs. Physicians from major Italian Primary Immunodeficiency Network centers formulated and answered questions after examining the currently published literature on the transition from childhood to adulthood. The authors voted on each recommendation. The most frequent IEIs sharing common main clinical problems requiring full attention during the transitional phase were categorized into different groups of clinically related disorders. For each group of clinically related disorders, physicians from major Italian Primary Immunodeficiency Network institutions focused on selected clinical issues representing the clinical hallmark during early adulthood.
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Affiliation(s)
- Emilia Cirillo
- Department of Translational Medical Sciences, Pediatric Section, Federico II University, Naples, Italy
| | - Giuliana Giardino
- Department of Translational Medical Sciences, Pediatric Section, Federico II University, Naples, Italy
| | - Silvia Ricci
- Division of Pediatric Immunology, Department of Health Sciences, University of Florence and Meyer Children's Hospital, Florence, Italy
| | - Viviana Moschese
- Pediatric Immunopathology and Allergology Unit, University of Rome Tor Vergata, Rome, Italy
| | - Vassilios Lougaris
- Department of Clinical and Experimental Sciences, University of Brescia and Department of Pediatrics, ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Conti
- Unit of Pediatrics, University of Bologna, St. Orsola University Hospital, Bologna, Italy
| | - Chiara Azzari
- Division of Pediatric Immunology, Department of Health Sciences, University of Florence and Meyer Children's Hospital, Florence, Italy
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy and Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Clementina Canessa
- Division of Pediatric Immunology, Department of Health Sciences, University of Florence and Meyer Children's Hospital, Florence, Italy
| | - Baldassarre Martire
- Unit of Pediatric and Neonatology, Maternal-Infant Department, Mons A. R. Dimiccoli Hospital, Barletta, Italy
| | - Raffaele Badolato
- Department of Clinical and Experimental Sciences, University of Brescia and Department of Pediatrics, ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Laura Dotta
- Department of Clinical and Experimental Sciences, University of Brescia and Department of Pediatrics, ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Annarosa Soresina
- Department of Clinical and Experimental Sciences, University of Brescia and Department of Pediatrics, ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Caterina Cancrini
- Unit of Immunology and Infectious Diseases, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Finocchi
- Unit of Immunology and Infectious Diseases, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Davide Montin
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, Regina Margherita Children Hospital, University of Turin, Turin, Italy
| | - Roberta Romano
- Department of Translational Medical Sciences, Pediatric Section, Federico II University, Naples, Italy
| | - Donato Amodio
- Unit of Immunology and Infectious Diseases, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Francesca Ferrua
- San Raffaele Telethon Institute for Gene Therapy and Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Tommasini
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste and Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Lucia Augusta Baselli
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Department of Pediatrics, Milan, Italy
| | - Rosa Maria Dellepiane
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Department of Pediatrics, Milan, Italy
| | - Agata Polizzi
- Department of Educational Sciences, University of Catania, Catania, Italy
| | - Luciana Chessa
- Department of Clinical and Molecular Medicine, Sapienza, University of Rome, Rome, Italy
| | - Antonio Marzollo
- Department of Women's and Children's Health, Pediatric Hematology-Oncology Unit, University of Padua, Padua, Italy
| | - Maria Pia Cicalese
- San Raffaele Telethon Institute for Gene Therapy and Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Caterina Putti
- Department of Women's and Children's Health, Pediatric Hematology-Oncology Unit, University of Padua, Padua, Italy
| | - Andrea Pession
- Unit of Pediatrics, University of Bologna, St. Orsola University Hospital, Bologna, Italy
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy and Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Childrens' Hospital, Sapienza, University of Rome, Rome Italy
| | - Alessandro Plebani
- Department of Clinical and Experimental Sciences, University of Brescia and Department of Pediatrics, ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences, Pediatric Section, Federico II University, Naples, Italy.
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