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Wouters M, Ehlers L, Dzhus M, Kienapfel V, Bucciol G, Delafontaine S, Hombrouck A, Pillay B, Moens L, Meyts I. Human ADA2 Deficiency: Ten Years Later. Curr Allergy Asthma Rep 2024:10.1007/s11882-024-01163-9. [PMID: 38970744 DOI: 10.1007/s11882-024-01163-9] [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] [Accepted: 06/26/2024] [Indexed: 07/08/2024]
Abstract
PURPOSE OF REVIEW In this review, an update is provided on the current knowledge and pending questions about human adenosine deaminase type 2 deficiency. Patients have vasculitis, immunodeficiency and some have bone marrow failure. Although the condition was described ten years ago, the pathophysiology is incompletely understood RECENT FINDINGS: Endothelial instability due to increased proinflammatory macrophage development is key to the pathophysiology. However, the physiological role of ADA2 is a topic of debate as it is hypothesized that ADA2 fulfils an intracellular role. Increasing our knowledge is urgently needed to design better treatments for the bone marrow failure. Indeed, TNFi treatment has been successful in treating DADA2, except for the bone marrow failure. Major advances have been made in our understanding of DADA2. More research is needed into the physiological role of ADA2.
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Affiliation(s)
- Marjon Wouters
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium.
| | - Lisa Ehlers
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Mariia Dzhus
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Verena Kienapfel
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Giorgia Bucciol
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
- Department of Pediatrics, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - Selket Delafontaine
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Anneleen Hombrouck
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Bethany Pillay
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Leen Moens
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
| | - Isabelle Meyts
- Laboratory for Inborn Errors of Immunity, Microbiology Immunology and Transplantation, KU Leuven, Louvain, Belgium
- Department of Pediatrics, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium
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2
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Gardner LS, Vaughan L, Avery DT, Meyts I, Ma CS, Tangye SG, Varikatt W, Lin MW. Development of EBV Related Diffuse Large B-cell Lymphoma in Deficiency of Adenosine Deaminase 2 with Uncontrolled EBV Infection. J Clin Immunol 2024; 44:118. [PMID: 38758417 PMCID: PMC11101521 DOI: 10.1007/s10875-024-01712-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/17/2024] [Indexed: 05/18/2024]
Abstract
Deficiency of Adenosine Deaminase 2 (DADA2) patients presenting with primary immunodeficiency are at risk of uncontrolled EBV infection and secondary malignancies including EBV-related lymphoproliferative disorders (LPD). This paper describes the first case of EBV related diffuse large B-cell lymphoma in a patient with DADA2 and uncontrolled EBV infection. Consideration should be given to monitoring for EBV viraemia and to preventative EBV specific therapy in DADA2 and patients with at risk primary immunodeficiencies. A type I interferon (IFN) gene signature is associated with DADA2 though its association with immune dysregulation is unclear.
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Affiliation(s)
- Logan S Gardner
- School of Public Health and Preventive Medicine, Monash University, Clayton, Australia.
- ICPMR, NSW Health Pathology, Westmead Hospital, Sydney, Australia.
- Department of Immunology, Westmead Hospital, Westmead, Sydney, Australia.
| | - Lachlin Vaughan
- ICPMR, NSW Health Pathology, Westmead Hospital, Sydney, Australia
- The Lowy Cancer Research Centre, Kensington, Australia
| | | | - Isabelle Meyts
- Department of Immunology and Microbiology, Laboratory for Inborn Errors of Immunity, Department of Pediatrics, University Hospitals Leuven and KU Leuven, Leuven, EU, Belgium
| | - Cindy S Ma
- Garvan Institute of Medical Research, Darlinghurst, Australia
- Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Darlinghurst, Australia
- Faculty of Medicine and Health, St Vincent's Clinical School, UNSW Sydney, Sydney, Australia
| | - Stuart G Tangye
- Garvan Institute of Medical Research, Darlinghurst, Australia
- Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Darlinghurst, Australia
- Faculty of Medicine and Health, St Vincent's Clinical School, UNSW Sydney, Sydney, Australia
| | - Winny Varikatt
- ICPMR, NSW Health Pathology, Westmead Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Ming-Wei Lin
- ICPMR, NSW Health Pathology, Westmead Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Camperdown, Australia
- Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Darlinghurst, Australia
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3
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Maccora I, Maniscalco V, Campani S, Carrera S, Abbati G, Marrani E, Mastrolia MV, Simonini G. A wide spectrum of phenotype of deficiency of deaminase 2 (DADA2): a systematic literature review. Orphanet J Rare Dis 2023; 18:117. [PMID: 37179309 PMCID: PMC10183141 DOI: 10.1186/s13023-023-02721-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Deficiency of adenosine deaminase 2 (DADA2) is a rare monogenic autoinflammatory disease, whose clinical phenotype was expanded since the first cases, originally described as mimicker of polyarteritis nodosa, with immunodeficiency and early-onset stroke. METHODS A systematic review according to PRISMA approach, including all articles published before the 31st of August 2021 in Pubmed and EMBASE database was performed. RESULTS The search identified 90 publications describing 378 unique patients (55.8% male). To date 95unique mutations have been reported. The mean age at disease onset was 92.15 months (range 0-720 months), 32 (8.5%) showed an onset of the first signs/symptoms after 18 years old and 96 (25.4%) after 10 years old. The most frequent clinical characteristics described were cutaneous (67.9%), haematological manifestations (56.3%), recurrent fever (51.3%), neurological as stroke and polyneuropathy (51%), immunological abnormalities (42.3%), arthralgia/arthritis (35.4%), splenomegaly (30.6%), abdominal involvement (29.8%), hepatomegaly (23.5%), recurrent infections (18.5%), myalgia (17.9%), kidney involvement (17.7%) etc. Patients with skin manifestations were older than the others (101.1 months SD ± 116.5, vs. 75.3 SD ± 88.2, p 0.041), while those with a haematological involvement (64.1 months SD ± 75.6 vs. 133.1 SD ± 133.1, p < 0.001) and immunological involvement (73.03 months SD ± 96.9 vs. 103.2 SD ± 112.9, p 0.05) are younger than the others. We observed different correlations among the different clinical manifestations. The use of anti-TNFα and hematopoietic cell stems transplantation (HCST) has improved the current history of the disease. CONCLUSION Due to this highly variable phenotype and age of presentation, patients with DADA2 may present to several type of specialists. Given the important morbidity and mortality, early diagnosis and treatment are mandatory.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy.
- NeuroFARBA Department, University of Florence, Florence, Italy.
| | | | - Silvia Campani
- School of Health Science, University of Florence, Florence, Italy
| | - Simona Carrera
- School of Health Science, University of Florence, Florence, Italy
| | - Giulia Abbati
- School of Health Science, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy
| | | | - Gabriele Simonini
- Rheumatology Unit, ERN ReConnet Center, Meyer Children's Hospital IRCCS, Florence, Italy
- NeuroFARBA Department, University of Florence, Florence, Italy
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4
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Signa S, Bertoni A, Penco F, Caorsi R, Cafaro A, Cangemi G, Volpi S, Gattorno M, Schena F. Adenosine Deaminase 2 Deficiency (DADA2): A Crosstalk Between Innate and Adaptive Immunity. Front Immunol 2022; 13:935957. [PMID: 35898506 PMCID: PMC9309328 DOI: 10.3389/fimmu.2022.935957] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022] Open
Abstract
Deficiency of Adenosine deaminase 2 (DADA2) is a monogenic autoinflammatory disorder presenting with a broad spectrum of clinical manifestations, including immunodeficiency, vasculopathy and hematologic disease. Biallelic mutations in ADA2 gene have been associated with a decreased ADA2 activity, leading to reduction in deamination of adenosine and deoxyadenosine into inosine and deoxyinosine and subsequent accumulation of extracellular adenosine. In the early reports, the pivotal role of innate immunity in DADA2 pathogenic mechanism has been underlined, showing a skewed polarization from the M2 macrophage subtype to the proinflammatory M1 subtype, with an increased production of inflammatory cytokines such as TNF-α. Subsequently, a dysregulation of NETosis, triggered by the excess of extracellular Adenosine, has been implicated in the pathogenesis of DADA2. In the last few years, evidence is piling up that adaptive immunity is profoundly altered in DADA2 patients, encompassing both T and B branches, with a disrupted homeostasis in T-cell subsets and a B-cell skewing defect. Type I/type II IFN pathway upregulation has been proposed as a possible core signature in DADA2 T cells and monocytes but also an increased IFN-β secretion directly from endothelial cells has been described. So far, a unifying clear pathophysiological explanation for the coexistence of systemic inflammation, immunedysregulation and hematological defects is lacking. In this review, we will explore thoroughly the latest understanding regarding DADA2 pathophysiological process, with a particular focus on dysregulation of both innate and adaptive immunity and their interacting role in the development of the disease.
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Affiliation(s)
- Sara Signa
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Arinna Bertoni
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Federica Penco
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Roberta Caorsi
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Stefano Volpi
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Sciences (DINOGMI), University of Genoa, Genoa, Italy
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- *Correspondence: Marco Gattorno,
| | - Francesca Schena
- Center for Autoinflammatory Diseases and Immunodeficiencies, Istituto di Ricovero e cura a carattere scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
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5
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Hashem H, Dimitrova D, Meyts I. Allogeneic Hematopoietic Cell Transplantation for Patients With Deficiency of Adenosine Deaminase 2 (DADA2): Approaches, Obstacles and Special Considerations. Front Immunol 2022; 13:932385. [PMID: 35911698 PMCID: PMC9336546 DOI: 10.3389/fimmu.2022.932385] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/20/2022] [Indexed: 01/07/2023] Open
Abstract
Deficiency of adenosine deaminase 2 (DADA2) is an inherited autosomal recessive disease characterized by autoinflammation (recurrent fever), vasculopathy (livedo racemosa, polyarteritis nodosa, lacunar ischemic strokes, and intracranial hemorrhages, end organ vasculitis), immunodeficiency, lymphoproliferation, immune cytopenias, and bone marrow failure. Allogeneic hematopoietic cell transplantation (HCT) is curative for DADA2 as it reverses the hematological, immune and vascular phenotype of DADA2. The primary goal of HCT in DADA2, like in other non-malignant diseases, is engraftment with the establishment of normal hematopoiesis and normal immune function. Strategies in selecting a preparative regimen should take into consideration the specific vulnerabilities to endothelial dysfunction and liver toxicity in DADA2 patients. Overcoming an increased risk of graft rejection while minimizing organ toxicity, graft-versus-host disease, and infections can be particularly challenging in DADA2 patients. This review will discuss approaches to HCT in DADA2 patients including disease-specific considerations, barriers to successful engraftment, post-HCT complications, and clinical outcomes of published patients with DADA2 who have undergone HCT to date.
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Affiliation(s)
- Hasan Hashem
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Bone Marrow Transplant Unit, King Hussein Cancer Center (KHCC), Amman, Jordan
- *Correspondence: Hasan Hashem, ; Isabelle Meyts,
| | - Dimana Dimitrova
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute of the National Institutes of Health, Bethesda, MD, United States
| | - Isabelle Meyts
- Department of Pediatrics, Microbiology, Immunology, and Transplantation, The European Reference Network Rare Immunodeficiency Autoinflammatory and Autoimmune Diseases Network (ERN RITA) Core Center, University Hospitals Leuven, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- *Correspondence: Hasan Hashem, ; Isabelle Meyts,
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Pilania RK, Banday AZ, Sharma S, Kumrah R, Joshi V, Loganathan S, Dhaliwal M, Jindal AK, Vignesh P, Suri D, Rawat A, Singh S. Deficiency of Human Adenosine Deaminase Type 2 - A Diagnostic Conundrum for the Hematologist. Front Immunol 2022; 13:869570. [PMID: 35592317 PMCID: PMC9110783 DOI: 10.3389/fimmu.2022.869570] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Deficiency of adenosine deaminase type 2 (DADA2) was first described in 2014 as a monogenic cause of polyartertitis nodosa (PAN), early onset lacunar stroke and livedo reticularis. The clinical phenotype of DADA2 is, however, very broad and may involve several organ systems. Apart from vasculitis, children may present with i) Hematological manifestations (ii) Lymphoproliferation and iii) Immunodeficiencies. Patients with DADA2 can have variable patterns of cytopenias and bone marrow failure syndromes. Patients with DADA2 who have predominant haematological manifestations are associated with ADA2 gene variants that result in minimal or no residual ADA2 activity. Lymphoproliferation in patients with DADA2 may range from benign lymphoid hyperplasia to lymphoreticular malignancies. Patients may present with generalized lymphadenopathy, splenomegaly, autoimmune lymphoproliferative syndrome (ALPS) like phenotype, Hodgkin lymphoma, T-cell large granular lymphocytic infiltration of bone marrow and multicentric Castleman disease. Immunodeficiencies associated with DADA are usually mild. Affected patients have variable hypogammaglobulinemia, decrease in B cells, low natural killer cells, common variable immunodeficiency and rarely T cell immunodeficiency. To conclude, DADA2 has an extremely variable phenotype and needs to be considered as a differential diagnosis in diverse clinical conditions. In this review, we describe the evolving clinical phenotypes of DADA2 with a special focus on haematological and immunological manifestations.
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Affiliation(s)
- Rakesh Kumar Pilania
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Aaqib Zaffar Banday
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Saniya Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajni Kumrah
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vibhu Joshi
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sathish Loganathan
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manpreet Dhaliwal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pandiarajan Vignesh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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7
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Savic S, Coe J, Laws P. Autoinflammation: Interferonopathies and Other Autoinflammatory Diseases. J Invest Dermatol 2021; 142:781-792. [PMID: 34887082 DOI: 10.1016/j.jid.2021.07.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022]
Abstract
The family of autoinflammatory diseases (AIDs) continues to expand and now includes over 40 genetically defined disorders. Their defining feature is a dysregulated inflammatory innate immune response. Many AIDs have overlapping clinical characteristics, and dermatological manifestations are common. Autoinflammatory features have also been recognized in more common dermatological conditions such as psoriasis. Furthermore, there is an increasing understanding that immunodeficiencies, autoimmune disorders, and even some allergic disorders share overlapping autoinflammatory features. The discovery that certain somatic mutations, arising within the bone marrow and restricted to the myeloid cell lineage can cause acquired AID heralds a new era of discoveries in this field.
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Affiliation(s)
- Sinisa Savic
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, School of Medicine, University of Leeds, Leeds, United Kingdom; Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Leeds, United Kingdom; Department of Allergy and Clinical Immunology, The Leeds Teaching Hospitals, National Health Service (NHS) Trust, Leeds, United Kingdom.
| | - James Coe
- Leeds Centre for Dermatology, Leeds Teaching Hospitals, National Health Service (NHS) Trust, Leeds, United Kingdom
| | - Philip Laws
- Leeds Centre for Dermatology, Leeds Teaching Hospitals, National Health Service (NHS) Trust, Leeds, United Kingdom
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8
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Yap JY, Moens L, Lin MW, Kane A, Kelleher A, Toong C, Wu KHC, Sewell WA, Phan TG, Hollway GE, Enthoven K, Gray PE, Casas-Martin J, Wouters C, De Somer L, Hershfield M, Bucciol G, Delafontaine S, Ma CS, Tangye SG, Meyts I. Intrinsic Defects in B Cell Development and Differentiation, T Cell Exhaustion and Altered Unconventional T Cell Generation Characterize Human Adenosine Deaminase Type 2 Deficiency. J Clin Immunol 2021; 41:1915-1935. [PMID: 34657246 PMCID: PMC8604888 DOI: 10.1007/s10875-021-01141-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/22/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Deficiency of adenosine deaminase type 2 (ADA2) (DADA2) is a rare inborn error of immunity caused by deleterious biallelic mutations in ADA2. Clinical manifestations are diverse, ranging from severe vasculopathy with lacunar strokes to immunodeficiency with viral infections, hypogammaglobulinemia and bone marrow failure. Limited data are available on the phenotype and function of leukocytes from DADA2 patients. The aim of this study was to perform in-depth immunophenotyping and functional analysis of the impact of DADA2 on human lymphocytes. METHODS In-depth immunophenotyping and functional analyses were performed on ten patients with confirmed DADA2 and compared to heterozygous carriers of pathogenic ADA2 mutations and normal healthy controls. RESULTS The median age of the patients was 10 years (mean 20.7 years, range 1-44 years). Four out of ten patients were on treatment with steroids and/or etanercept or other immunosuppressives. We confirmed a defect in terminal B cell differentiation in DADA2 and reveal a block in B cell development in the bone marrow at the pro-B to pre-B cell stage. We also show impaired differentiation of CD4+ and CD8+ memory T cells, accelerated exhaustion/senescence, and impaired survival and granzyme production by ADA2 deficient CD8+ T cells. Unconventional T cells (i.e. iNKT, MAIT, Vδ2+ γδT) were diminished whereas pro-inflammatory monocytes and CD56bright immature NK cells were increased. Expression of the IFN-induced lectin SIGLEC1 was increased on all monocyte subsets in DADA2 patients compared to healthy donors. Interestingly, the phenotype and function of lymphocytes from healthy heterozygous carriers were often intermediate to that of healthy donors and ADA2-deficient patients. CONCLUSION Extended immunophenotyping in DADA2 patients shows a complex immunophenotype. Our findings provide insight into the cellular mechanisms underlying some of the complex and heterogenous clinical features of DADA2. More research is needed to design targeted therapy to prevent viral infections in these patients with excessive inflammation as the overarching phenotype.
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Affiliation(s)
- Jin Yan Yap
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Leen Moens
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium
| | - Ming-Wei Lin
- Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Department of Clinical Immunology and Immunopathology, Westmead Hospital, Westmead, NSW, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Alisa Kane
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Department of Immunology, Liverpool Hospital, Allergy and HIV, Liverpool, Sydney, Australia.,HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Anthony Kelleher
- HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia.,The Kirby Institute for Infection and Immunity in Society, Sydney, Australia
| | - Catherine Toong
- Department of Immunology, Liverpool Hospital, Allergy and HIV, Liverpool, Sydney, Australia
| | - Kathy H C Wu
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,St Vincent's Clinical Genomics, St Vincent's Hospital Darlinghurst, Darlinghurst, NSW, Australia.,School of Medicine, UNSW Sydney, Sydney, Australia.,Discipline of Genetic Medicine, University of Sydney, Sydney, Australia.,School of Medicine, University of Notre Dame, Fremantle, Australia
| | - William A Sewell
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Tri Giang Phan
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,HIV and Immunology Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Georgina E Hollway
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Karen Enthoven
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia
| | - Paul E Gray
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jose Casas-Martin
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium
| | - Carine Wouters
- Department of Microbiology and Immunology, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, EU, Belgium
| | - Lien De Somer
- Department of Microbiology and Immunology, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, University Hospitals Leuven, Leuven, EU, Belgium
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA
| | - Giorgia Bucciol
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, Division of Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, EU Leuven, Belgium
| | - Selket Delafontaine
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium.,Department of Pediatrics, Division of Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, EU Leuven, Belgium
| | - Cindy S Ma
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia.,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia
| | - Stuart G Tangye
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia. .,Clinical Immunogenomics Research Consortium of Australasia (CIRCA), Sydney, NSW, Australia. .,Faculty of Medicine, St Vincent's Clinical School, Sydney, NSW, Australia.
| | - Isabelle Meyts
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, KU Leuven, Herestraat 49, 3000, Leuven, EU, Belgium. .,Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA.
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Hashem H, Bucciol G, Ozen S, Unal S, Bozkaya IO, Akarsu N, Taskinen M, Koskenvuo M, Saarela J, Dimitrova D, Hickstein DD, Hsu AP, Holland SM, Krance R, Sasa G, Kumar AR, Müller I, de Sousa MA, Delafontaine S, Moens L, Babor F, Barzaghi F, Cicalese MP, Bredius R, van Montfrans J, Baretta V, Cesaro S, Stepensky P, Benedicte N, Moshous D, Le Guenno G, Boutboul D, Dalal J, Brooks JP, Dokmeci E, Dara J, Lucas CL, Hambleton S, Wilson K, Jolles S, Koc Y, Güngör T, Schnider C, Candotti F, Steinmann S, Schulz A, Chambers C, Hershfield M, Ombrello A, Kanakry JA, Meyts I. Hematopoietic Cell Transplantation Cures Adenosine Deaminase 2 Deficiency: Report on 30 Patients. J Clin Immunol 2021; 41:1633-1647. [PMID: 34324127 PMCID: PMC8452581 DOI: 10.1007/s10875-021-01098-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/06/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Deficiency of adenosine deaminase 2 (DADA2) is an inherited inborn error of immunity, characterized by autoinflammation (recurrent fever), vasculopathy (livedo racemosa, polyarteritis nodosa, lacunar ischemic strokes, and intracranial hemorrhages), immunodeficiency, lymphoproliferation, immune cytopenias, and bone marrow failure (BMF). Tumor necrosis factor (TNF-α) blockade is the treatment of choice for the vasculopathy, but often fails to reverse refractory cytopenia. We aimed to study the outcome of hematopoietic cell transplantation (HCT) in patients with DADA2. METHODS We conducted a retrospective study on the outcome of HCT in patients with DADA2. The primary outcome was overall survival (OS). RESULTS Thirty DADA2 patients from 12 countries received a total of 38 HCTs. The indications for HCT were BMF, immune cytopenia, malignancy, or immunodeficiency. Median age at HCT was 9 years (range: 2-28 years). The conditioning regimens for the final transplants were myeloablative (n = 20), reduced intensity (n = 8), or non-myeloablative (n = 2). Donors were HLA-matched related (n = 4), HLA-matched unrelated (n = 16), HLA-haploidentical (n = 2), or HLA-mismatched unrelated (n = 8). After a median follow-up of 2 years (range: 0.5-16 years), 2-year OS was 97%, and 2-year GvHD-free relapse-free survival was 73%. The hematological and immunological phenotypes resolved, and there were no new vascular events. Plasma ADA2 enzyme activity normalized in 16/17 patients tested. Six patients required more than one HCT. CONCLUSION HCT was an effective treatment for DADA2, successfully reversing the refractory cytopenia, as well as the vasculopathy and immunodeficiency. CLINICAL IMPLICATIONS HCT is a definitive cure for DADA2 with > 95% survival.
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Affiliation(s)
- Hasan Hashem
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Bone Marrow Transplant Unit, King Hussein Cancer Center (KHCC), P.O Box 1269, Amman, 11941, Jordan.
| | - Giorgia Bucciol
- Department of Pediatrics, ERN RITA Core Center, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University, Ankara, Turkey
- Hacettepe University Vasculitis Research Center, Ankara, Turkey
| | - Sule Unal
- Department of Pediatric Hematology, Research Center for Fanconi Anemia and Other Inherited Bone Marrow Failure Syndromes, Hacettepe University, Ankara, Turkey
| | - Ikbal Ok Bozkaya
- Division of Pediatric Hematology and Oncology, Bone Marrow Transplant Unit, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nurten Akarsu
- Department of Medical Genetics, Hacettepe University, Sihhiye, 06100, Ankara, Turkey
| | - Mervi Taskinen
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Helsinki University Hospital, Helsinki, Finland
| | - Minna Koskenvuo
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Children and Adolescents, Helsinki University Hospital, Helsinki, Finland
| | - Janna Saarela
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
- Centre for Molecular Medicine Norway, University of Oslo, Oslo, Norway
| | - Dimana Dimitrova
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute of the National Institutes of Health, Bethesda, MD, USA
| | | | - Amy P Hsu
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Steven M Holland
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Robert Krance
- Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Ghadir Sasa
- Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Ashish R Kumar
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ingo Müller
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monica Abreu de Sousa
- Division of Pediatric Stem Cell Transplantation and Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Selket Delafontaine
- Department of Pediatrics, ERN RITA Core Center, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Leen Moens
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Florian Babor
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy (TIGET), Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute Milan, Milan, Italy
| | - Maria Pia Cicalese
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Robbert Bredius
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - Joris van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Valentina Baretta
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Medical Center, Jerusalem, Israel
| | - Neven Benedicte
- Pediatric Immunology, Hematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Despina Moshous
- Pediatric Immunology, Hematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, University Hospital Estaing, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - David Boutboul
- Clinical Immunology Department, Hospital Saint Louis, Université de Paris, Paris, France
| | - Jignesh Dalal
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Joel P Brooks
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Elif Dokmeci
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Jasmeen Dara
- Department of Pediatrics, Division of Allergy, Immunology, Blood and Marrow Transplantation, University of California San Francisco, San Francisco, CA, USA
| | - Carrie L Lucas
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Sophie Hambleton
- Newcastle University Translational and Clinical Research Institute and Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, , Newcastle Upon Tyne, UK
| | - Keith Wilson
- Department of Hematology, University Hospital of Wales, Cardiff, UK
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, UK
| | - Yener Koc
- Stem Cell Transplant Unit, Medicana International, Istanbul, Turkey
| | - Tayfun Güngör
- Division of Hematology/Oncology/Immunology, Gene Therapy, and Stem Cell Transplantation, University Children's Hospital Zurich - Eleonore Foundation & Children's Research Center (CRC), Steinwiesstrasse 75, CH-8032, Zurich, Switzerland
| | - Caroline Schnider
- Pediatric Immuno-Rheumatology of Western Switzerland, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio Candotti
- Division of Immunology and Allergy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sandra Steinmann
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Chip Chambers
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Hershfield
- Department of Medicine and Biochemistry, Duke University Medical Center, Durham, NC, USA
| | - Amanda Ombrello
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute (NHGRI), Bethesda, MD, USA
| | - Jennifer A Kanakry
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Isabelle Meyts
- Department of Pediatrics, ERN RITA Core Center, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Microbiology, Immunology and Transplantation, Laboratory for Inborn Errors of Immunity, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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