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Silva H, Brito CGXD, Hall A, Eden N, Somers H, Burke N, Burns SO, Lowe D, Thorburn D, Halliday N, Quaglia A. Common variable immunodeficiency disorder (CVID)-related liver disease: assessment of the main histological aspects using novel semiquantitative scoring systems, image analysis and correlation with clinical parameters of liver stiffness and portal hypertension. J Clin Pathol 2024; 77:709-716. [PMID: 37553247 DOI: 10.1136/jcp-2023-208977] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/14/2023] [Indexed: 08/10/2023]
Abstract
AIMS We aimed to investigate the relationship between T-cell-mediated sinusoidal injury, nodular regenerative hyperplasia like changes (NRH-LC) and fibrosis, clinical measures of fibrosis and portal hypertension, and progression rate in common variable immunodeficiency disorder (CVID)-related liver disease. METHODS This is a retrospective single-centre study. Liver biopsies from CVID patients with liver disease were reviewed to assess for NRH-LC, fibrosis and elastosis, including collagen and elastin proportionate areas. CD3 positive T-cells infiltration and sinusoidal endothelial changes by CD34 expression were quantified by image analysis and a semiquantitative method, respectively. These findings were correlated with liver stiffness measurements (LSM) and hepatic venous pressure gradient (HVPG). RESULTS NRH-LC and pericellular elastosis were present in most biopsies (32/40 and 38/40, respectively). All biopsies showed fibrosis, which was limited to pericellular in 21/40 (52.5%) and included bridging fibrous septa in 19/40 (47.5%). 28/40 liver biopsies showed enhanced sinusoidal expression of CD34. There were more CD3 positive cells in biopsies with NRH-LC compared with those without. There was no significant correlation between LSM, HVPG and fibrosis/elastosis scores. Five of seven patients with at least two biopsies showed progression in fibrosis stage. CONCLUSIONS NRH-LC and fibrosis in CVID patients often coexist along with the presence of sinusoidal endothelial changes and sinusoidal lymphocytic infiltration. Fibrosis progresses over time, and significant fibrosis can be observed in young patients (<30 years old), potentially reflecting a more aggressive form of CVID-related liver disease. Further studies are necessary to investigate the relationship between histological findings, clinical measures of fibrosis and portal hypertension and outcome.
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Affiliation(s)
- Hiroshi Silva
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew Hall
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Nadia Eden
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Henry Somers
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Niall Burke
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Siobhan O Burns
- Institute of Immunity and Transplantation, University College London, London, UK
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - David Lowe
- Institute of Immunity and Transplantation, University College London, London, UK
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Neil Halliday
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Alberto Quaglia
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
- Institute for Liver and Digestive Health, University College London, London, UK
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Ayar ŞN, Soyak Aytekin E, Şimşek C, Dağ O, Çağdaş D, Balaban YH. Inborn Errors of Immunity in Adults with Autoimmune Liver Diseases. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2024; 35:560-567. [PMID: 39128084 PMCID: PMC11363372 DOI: 10.5152/tjg.2024.23171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/21/2023] [Indexed: 08/13/2024]
Abstract
BACKGROUND/AIMS Inborn errors of immunity (IEI) may associate with autoimmune diseases, including autoimmune liver diseases (AILD). However, both the IEI frequency and secondary effects of immunosuppressives are unknown in patients with AILD due to the lack of data. We aimed to evaluate the ratio of IEI in AILD. MATERIALS AND METHODS A total of 82 patients with AILD (39 autoimmune hepatitis, 32 primary biliary cholangitis, 7 variant syndromes (VS), and 4 primary sclerosing cholangitis patients) were included in this single-center, cross-sectional, and descriptive study. The patients were evaluated and classified according to diagnostic criteria for IEI. RESULTS Out of 82 patients with AILD, female/male ratio was 3.6. Median age of diagnosis of AILD was 45 years. We diagnosed 15 (18%) patients with immunodeficiency (ID). Inborn errors of immunity ratio was highest in VS patient group (29%). Out of 15 patients with ID, 4 (4.8%) patients had common variable immunodeficiency, 4 (4.8%) had partial immunoglobulin A deficiency, 4 (4.8%) had selective immunoglobulin M deficiency, and 3 (3.6%) had combined immunodeficiency. CONCLUSION We detect ID in about one-fifth of the patients with AILD. The present study showed a significant risk of IEI that is blurred by the shadow of immune suppressive treatments. We suggest that the AILD patients with ID will benefit from the individualized and targeted therapeutic options used in IEI. Further research with larger patient groups and long-term follow-up are desperately needed to elucidate the diagnostic, therapeutic, and prognostic impacts of IEI-related individualized therapy on AILD patients.
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Affiliation(s)
- Şefika Nur Ayar
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Elif Soyak Aytekin
- Department of Pediatric Immunology, Hacettepe University İhsan Doğramacı Children’s Hospital, Ankara, Türkiye
| | - Cem Şimşek
- Division of Gastroenterology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Osman Dağ
- Department of Biostatistics, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Deniz Çağdaş
- Department of Pediatric Immunology, Hacettepe University İhsan Doğramacı Children’s Hospital, Ankara, Türkiye
| | - Yasemin H. Balaban
- Division of Gastroenterology, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Türkiye
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Ganapathi L, Cochran RL, Robbins GK, Barmettler S, Holland SM, Ababneh EI. Case 20-2024: A 73-Year-Old Man with Recurrent Fever and Liver Lesions. N Engl J Med 2024; 390:2309-2319. [PMID: 38924735 DOI: 10.1056/nejmcpc2309383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Lakshmi Ganapathi
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Rory L Cochran
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Gregory K Robbins
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Sara Barmettler
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Steven M Holland
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
| | - Emad I Ababneh
- From the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Massachusetts General Hospital, and the Departments of Pediatrics (L.G.), Radiology (R.L.C.), Medicine (G.K.R., S.B.), and Pathology (E.I.A.), Harvard Medical School - both in Boston; and the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (S.M.H.)
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Messelink MA, Welsing PMJ, Devercelli G, Marsden JWN, Leavis HL. Clinical Validation of a Primary Antibody Deficiency Screening Algorithm for Primary Care. J Clin Immunol 2023; 43:2022-2032. [PMID: 37715890 PMCID: PMC10660978 DOI: 10.1007/s10875-023-01575-8] [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: 07/07/2023] [Accepted: 08/27/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE The diagnostic delay of primary antibody deficiencies (PADs) is associated with increased morbidity, mortality, and healthcare costs. Therefore, a screening algorithm was previously developed for the early detection of patients at risk of PAD in primary care. We aimed to clinically validate and optimize the PAD screening algorithm by applying it to a primary care database in the Netherlands. METHODS The algorithm was applied to a data set of 61,172 electronic health records (EHRs). Four hundred high-scoring EHRs were screened for exclusion criteria, and remaining patients were invited for serum immunoglobulin analysis and referred if clinically necessary. RESULTS Of the 104 patients eligible for inclusion, 16 were referred by their general practitioner for suspected PAD, of whom 10 had a PAD diagnosis. In patients selected by the screening algorithm and included for laboratory analysis, prevalence of PAD was ~ 1:10 versus 1:1700-1:25,000 in the general population. To optimize efficiency of the screening process, we refitted the algorithm with the subset of high-risk patients, which improved the area under the curve-receiver operating characteristics curve value to 0.80 (95% confidence interval 0.63-0.97). We propose a two-step screening process, first applying the original algorithm to distinguish high-risk from low-risk patients, then applying the optimized algorithm to select high-risk patients for serum immunoglobulin analysis. CONCLUSION Using the screening algorithm, we were able to identify 10 new PAD patients from a primary care population, thus reducing diagnostic delay. Future studies should address further validation in other populations and full cost-effectiveness analyses. REGISTRATION Clinicaltrials.gov record number NCT05310604, first submitted 25 March 2022.
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Affiliation(s)
- Marianne A Messelink
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Jan Willem N Marsden
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Helen L Leavis
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
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Baumert LS, Shih A, Chung RT. Management of liver disease and portal hypertension in common variable immunodeficiency (CVID). JHEP Rep 2023; 5:100882. [PMID: 37869072 PMCID: PMC10585302 DOI: 10.1016/j.jhepr.2023.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/30/2023] [Accepted: 07/22/2023] [Indexed: 10/24/2023] Open
Abstract
Patients with common variable immunodeficiency (CVID) frequently develop liver disease and associated complications, which represent an increasingly prevalent unmet medical need. The main hepatic manifestation of CVID is nodular regenerative hyperplasia (NRH), resulting in non-cirrhotic portal hypertension (NCPH). Liver disease is often underdiagnosed, leading to poor outcomes and decreased survival. The increasing numbers of patients with CVID who are diagnosed late with progressive liver disease underscores the importance of appropriate clinical management and treatment of liver complications. At the same time, specific guidelines for the clinical management of CVID-related liver disease are still lacking. Here, we review the epidemiology of CVID-related liver disease, reveal new insights into NRH and NCPH biology and highlight recently uncovered opportunities for NCPH diagnostics in CVID. Finally, we focus on current management of liver disease, portal hypertension and its complications - the key challenge in patients with CVID. Specifically, we review recent data regarding the role of transjugular intrahepatic portosystemic shunt and liver transplantation in clinical management. The role for anticoagulants and immunosuppressants targeting the pathogenesis of NRH will also be discussed. We propose an updated algorithm for the diagnostic work-up and treatment of NCPH in CVID. Finally, we consider future needs and therapeutic opportunities for CVID-related liver disease.
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Affiliation(s)
- Lukas S. Baumert
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Faculty of Medicine, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Angela Shih
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond T. Chung
- Liver Center, Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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6
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Deng F, Wang H, Wang X. Chronic Diarrhea with Villous Blunting of the Small Intestine Under Capsule Endoscopy in Common Variable Immunodeficiency and X-Linked Agammaglobulinemia: A Case Series. J Asthma Allergy 2023; 16:997-1006. [PMID: 37772267 PMCID: PMC10522781 DOI: 10.2147/jaa.s418996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction Primary immunodeficiencies (PIDs) are a heterogeneous group of disorders, common variable immunodeficiency disorder (CVID) and X-linked agammaglobulinemia (XLA) are PIDs related to B-cell defect, characterized by reduced levels of immunoglobulins and immune dysregulation. Infections are the most common clinical manifestations, while underlying autoimmune and inflammatory conditions are present in some patients with CVID and XLA, leading to clinical misdiagnosis and diagnostic delay. Chronic diarrhea in patients with CVID and XLA, particularly complicated malabsorption and protein-energy malnutrition, is responsible for poor prognostic outcomes. Methods In this study, we described three PID adult patients (two with CVID and one with XLA) who presented with varying degrees of chronic diarrhea, weight loss, and protein-energy malnutrition. We suggest that villous blunting of the small intestine under capsule endoscopy may be an endoscopic feature of PID-related enteropathy, thus highlighting the application of capsule endoscopy in patients with CVID and XLA presenting with chronic diarrhea. Conclusion We also summarize regular Ig supplementation is the basic treatment for CVID and XLA patients, proper enteral nutrition and probiotic therapy can be explored to use to alter gut microbiota and modulate intestinal immune response. However, vedolizumab is not helpful to PID-related enteropathy therapy, as it exacerbates the inflammatory response in extra-intestinal organs and ultimately causes poor clinical outcomes.
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Affiliation(s)
- Feihong Deng
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Hanyu Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People’s Republic of China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, People’s Republic of China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, 410011, People’s Republic of China
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7
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Fiel MI, Schiano TD. Systemic Disease and the Liver Part 2: Pregnancy-Related Liver Injury, Sepsis/Critical Illness, Hypoxia, Psoriasis, Scleroderma/Sjogren's Syndrome, Sarcoidosis, Common Variable Immune Deficiency, Cystic Fibrosis, Inflammatory Bowel Disease, and Hematologic Disorders. Surg Pathol Clin 2023; 16:485-498. [PMID: 37536884 DOI: 10.1016/j.path.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The liver is involved in many multisystem diseases and commonly may manifest with abnormal liver chemistry tests. The liver test perturbations may be multifactorial in nature, however, as patients are receiving many different medications and can also have intrinsic liver disease that may be exacerbated by the systemic disorder. Some disorders have typical histologic findings that can be diagnosed on liver biopsy, whereas others will show a more nonspecific histology. Clinicians should be aware of these conditions so as to consider the performance of a liver biopsy at the most opportune time and setting to help establish the diagnosis of acute or chronic liver disease.
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Affiliation(s)
- Maria Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA.
| | - Thomas D Schiano
- Division of Liver Diseases, Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place-Box 1104, New York, NY 10029, USA
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Sanchez DA, Rotella K, Toribio C, Hernandez M, Cunningham-Rundles C. Characterization of infectious and non-infectious gastrointestinal disease in common variable immunodeficiency: analysis of 114 patient cohort. Front Immunol 2023; 14:1209570. [PMID: 37711607 PMCID: PMC10498782 DOI: 10.3389/fimmu.2023.1209570] [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: 04/20/2023] [Accepted: 07/31/2023] [Indexed: 09/16/2023] Open
Abstract
Common Variable Immunodeficiency (CVID), a complex primary immunodeficiency syndrome defined by defective B cell responses to infection and vaccination, has heterogeneous clinical manifestations. Gastrointestinal (GI) complications in CVID, both infectious and non-infectious, can cause significant impairment leading to malabsorption and frank malnutrition. In order to better characterize the spectrum of GI disease associated with CVID, we describe 114 patients with GI disease (15.6%) from our 728 patient single center CVID cohort. Norovirus, Giardia and Cytomegalovirus were the most frequently isolated infectious pathogens. CVID enteropathy was the most encountered GI diagnosis based on endoscopy, with only a minority of patients having Crohn's disease (6.1%) or ulcerative colitis/proctitis (4.5%). Concurrent autoimmunity (30.7%), lung disease (18.4%) and malignancy (8.7%) were also present in significant proportion of subjects. Lastly, 16 of 47 (34%) who underwent whole exome sequencing demonstrated a culprit gene defect associated with CVID.
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Affiliation(s)
- David A. Sanchez
- Division of Allergy and Immunology, Mount Sinai, New York, NY, United States
| | - Karina Rotella
- Division of Allergy and Immunology, Mount Sinai, New York, NY, United States
| | | | - Matthew Hernandez
- Division of Allergy and Immunology, Mount Sinai, New York, NY, United States
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Grümme L, Schulze-Koops H. Management of a patient with common variable immunodeficiency and hepatopathy. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:50. [PMID: 37277808 DOI: 10.1186/s13223-023-00799-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/24/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Common variable Immunodeficiency (CVID) is a primary immunodeficiency disorder and the most common form of severe antibody deficiency. Both children and adults are affected and clinical manifestations vary widely. Often, CVID manifests with infections, autoimmune phenomena or chronic lung disease, but it also frequently affects the liver. The differential diagnoses of hepatopathies in CVID patients are diverse and the characteristics of CVID patients often make it difficult to determine the correct diagnosis. CASE PRESENTATION We present the case of a 39-year-old patient with CVID and elevated liver enzymes, nausea and unintended weight loss, who was referred to our clinic with the suspected diagnose of autoimmune hepatitis or immunoglobulin-induced hepatopathy. Prior, the patient had undergone an extensive diagnostic work-up including liver biopsy but viral hepatitides had only been investigated serologically - with negative antibody results. We searched for viral nucleic acid by polymerase chain reaction and detected hepatitis E virus-RNA. Antiviral therapy was started and the patient recovered quickly. CONCLUSION Hepatopathies in CVID patients are common with a broad spectrum of possible causes. While treating CVID patients, the distinct diagnostic and therapeutic requirements of the CVID patients should be closely considered and diagnosed by the appropriate measures.
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Affiliation(s)
- Lea Grümme
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU Clinic Munich, Munich, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Medicine IV, LMU Clinic Munich, Munich, Germany.
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Daza-Cajigal V, Segura-Guerrero M, López-Cueto M, Robles-Marhuenda Á, Camara C, Gerra-Galán T, Gómez-de-la-Torre R, Avendaño-Monje CL, Sánchez-Ramón S, Bosque-Lopez MJ, Quintero-Duarte A, Bonet-Vidal ML, Pons J. Clinical manifestations and approach to the management of patients with common variable immunodeficiency and liver disease. Front Immunol 2023; 14:1197361. [PMID: 37342345 PMCID: PMC10277479 DOI: 10.3389/fimmu.2023.1197361] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/22/2023] Open
Abstract
Purpose The clinical spectrum of common variable immunodeficiency (CVID) includes predisposition to infections, autoimmune/inflammatory complications and malignancy. Liver disease is developed by a proportion of patients with CVID, but limited evidence is available about its prevalence, pathogenesis and prognostic outcome. This lack of evidence leads to the absence of guidelines in clinical practice. In this study, we aimed at defining the characteristics, course and management of this CVID complication in Spain. Methods Spanish reference centers were invited to complete a cross-sectional survey. Thirty-eight patients with CVID-related liver disease from different hospitals were evaluated by a retrospective clinical course review. Results In this cohort, abnormal liver function and thrombocytopenia were found in most of the patients (95% and 79% respectively), in keeping with the higher incidence of abnormal liver imaging and splenomegaly. The most common histological findings included nodular regenerative hyperplasia (NRH) and lymphocytic infiltration, which have been associated with portal hypertension (PHTN) leading to a poorer prognosis. Autoimmune/inflammatory complications occurred in 82% of the CVID patients that developed liver disease and 52% of the patients treated with immunomodulators showed a reduction in the liver function tests' abnormalities during treatment. Among the experts that conducted the survey, there was 80% or more consensus that the workup of CVID-related liver disease requires liver profile, abdominal ultrasound and transient elastography. The majority agreed that liver biopsy should be essential for diagnosis. There was 94% consensus that endoscopic studies should be performed in the presence of PHTN. However, there was 89% consensus that there is insufficient evidence on the management of these patients. Conclusion Liver disease varies in severity and may contribute substantially to morbidity and mortality in patients with CVID. Hence the importance of close follow-up and screening of this CVID complication to prompt early targeted intervention. Further research is needed to evaluate the pathophysiology of liver disease in patients with CVID to identify personalized treatment options. This study emphasizes the urgent need to develop international guidelines for the diagnosis and management of this CVID complication.
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Affiliation(s)
- Vanessa Daza-Cajigal
- Department of Immunology, Hospital Universitario Son Espases, Palma, Spain
- Research Unit, Balearic Islands Health Research Institute (IdISBa), Palma, Spain
| | - Marina Segura-Guerrero
- Department of Immunology, Hospital Universitario Son Espases, Palma, Spain
- Research Unit, Balearic Islands Health Research Institute (IdISBa), Palma, Spain
| | - María López-Cueto
- Department of Immunology, Hospital Universitario Son Espases, Palma, Spain
- Research Unit, Balearic Islands Health Research Institute (IdISBa), Palma, Spain
| | | | - Carmen Camara
- Department of Immunology, Hospital Universitario La Paz, Madrid, Spain
| | - Teresa Gerra-Galán
- Department of Clinical Immunology, Instituto de Medicina del Laboratorio (IML), Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - Silvia Sánchez-Ramón
- Department of Clinical Immunology, Instituto de Medicina del Laboratorio (IML), Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - María L. Bonet-Vidal
- Department of Gastroenterology, Hospital Universitario Son Espases, Palma, Spain
| | - Jaime Pons
- Department of Immunology, Hospital Universitario Son Espases, Palma, Spain
- Research Unit, Balearic Islands Health Research Institute (IdISBa), Palma, Spain
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Messelink MA, Berbers RM, van Montfrans JM, Ellerbroek PM, Gladiator A, Welsing PMJ, Leavis H. Development of a primary care screening algorithm for the early detection of patients at risk of primary antibody deficiency. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:44. [PMID: 37245042 DOI: 10.1186/s13223-023-00790-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 04/09/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Primary antibody deficiencies (PAD) are characterized by a heterogeneous clinical presentation and low prevalence, contributing to a median diagnostic delay of 3-10 years. This increases the risk of morbidity and mortality from undiagnosed PAD, which may be prevented with adequate therapy. To reduce the diagnostic delay of PAD, we developed a screening algorithm using primary care electronic health record (EHR) data to identify patients at risk of PAD. This screening algorithm can be used as an aid to notify general practitioners when further laboratory evaluation of immunoglobulins should be considered, thereby facilitating a timely diagnosis of PAD. METHODS Candidate components for the algorithm were based on a broad range of presenting signs and symptoms of PAD that are available in primary care EHRs. The decision on inclusion and weight of the components in the algorithm was based on the prevalence of these components among PAD patients and control groups, as well as clinical rationale. RESULTS We analyzed the primary care EHRs of 30 PAD patients, 26 primary care immunodeficiency patients and 58,223 control patients. The median diagnostic delay of PAD patients was 9.5 years. Several candidate components showed a clear difference in prevalence between PAD patients and controls, most notably the mean number of antibiotic prescriptions in the 4 years prior to diagnosis (5.14 vs. 0.48). The final algorithm included antibiotic prescriptions, diagnostic codes for respiratory tract and other infections, gastro-intestinal complaints, auto-immune symptoms, malignancies and lymphoproliferative symptoms, as well as laboratory values and visits to the general practitioner. CONCLUSIONS In this study, we developed a screening algorithm based on a broad range of presenting signs and symptoms of PAD, which is suitable to implement in primary care. It has the potential to considerably reduce diagnostic delay in PAD, and will be validated in a prospective study. Trial registration The consecutive prospective study is registered at clinicaltrials.gov under NCT05310604.
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Affiliation(s)
- Marianne A Messelink
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
| | - Roos M Berbers
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Joris M van Montfrans
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Pauline M Ellerbroek
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - André Gladiator
- Takeda Pharmaceuticals International AG, Thurgauerstrasse 130, 8152, Glattpark-Opfikon, Zurich, Switzerland
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - Helen Leavis
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
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12
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Mohammadi F, Yadegar A, Mardani M, Ayati A, Abolhassani H, Rezaei N. Organ-based clues for diagnosis of inborn errors of immunity: A practical guide for clinicians. Immun Inflamm Dis 2023; 11:e833. [PMID: 37102642 PMCID: PMC10091206 DOI: 10.1002/iid3.833] [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: 02/16/2023] [Accepted: 03/24/2023] [Indexed: 04/28/2023] Open
Abstract
Inborn errors of immunity (IEI) comprise a group of about 490 genetic disorders that lead to aberrant functioning or the development of distinct immune system components. So far, a broad spectrum of IEI-related manifestations has been noted in the literature. Due to overlapping signs and symptoms of IEI, physicians face challenges in appropriately diagnosing and managing affected individuals. The last decade has witnesses improving in the molecular diagnosis of IEI patients. As a result, it can be the mainstay of diagnostic algorithms, prognosis, and possibly therapeutic interventions in patients with IEI. Furthermore, reviewing IEI clinical complications demonstrates that the manifestations and severity of the symptoms depend on the involved gene that causes the disease and its penetrance. Although several diagnostic criteria have been used for IEI, not every patient can be explored in the same way. As a result of the failure to consider IEI diagnosis and the variety of diagnostic capabilities and laboratory facilities in different regions, undiagnosed patients are increasing. On the other hand, early diagnosis is an almost essential element in improving the quality of life in IEI patients. Since there is no appropriate guideline for IEI diagnosis in different organs, focusing on the clues in the patient's chief complaint and physical exams can help physicians narrow their differential diagnosis. This article aims to provide a practical guide for IEI diagnosis based on the involved organ. We hope to assist clinicians in keeping IEI diagnosis in mind and minimizing possible related complications due to delayed diagnosis.
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Affiliation(s)
- Fatemeh Mohammadi
- School of MedicineTehran University of Medical SciencesTehranIran
- Universal Scientific Education and Research Network (USERN)Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA)TehranIran
| | - Amirhossein Yadegar
- School of MedicineTehran University of Medical SciencesTehranIran
- Universal Scientific Education and Research Network (USERN)Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA)TehranIran
| | - Mahta Mardani
- School of MedicineTehran University of Medical SciencesTehranIran
- Universal Scientific Education and Research Network (USERN)Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA)TehranIran
| | - Aryan Ayati
- Research Center for Advanced Technologies in Cardiovascular Medicine, Tehran Heart CenterTehran University of Medical ScienceTehranIran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical CenterTehran University of Medical SciencesTehranIran
| | - Nima Rezaei
- Universal Scientific Education and Research Network (USERN)Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA)TehranIran
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical CenterTehran University of Medical SciencesTehranIran
- Primary Immunodeficiency Diseases Network (PIDNet)TehranIran
- Children's Medical CenterTehranIran
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13
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Bonatti HJR, Roman AL, Krebs E, Sifri CD, Hagspiel KD, Sawyer RG, Pruett TL. Good Long-Term Outcome Following Liver Transplant in a Patient With Common Variable Immunodeficiency Syndrome Despite Multiple Infections and Recurrent Nodular Regenerative Hyperplasia. EXP CLIN TRANSPLANT 2023; 21:66-69. [PMID: 36259616 DOI: 10.6002/ect.2022.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Common variable immunodeficiency can be associated with various hepatic conditions, the most common being nodular regenerative hyperplasia. Multiple cases of liver transplant in adults with common variable immunodeficiency have been reported. Here, we report a 51-year-old man with common variable immunodeficiency and noncirrhotic portal hypertension due to nodular regenerative hyperplasia who underwent liver transplant. The patient received tacrolimus/steroid immunosuppression and remained rejection free; however, he developed cytomegalovirus infection, disseminated nocardiosis, Pseudomonas pneumonia, and Clostridioides difficile- associated colitis. All infections were successfully managed. The graft was well functioning after 18 months; however, alkaline phosphatase remained elevated and a liver biopsy showed evidence of recurrent nodular regenerative hyperplasia. The patient was started on a steroid taper, which led to normalization of the alkaline phosphatase. Two years later, a repeat biopsy confirmed recurrent nodular regenerative hyperplasia. Immunosuppression was kept low, and intravenous immunoglobulin infusions were continued. More than 10 years later, the patient is alive with a functioning graft. This case emphasizes that intensified prophylaxis for infections and less intense immunosuppression may be strategies to enable long-term survival in liver transplant recipients with common variable immunodeficiency and nodular regenerative hyperplasia relapse despite recently reported poor outcomes in this patient population.
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Affiliation(s)
- Hugo J R Bonatti
- From the Department of Surgery, University of Virginia Health Services, Charlottesville, Virginia, USA.,From the Department of Surgery, Western Michigan University, School of Medicine, Kalamazoo, Michigan, USA
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14
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Yazdanpanah N, Rezaei N. Autoimmune disorders associated with common variable immunodeficiency: prediction, diagnosis, and treatment. Expert Rev Clin Immunol 2022; 18:1265-1283. [PMID: 36197300 DOI: 10.1080/1744666x.2022.2132938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency. Due to the wide spectrum of the CVID manifestations, the differential diagnosis becomes complicated, ends in a diagnostic delay and increased morbidity and mortality rates. Autoimmunity is one of the important complications associated with CVID. While immunoglobulin replacement therapy has considerably decreased the mortality rate in CVID patients, mainly infection-related mortality, other complications such as autoimmunity appeared prevalent and, in some cases, life threatening. AREAS COVERED In this article, genetics, responsible immune defects, autoimmune manifestations in different organs, and the diagnosis and treatment processes in CVID patients are reviewed, after searching the literature about these topics. EXPERT OPINION Considering the many phenotypes of CVID and the fact that it remained undiagnosed until older ages, it is important to include various manifestations of CVID in the differential diagnosis. Due to the different manifestations of CVID, including autoimmune diseases, interdisciplinary collaboration of physicians from different fields is highly recommended, as discussed in the manuscript. Meanwhile, it is important to determine which patients could benefit from genetic diagnostic studies since such studies are not necessary for establishing the diagnosis of CVID.
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Affiliation(s)
- Niloufar Yazdanpanah
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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15
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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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16
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Muacevic A, Adler JR. Severe Ascites in Common Variable Immunodeficiency. Cureus 2022; 14:e30274. [PMID: 36381720 PMCID: PMC9653241 DOI: 10.7759/cureus.30274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/22/2022] Open
Abstract
Liver disease is one of the possible clinical manifestations of common variable immunodeficiency and can range from mild hepatomegaly and persistent elevation of liver enzymes to cirrhosis, portal hypertension, and nodular regenerative hyperplasia. The last one is the most common histologic presentation of liver involvement by common variable immunodeficiency and its clinical spectrum can range from asymptomatic to cholestasis, liver cirrhosis, or idiopathic non-cirrhotic portal hypertension, with the severe manifestations being less recognised. We present a case of a 48-year-old woman who was referred for an internal medicine consultation for evaluation of rapidly progressing (span of three months) large-volume ascites and marked asthenia. The patient had a past medical history of common variable immunodeficiency and a recent episode of severe haemolytic anaemia. Peritoneal fluid analyses identified portal hypertension as the cause of the ascites. Abdominal Doppler ultrasound and contrasted abdominal computed tomography confirmed the presence of permeable hepatic and portal veins. Liver biopsy revealed regenerative nodular hyperplasia without cirrhosis. A diagnosis of idiopathic non-cirrhotic portal hypertension secondary to common variable immunodeficiency was made. Treatment was adjusted with considerable improvement in ascites. In conclusion, idiopathic non-cirrhotic portal hypertension is a possible and often overlooked complication in patients with common variable immunodeficiency and is an exclusion diagnosis that requires a high level of suspicion, especially in patients with ascites.
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17
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Nolan PE, Catania R, Vendrami CL, Borhani AA, Miller FH. Large Regenerative Nodules and Focal Nodular Hyperplasia-Like Lesions. Radiol Clin North Am 2022; 60:795-808. [DOI: 10.1016/j.rcl.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Costagliola G, Peroni DG, Consolini R. Beyond Infections: New Warning Signs for Inborn Errors of Immunity in Children. Front Pediatr 2022; 10:855445. [PMID: 35757131 PMCID: PMC9226481 DOI: 10.3389/fped.2022.855445] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
Patients with inborn errors of immunity (IEI) are susceptible to developing a severe infection-related clinical phenotype, but the clinical consequences of immune dysregulation, expressed with autoimmunity, atopy, and lymphoproliferation could represent the first sign in a significant percentage of patients. Therefore, during the diagnostic work-up patients with IEI are frequently addressed to different specialists, including endocrinologists, rheumatologists, and allergologists, often resulting in a delayed diagnosis. In this paper, the most relevant non-infectious manifestations of IEI are discussed. Particularly, we will focus on the potential presentation of IEI with autoimmune cytopenia, non-malignant lymphoproliferation, severe eczema or erythroderma, autoimmune endocrinopathy, enteropathy, and rheumatologic manifestations, including vasculitis and systemic lupus erythematosus. This paper aims to identify new warning signs to suspect IEI and help in the identification of patients presenting with atypical/non-infectious manifestations.
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Affiliation(s)
- Giorgio Costagliola
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diego G Peroni
- Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rita Consolini
- Section of Clinical and Laboratory Immunology, Division of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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19
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Challenges in liver transplantation for common variable immunodeficiency-related liver disease: a case series and systematic review. JOURNAL OF LIVER TRANSPLANTATION 2021. [DOI: 10.1016/j.liver.2021.100038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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20
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Autoimmune Hepatitis in a Patient With Common Variable Immunodeficiency. ACG Case Rep J 2021; 8:e00547. [PMID: 34549051 PMCID: PMC8443823 DOI: 10.14309/crj.0000000000000547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/04/2020] [Indexed: 12/12/2022] Open
Abstract
Common variable immunodeficiency (CVID) is characterized by defective immunoglobulin synthesis because of impaired B-cell function. Liver abnormalities including autoimmune hepatitis (AIH) have been described in up to 10% of patients. We report a 27-year-old woman with CVID who presented with liver dysfunction secondary to AIH. AIH is both uncommon and challenging diagnostically in patients with CVID because they have low IgG levels and often have low or undetectable autoantibody levels. Liver biopsy and response to therapy play an important role in establishing the diagnosis. Corticosteroids are the mainstay of therapy, with or without immune modulators.
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21
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Picado C, de Landazuri IO, Vlagea A, Bobolea I, Arismendi E, Amaro R, Sellarés J, Bartra J, Sanmarti R, Hernandez-Rodriguez J, Mascaró JM, Colmenero J, Vaquero EC, Pascal M. Spectrum of Disease Manifestations in Patients with Selective Immunoglobulin E Deficiency. J Clin Med 2021; 10:jcm10184160. [PMID: 34575269 PMCID: PMC8466644 DOI: 10.3390/jcm10184160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Selective IgE deficiency (SIgED) has been previously evaluated in selected patients from allergy units. This study investigates the effects of SIgED on the entire population in a hospital setting and sought to delineate in detail the clinical aspects of SIgED. METHODS A retrospective study of the data obtained from electronic medical records of 52 adult patients (56% female) with a mean age of 43 years and IgE levels of <2.0 kU/L with normal immunoglobulin (Ig) IgG, IgA, and IgM levels, seen at our hospital, without selection bias, from 2010 to 2019. RESULTS Recurrent upper respiratory infections were recorded in 18 (34.6%) patients, pneumonia was recorded in 16 (30.7%) patients, bronchiectasis was recorded in 16 (30.7%) patients, and asthma was recorded in 10 (19.2%) patients. Eighteen patients (34.6%) suffered autoimmune clinical manifestations either isolated (19%) or combining two or more diseases (15%), Hashimoto's thyroiditis being the most frequent (19%), which was followed by arthritis (10%) and thrombocytopenia and/or neutropenia (5.7%). Other less frequent associations were Graves' disease, primary sclerosing cholangitis, Sjögren's syndrome, and autoimmune hepatitis. Eczematous dermatitis (15.3%), chronic spontaneous urticaria (17.3%), and symptoms of enteropathy (21%) were also highly prevalent. Thirty percent of patients developed malignancies, with non-Hodgkin lymphomas (13.4%) being the most prevalent. CONCLUSIONS The clinical manifestations of SIgED encompass a variety of infectious, non-infectious complications, and malignancy. Since it cannot be ruled out that some type of selection bias occurred in the routine assessment of IgE serum Ievels, prospective studies are required to better characterize SIgED and to determine whether it should be added to the list of antibody deficiencies.
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Affiliation(s)
- César Picado
- Institut Clinic Respiratory, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.B.); (E.A.); (R.A.); (J.S.); (J.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain
- Correspondence:
| | - Iñaki Ortiz de Landazuri
- Immunology Department, CDB. Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.O.d.L.); (A.V.)
| | - Alexandru Vlagea
- Immunology Department, CDB. Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.O.d.L.); (A.V.)
| | - Irina Bobolea
- Institut Clinic Respiratory, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.B.); (E.A.); (R.A.); (J.S.); (J.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain
| | - Ebymar Arismendi
- Institut Clinic Respiratory, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.B.); (E.A.); (R.A.); (J.S.); (J.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain
| | - Rosanel Amaro
- Institut Clinic Respiratory, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.B.); (E.A.); (R.A.); (J.S.); (J.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain
| | - Jacobo Sellarés
- Institut Clinic Respiratory, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.B.); (E.A.); (R.A.); (J.S.); (J.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain
| | - Joan Bartra
- Institut Clinic Respiratory, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.B.); (E.A.); (R.A.); (J.S.); (J.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
| | - Raimon Sanmarti
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Department of Rheumatology, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - José Hernandez-Rodriguez
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Department of Autoimmune Diseases, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - José-Manuel Mascaró
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Department of Dermatology, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Jordi Colmenero
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Liver Unit, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
- Centro de Investigaciones en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28029 Madrid, Spain
| | - Eva C. Vaquero
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Centro de Investigaciones en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28029 Madrid, Spain
- Department of Gastroenterology, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Mariona Pascal
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (R.S.); (J.H.-R.); (J.-M.M.); (J.C.); (E.C.V.); (M.P.)
- Immunology Department, CDB. Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain; (I.O.d.L.); (A.V.)
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22
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Thoré P, Jaïs X, Savale L, Dorfmuller P, Boucly A, Devilder M, Meyrignac O, Pichon J, Mankikian J, Riou M, Boiffard E, Boissin C, De Groote P, Chabanne C, Gagnadoux F, Bergeron A, Noel N, Sitbon O, Humbert M, Montani D. Pulmonary Hypertension in Patients with Common Variable Immunodeficiency. J Clin Immunol 2021; 41:1549-1562. [PMID: 34110542 DOI: 10.1007/s10875-021-01064-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Common variable immunodeficiency (CVID) is known to cause infectious, inflammatory, and autoimmune manifestations. Pulmonary hypertension (PH) is an unusual complication of CVID with largely unknown characteristics and mechanisms. METHODS We report the clinical, functional, hemodynamics, radiologic and histologic characteristics, and outcomes of CVID-associated PH patients from the French PH Network. RESULTS Ten patients were identified. The median (range) age at CVID diagnosis was 36.5 (4-49) years and the median delay between CVID and PH diagnosis was 12 (0-30) years. CVID-associated PH affected predominantly women (female-to-male ratio 9:1). Most patients were New York Heart Association functional class III with a severe hemodynamic profile and frequent portal hypertension (n = 6). Pulmonary function tests were almost normal in 70% of patients and showed a mild restrictive syndrome in 30% of patients while the diffusing capacity for carbon monoxide was decreased in all but one patient. High-resolution computed tomography found enlarged mediastinal nodes, mild interstitial infiltration with reticulations and nodules. Two patients had a CIVD-interstitial lung disease, and one presented with bronchiectasis. Pathologic assessment of lymph nodes performed in 5 patients revealed the presence of granulomas (n = 5) and follicular lymphoid hyperplasia (n = 3). At last follow-up (median 24.5 months), 9 patients were alive, and one patient died of Hodgkin disease. CONCLUSION PH is a possible complication of CVID whose pathophysiological mechanisms, while still unclear, would be due to the inflammatory nature of CVID. CVID-associated PH presents as precapillary PH with multiple possible causes, acting in concert in some patients: a portal hypertension, a pulmonary vascular remodeling, sometimes a pulmonary parenchymal involvement and occasionally an extrinsic compression by mediastinal lymphadenopathies, which would be consistent with its classification in group 5 of the current PH classification.
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Affiliation(s)
- Pierre Thoré
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Department of Pneumology, Hôpital Brabois, Vandoeuvre-lès-Nancy, France.,INSERM UMR_S 1116 "Défaillance Cardiovasculaire Aigüe Et Chronique", School of Medicine of Nancy, University of Lorraine, Nancy, France
| | - Xavier Jaïs
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Laurent Savale
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Peter Dorfmuller
- Department of Pathology, University Hospital of Giessen and Marburg (UKGM), Giessen, Germany
| | - Athénaïs Boucly
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Matthieu Devilder
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Radiology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Meyrignac
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Radiology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Jérémie Pichon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Julie Mankikian
- Centre Hospitalier Régional Universitaire (CHRU) de Tours, Department of Pneumology, Hôpital Bretonneau, Tours, France
| | - Marianne Riou
- Department of Pneumology, Centre Hospitalier Universitaire (CHU) de Strasbourg, Nouvel Hôpital Civil (NHC) de Strasbourg, Strasbourg, France
| | - Emmanuel Boiffard
- Centre Hospitalier Départemental (CHD) de Vendée, Department of Cardiology, Hôpital de La Roche sur Yon, La Roche sur Yon, France
| | - Clément Boissin
- Centre Hospitalier Universitaire (CHU) de Montpellier, Department of Pneumology, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Pascal De Groote
- Centre Hospitalier Universitaire (CHU) de Lille, Department of Cardiology, Hôpital Albert Calmette, Lille, France.,Inserm U1167, Institut Pasteur de Lille, Lille, France
| | - Céline Chabanne
- Department of Cardiology and Vascular Diseases, Cardio-pneumologic Center, Centre Hospitalier Universitaire (CHU) de Rennes, Rennes, France
| | - Frédéric Gagnadoux
- Department of Pneumology, Centre Hospitalier Universitaire (CHU) D'Angers, Angers, France.,INSERM U1063, School of Medicine, Angers, France
| | - Anne Bergeron
- Université de Paris, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Pneumology, Hôpital Saint-Louis, Paris, France.,INSERM UMR_S 1153 "Centre de Recherche Épidémiologie Et Statistique Sorbonne Paris Cité (CRESS)", Hôpital Saint-Louis, Paris, France
| | - Nicolas Noel
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Internal Medicine and Immunology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,UMR INSERM/CEA 1184, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - David Montani
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France. .,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France. .,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
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23
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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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24
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Viallard JF, Lebail B, Begueret H, Fieschi C. [Common variable immunodeficiency disorders: Part 2. Updated clinical manifestations and therapeutic management]. Rev Med Interne 2021; 42:473-481. [PMID: 33516581 DOI: 10.1016/j.revmed.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 12/04/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are the most common symptomatic primary antibody deficiency in adults with an estimated prevalence of 1/25,000. The most frequent clinical manifestations are upper respiratory tract infections (including pneumonia, bronchitis, and sinusitis) predominantly with Streptococcus pneumoniae or H. influenzae. However, CVID are complicated in 20 to 30 % of cases of non-infectious manifestations which have been well characterized in recent years. Several complications can be observed including autoimmune, lymphoproliferative, granulomatous or cancerous manifestations involving one or more organs. These complications, mostly antibody-mediated cytopenias, are correlated with a decrease in the number of circulating switched memory B cells. Replacement therapy with polyvalent gammaglobulins has greatly improved the prognosis of these patients but it remains poor in the presence of digestive complications (especially in the case of chronic enteropathy and/or porto-sinusoidal vascular disease), pulmonary complications (bronchiectasis and/or granulomatous lymphocytic interstitial lung disease) and when progression to lymphoma. Much progress is still to be made, in particular on the therapeutic management of non-infectious complications which should benefit in the future from targeted treatments based on knowledge of genetics and immunology.
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Affiliation(s)
- J F Viallard
- Service de médecine interne et maladies infectieuses, hôpital Haut-Lévêque, CHU de Bordeaux, 5, avenue de Magellan, 33604 Pessac, France; Université de Bordeaux, Bordeaux, France.
| | - B Lebail
- Université de Bordeaux, Bordeaux, France; Service d'anatomopathologie, hôpital Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
| | - H Begueret
- Service d'anatomopathologie, CHU Bordeaux, hôpital Haut-Lévêque, 5, avenue de Magellan, 33604 Pessac, France
| | - C Fieschi
- Département d'immunologie, université de Paris, AP-HP, France; INSERM U1126, centre Hayem, hôpital Saint-Louis, Paris, France
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25
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Detry O, Meurisse N, Jouret F, Bletard N, Delwaide J, Moutschen M. Immunosuppression Withdrawal After Liver Transplantation for Common Variable Immunodeficiency. Liver Transpl 2021; 27:456-458. [PMID: 32810897 DOI: 10.1002/lt.25873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/21/2020] [Accepted: 08/09/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Olivier Detry
- Departments of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire Liège, University of Liege, Liège, Belgium
| | - Nicolas Meurisse
- Departments of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire Liège, University of Liege, Liège, Belgium
| | - François Jouret
- Nephrology, Centre Hospitalier Universitaire Liège, University of Liege, Liège, Belgium
| | - Noella Bletard
- Pathology, Centre Hospitalier Universitaire Liège, University of Liege, Liège, Belgium
| | - Jean Delwaide
- Hepatogastroenterology, Centre Hospitalier Universitaire Liège, University of Liege, Liège, Belgium
| | - Michel Moutschen
- Infectious Diseases and General Internal Medicine, Centre Hospitalier Universitaire Liège, University of Liege, Liège, Belgium
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26
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Li Y, Xu C, Lin N, Zhao Y, Song J. Nodular regenerative hyperplasia and portal hypertension are the characteristics of liver abnormalities in patients with selective immunoglobulin A deficiency. Clin Res Hepatol Gastroenterol 2020; 44:e123-e125. [PMID: 32146091 DOI: 10.1016/j.clinre.2020.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/14/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Yang Li
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Can Xu
- Department of Pathology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Nan Lin
- Department of Radiology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Yue Zhao
- Hematology Laboratory, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China
| | - Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, 110004 Shenyang, Liaoning, PR China.
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27
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Abstract
Common variable immunodeficiency (CVID) has a heterogenous clinical presentation and can be challenging to diagnose. Distinct histologic changes have been linked with CVID in several organ systems, which can help identify the correct diagnosis. In this study we review a cohort of hepatic CVID biopsies, to better define the spectrum of histologic and biochemical alterations. We reviewed 26 liver biopsies from 24 patients with CVID, obtained at 4 institutions between 2010 and 2019. Histologic slides were examined, and pathologic, biochemical, and clinical features were recorded. A control cohort of 21 patients with nodular regenerative hyperplasia (NRH) but lacking CVID was also examined. Liver function tests were frequently abnormal, especially alkaline phosphatase (median: 193 IU/L) and aspartate transaminase (median: 56 U/L), elevated in 23 and 17 of 25 biopsies, respectively. Fifteen patients had CVID involvement of other organs. Histologic features of primary biliary cholangitis were present in 2 patients, with florid duct lesions and prominent bile duct injury, in association with positive antimitochondrial antibodies. Among the other 24 biopsies, mild to moderate portal and lobular inflammation were present in 18 and 17 of 24 biopsies, respectively. Overall, 22 of 24 biopsies showed NRH-like changes. Plasma cell were absent. A distinct pattern of pericellular fibrosis was present in 23 of 26 biopsies overall. Involvement ranged from focal centrizonal fibrosis to bridging fibrosis and was accompanied by increased intrasinusoidal lymphocytes in 13 of 24 biopsies. Pericellular fibrosis was identified in 1 of 21 biopsies in the control cohort. Additional findings included granulomatous inflammation or nonhepatocellular foreign body-type multinucleate giant cells, identified in 4 biopsies. Three of 6 examined biopsies also demonstrated focal hepatocellular copper deposition. Hepatic disease in CVID is often associated with elevated alkaline phosphatase and aspartate transaminase and is characterized histologically by the mild nonspecific portal and lobular hepatitis, absence of plasma cells, NRH-like changes, and less commonly, typical histologic features of primary biliary cholangitis. We have also identified a distinctive pattern of delicate pericellular fibrosis that is a helpful clue to the diagnosis of hepatic disease in CVID, especially when accompanied by NRH-like changes.
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28
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Pecoraro A, Crescenzi L, Varricchi G, Marone G, Spadaro G. Heterogeneity of Liver Disease in Common Variable Immunodeficiency Disorders. Front Immunol 2020; 11:338. [PMID: 32184784 PMCID: PMC7059194 DOI: 10.3389/fimmu.2020.00338] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/11/2020] [Indexed: 12/13/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequent primary immunodeficiency (PID) in adulthood and is characterized by severe reduction of immunoglobulin serum levels and impaired antibody production in response to vaccines and pathogens. Beyond the susceptibility to infections, CVID encompasses a wide spectrum of clinical manifestations related to a complex immune dysregulation that also affects liver. Although about 50% CVID patients present persistently deranged liver function, burden, and nature of liver involvement have not been systematically investigated in most cohort studies published in the last decades. Therefore, the prevalence of liver disease in CVID widely varies depending on the study design and the sampling criteria. This review seeks to summarize the evidence about the most relevant causes of liver involvement in CVID, including nodular regenerative hyperplasia (NRH), infections and malignancies. We also describe the clinical features of liver disease in some monogenic forms of PID included in the clinical spectrum of CVID as ICOS, NFKB1, NFKB2, CTLA-4, PI3Kδ pathway, ADA2, and IL21-R genetic defects. Finally, we discuss the clinical applications of the various diagnostic tools and the possible therapeutic approaches for the management of liver involvement in the context of CVID.
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Affiliation(s)
- Antonio Pecoraro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Ludovica Crescenzi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research, WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Monaldi Hospital, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Center for Basic and Clinical Immunology Research, WAO Center of Excellence, University of Naples Federico II, Naples, Italy
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29
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Gereige JD, Maglione PJ. Current Understanding and Recent Developments in Common Variable Immunodeficiency Associated Autoimmunity. Front Immunol 2019; 10:2753. [PMID: 31921101 PMCID: PMC6914703 DOI: 10.3389/fimmu.2019.02753] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/11/2019] [Indexed: 12/14/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most prevalent symptomatic primary immunodeficiency and comprises a group of disorders with similar antibody deficiency but a myriad of different etiologies, most of which remain undefined. The variable aspect of CVID refers to the approximately half of patients who develop non-infectious complications in addition to heightened susceptibility to infection. The pathogenesis of these complications is poorly understood and somewhat counterintuitive because these patients that are defined by their immune futility simultaneously have elevated propensity for autoimmune disease. There are numerous aspects of immune dysregulation associated with autoimmunity in CVID that have only begun to be studied. These findings include elevations of T helper type 1 and follicular helper T cells and B cells expressing low levels of CD21 as well as reciprocal decreases in regulatory T cells and isotype-switched memory B cells. Recently, advances in genomics have furthered our understanding of the fundamental biology underlying autoimmunity in CVID and led to precision therapeutic approaches. However, these genetic etiologies are also associated with clinical heterogeneity and incomplete penetrance, highlighting the fact that continued research efforts remain necessary to optimize treatment. Additional factors, such as commensal microbial dysbiosis, remain to be better elucidated. Thus, while recent advances in our understanding of CVID-associated autoimmunity have been exciting and substantial, these current scientific advances must now serve as building blocks for the next stages of discovery.
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Affiliation(s)
- Jessica D Gereige
- Department of Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Paul J Maglione
- Department of Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
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30
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Swain S, Selmi C, Gershwin ME, Teuber SS. The clinical implications of selective IgA deficiency. J Transl Autoimmun 2019; 2:100025. [PMID: 32743511 PMCID: PMC7388344 DOI: 10.1016/j.jtauto.2019.100025] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 01/06/2023] Open
Abstract
Selective IgA deficiency (SIgAD) is the most common primary immunodeficiency but does not always result in clinical disease. This may in part be due to the definition based on serum IgA, while most IgA is secreted at mucosal surfaces, not amenable to measurement. Clinical complications include increased risk of sinopulmonary infections with bacteria and viruses, gastrointestinal infections with a predilection for Giardia lamblia, a myriad of autoimmune diseases including systemic lupus erythematosus, hyper- and hypo-thyroidism, Type 1 diabetes, celiac disease, and rarely, malignancy. SIgAD must be differentiated from IgA deficiency that may be seen with IgG2 or IgG4 deficiency, specific antibody deficiency, or as an early manifestation prior to a diagnosis of common variable immunodeficiency. Secondary IgA deficiency is increasingly recognized and may be due to medications such as anti-epileptics, or antibiotics with disruption of the microbiome which can influence IgA levels, infections or malignancies. Patients with SIgAD should be monitored at regular intervals and educated to be aware of particular complications. There is a rare chance of development of anti-IgA IgE antibodies in patients with complete deficiency, which can result in anaphylaxis if blood products with IgA are administered. Prophylactic antibiotics may be indicated in some cases, and very rarely, supplemental IgG infusions.
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Affiliation(s)
- Samantha Swain
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, USA
- Veterans Affairs Northern California Healthcare System, Mather, CA, USA
| | - Carlo Selmi
- Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy
- BIOMETRA Department, University of Milan, Milan, Italy
| | - M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, USA
| | - Suzanne S. Teuber
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, USA
- Veterans Affairs Northern California Healthcare System, Mather, CA, USA
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31
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32
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Crescenzi L, Pecoraro A, Fiorentino A, Poto R, Varricchi G, Rispo A, Morisco F, Spadaro G. Liver stiffness assessment by transient elastography suggests high prevalence of liver involvement in common variable immunodeficiency. Dig Liver Dis 2019; 51:1599-1603. [PMID: 31155490 DOI: 10.1016/j.dld.2019.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Up to 50% of patients with common variable immunodeficiency (CVID) present persistently increased serum levels of liver enzymes and/or mild hepatomegaly. Ultrasound-based transient elastography (TE) is largely used for early detection of the progression of chronic liver diseases, but has never been employed in CVID. We performed a cross-sectional study to evaluate TE values in a cohort of adult CVID-patients. METHODS Full blood count, liver function test, liver and spleen sonogram and ultrasound-based TE were performed in 77 adult CVID patients. Demographic and clinical data were retrospectively collected from medical files. RESULTS 33.8% (26/77) patients presented increased TE values ranging from moderate fibrosis to cirrhosis. TE values were positively correlated with ALP, γGT, spleen longitudinal diameter and peripheral blood counts (no significant correlation with BMI, AST, ALT, total proteins, albumin, bilirubin and hemoglobin). Moreover, liver stiffness was higher in patients with the clinical phenotypes polyclonal lymphoproliferation and enteropathy, and patients with both these complications had an increased risk (OR: 7.14) of presenting pathologic TE values compared with those without anyone of these. CONCLUSIONS Transient elastography is a useful tool to be used alongside clinical and laboratory data to assess liver involvement in CVID.
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Affiliation(s)
- Ludovica Crescenzi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Antonio Pecoraro
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Andrea Fiorentino
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Remo Poto
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Antonio Rispo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.
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33
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Agarwal S, Cunningham-Rundles C. Autoimmunity in common variable immunodeficiency. Ann Allergy Asthma Immunol 2019; 123:454-460. [PMID: 31349011 DOI: 10.1016/j.anai.2019.07.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Common variable immunodeficiency (CVID) is a primary immunodeficiency that is clinically heterogeneous, characterized by both infectious and noninfectious complications. Although the hallmark of disease presentation is commonly a history of recurrent sinopulmonary infections, autoimmunity and noninfectious inflammatory conditions are increasingly associated with CVID. DATA SOURCES A comprehensive literature search using PubMed of basic science and clinical articles was performed. STUDY SELECTIONS Articles discussing the association of autoimmunity with primary immunodeficiency, specifically CVID, were selected. RESULTS The most common autoimmune conditions are cytopenias, including immune thrombocytopenia purpura and hemolytic anemia, but organ-specific autoimmune/inflammatory complications involving the gastrointestinal, skin, joints, connective tissue, and respiratory tract. In most cases, immunoglobulin replacement therapy does not ameliorate or treat these inflammatory complications, and additional immunomodulatory treatments are needed. CONCLUSION Mechanisms producing these conditions are poorly understood but include cytokine and cellular inflammatory pathways, and loss of tolerance to self-antigens through the multiple signaling molecules and pathways common to tolerance and immune deficiency.
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Affiliation(s)
- Shradha Agarwal
- Icahn School of Medicine at Mount Sinai, Division of Allergy and Clinical Immunology, Department of Medicine, New York, New York.
| | - Charlotte Cunningham-Rundles
- Icahn School of Medicine at Mount Sinai, Division of Allergy and Clinical Immunology, Department of Medicine, New York, New York
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34
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Abstract
This article presents the most common gastrointestinal, hepatic, and pancreatic manifestations of the primary immunodeficiency diseases, including the appropriate laboratory testing, endoscopic evaluation, and recommendations for further management.
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Affiliation(s)
| | - Sarah Glover
- UF Health, PO Box 103643, Gainesville, FL 32610, USA.
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35
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Gupta S, Pattanaik D, Krishnaswamy G. Common Variable Immune Deficiency and Associated Complications. Chest 2019; 156:579-593. [PMID: 31128118 DOI: 10.1016/j.chest.2019.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/05/2019] [Accepted: 05/13/2019] [Indexed: 12/25/2022] Open
Abstract
Common variable immunodeficiency disorders refer to a relatively common primary immune deficiency group of diseases that present with infectious and inflammatory complications secondary to defects in antibody production and sometimes in cellular immunity. The disorder often presents in middle age or later with recurrent sinopulmonary infections, bronchiectasis, or a plethora of noninfectious complications such as autoimmune disorders, granulomatous interstitial lung disease, GI diseases, malignancies (including lymphoma), and multisystem granulomatous disease resembling sarcoidosis. Infusion of immunoglobulin by IV or subcutaneous is the mainstay of therapy. Management of complications is often difficult as immune suppression may be necessary in these conditions and entails the use of medications and biologicals which may further increase the risk for infections. Specifically, bronchiectasis, granulomatous lymphocytic interstitial lung disease, repeated sinopulmonary infections, and malignancies are sequelae of antibody deficiency that may present to the pulmonologist. This review will provide an updated understanding of the molecular aspects, differential diagnosis, presentations, and the management of common variable immunodeficiency disorders.
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Affiliation(s)
- Siddhi Gupta
- Department of Medicine, Division of Infectious Disease, Wake Forest School of Medicine, Winston Salem, NC
| | - Debendra Pattanaik
- Division of Allergy, Immunology and Rheumatology, University of Tennessee Health Science Center, Memphis TN
| | - Guha Krishnaswamy
- Department of Medicine, Division of Infectious Disease, Wake Forest School of Medicine, Winston Salem, NC; Division of Infectious Disease, Pulmonary, Allergy and Immunology, Wake Forest School of Medicine, Winston Salem, NC; Department of Medicine, Division of Allergy and Immunology, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC.
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Cunningham-Rundles C. Common variable immune deficiency: Dissection of the variable. Immunol Rev 2019; 287:145-161. [PMID: 30565247 PMCID: PMC6435035 DOI: 10.1111/imr.12728] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
Abstract
Starting about 60 years ago, a number of reports appeared that outlined the severe clinical course of a few adult subjects with profound hypogammaglobinemia. Puzzled by the lack of family history and adult onset of symptoms in most, the name "acquired" hypogammaglobinemia was given, but later altered to the current name common variable immune deficiency. Pathology reports remarked on the loss of lymph node architecture and paucity of plasma cells in lymphoid tissues in these subjects. While characterized by reduced serum IgG and IgA and often IgM, and thus classified among the B-cell defects, an increasing number of cellular defects in these patients have been recognized over time. In the early years, severe respiratory tract infections commonly led to a shortened life span, but the wide spread availability of immune globulin concentrates for the last 25 years has improved survival. However, chronic non-infectious inflammatory and autoimmune conditions have now emerged as challenging clinical problems; these require further immunologic understanding and additional therapeutic measures. Recent study of this phenotypic syndrome have provided an increasingly fertile ground for the identification of autosomal recessive and now more commonly, autosomal dominant gene defects which lead to the loss of B-cell development in this syndrome.
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Abstract
Hepatic granulomas are encountered in approximately 2% to 10% of liver biopsies. There are many potential infectious and noninfectious causes; granulomas can be generally classified by their morphology, which may be helpful in refining the differential diagnosis. This article provides a review of hepatic granulomas with an emphasis on infectious causes.
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Affiliation(s)
- Eun-Young Karen Choi
- Department of Pathology, University of Michigan, University of Michigan, 5231B Medical Science I, 1301 Catherine Street, SPC 5602, Ann Arbor, MI 48109, USA.
| | - Laura W Lamps
- Department of Pathology, University of Michigan, University of Michigan, 5231B Medical Science I, 1301 Catherine Street, SPC 5602, Ann Arbor, MI 48109, USA
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Queirós PDO, Sousa Martín JM. Autoimmune hepatitis as a complication of common variable immunodeficiency. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:212-213. [PMID: 29368942 DOI: 10.17235/reed.2018.5280/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In common variable immunodeficiency (CVID) there is a deregulation of the immune system, which frequently leads to an increased risk of infections, but also to autoimmunity phenomena. Autoimmune hepatitis may develop at any time of CVID's evolution, but it is difficult to diagnose due to the frequent absence of autoantibodies and low levels of IgG. Early diagnosis is important because targeted treatment may allow disease improvement. We present a case of autoimmune hepatitis in a patient with CVID.
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40
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Susheela AT, Hale A. Patients with common variable immunodeficiency paradoxically have increased rates of autoimmune disorders. BMJ Case Rep 2017; 2017:bcr-2017-221657. [PMID: 29030367 DOI: 10.1136/bcr-2017-221657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Common variable immunodeficiency (CVID), characterised by disordered B cell function, is one of the most common primary immunodeficiency disorders. Patients with CVID are at lifelong risk of recurrent infections, particularly of the respiratory and gastrointestinal tracts. Paradoxically, given their immunocompromised state, patients with CVID are also at significantly increased risk of autoimmune disorders, which are seen in almost 25% of cases. The authors report a 24-year-old female patient with CVID, manifested as severe hypogammaglobulinaemia with recurrent sinopulmonary infections and enterocolitis, who presented with transaminitis, chronic diarrhoea and haematemesis. No infectious aetiologies were identified. She was diagnosed with coeliac disease after a small bowel biopsy and positive response to gluten-free diet. Haematemesis was attributed to portal hypertension due to liver cirrhosis, which was confirmed via liver biopsy. Coeliac disease can be a cause of diarrhoea in patients with immunodeficiency disorders and is often underdiagnosed. It can also be the underlying source of liver disease and is an often under-recognised cause of cirrhosis. The case presented emphasises the paradoxical and challenging relationship that patients with CVID face between immunodeficiency and autoimmune disorders, and also highlights that coeliac disease is an under-recognised cause of liver disease.
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Affiliation(s)
- Ammu Thampi Susheela
- Division of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew Hale
- Department of Infectious Diseases, University of Vermont Medical Center and Larner College of Medicine, Boston, Massachusetts, USA
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