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Ameratunga R, Woon ST, Leung E, Lea E, Chan L, Mehrtens J, Longhurst HJ, Steele R, Lehnert K, Lindsay K. The autoimmune rheumatological presentation of Common Variable Immunodeficiency Disorders with an overview of genetic testing. Semin Arthritis Rheum 2024; 65:152387. [PMID: 38330740 DOI: 10.1016/j.semarthrit.2024.152387] [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: 11/06/2023] [Revised: 01/06/2024] [Accepted: 01/16/2024] [Indexed: 02/10/2024]
Abstract
Primary immunodeficiency Disorders (PIDS) are rare, mostly monogenetic conditions which can present to a number of specialties. Although infections predominate in most PIDs, some individuals can manifest autoimmune or inflammatory sequelae as their initial clinical presentation. Identifying patients with PIDs can be challenging, as some can present later in life. This is often seen in patients with Common Variable Immunodeficiency Disorders (CVID), where symptoms can begin in the sixth or even seventh decades of life. Some patients with PIDs including CVID can initially present to rheumatologists with autoimmune musculoskeletal manifestations. It is imperative for these patients to be identified promptly as immunosuppression could lead to life-threatening opportunistic infections in these immunocompromised individuals. These risks could be mitigated by prior treatment with subcutaneous or intravenous (SCIG/IVIG) immunoglobulin replacement or prophylactic antibiotics. Importantly, many of these disorders have an underlying genetic defect. Individualized treatments may be available for the specific mutation, which may obviate or mitigate the need for hazardous broad-spectrum immunosuppression. Identification of the genetic defect has profound implications not only for the patient but also for affected family members, who may be at risk of symptomatic disease following an environmental trigger such as a viral infection. Finally, there may be clinical clues to the underlying PID, such as recurrent infections, the early presentation of severe or multiple autoimmune disorders, as well as a relevant family history. Early referral to a clinical immunologist will facilitate appropriate diagnostic evaluation and institution of treatment such as SCIG/IVIG immunoglobulin replacement. This review comprises three sections; an overview of PIDs, focusing on CVID, secondly genetic testing of PIDs and finally the clinical presentation of these disorders to rheumatologists.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Euphemia Leung
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Edward Lea
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Lydia Chan
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - James Mehrtens
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Hilary J Longhurst
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Richard Steele
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Klaus Lehnert
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Applied Translational Genetics, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Karen Lindsay
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
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Ameratunga R, Leung E, Woon ST, Lea E, Allan C, Chan L, Longhurst H, Steele R, Snell R, Lehnert K. Challenges for gene editing in common variable immunodeficiency disorders: Current and future prospects. Clin Immunol 2024; 258:109854. [PMID: 38013164 DOI: 10.1016/j.clim.2023.109854] [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: 07/05/2023] [Revised: 09/09/2023] [Accepted: 09/21/2023] [Indexed: 11/29/2023]
Abstract
The original CRISPR Cas9 gene editing system and subsequent innovations offers unprecedented opportunities to correct severe genetic defects including those causing Primary Immunodeficiencies (PIDs). Common Variable Immunodeficiency Disorders (CVID) are the most frequent symptomatic PID in adults and children. Unlike many other PIDs, patients meeting CVID criteria do not have a definable genetic defect and cannot be considered to have an inborn error of immunity (IEI). Patients with a CVID phenotype carrying a causative mutation are deemed to have a CVID-like disorder consequent to an IEI. Patients from consanguineous families often have highly penetrant early-onset autosomal recessive forms of CVID-like disorders. Individuals from non-consanguineous families may have autosomal dominant CVID-like disorders with variable penetrance and expressivity. This essay explores the potential clinical utility as well as the current limitations and risks of gene editing including collateral genotoxicity. In the immediate future the main application of this technology is likely to be the in vitro investigation of epigenetic and polygenic mechanisms, which are likely to underlie many cases of CVID and CVID-like disorders. In the longer-term, the CRISPR Cas9 system and other gene-based therapies could be utilized to treat CVID-like disorders, where the underlying IEI is known.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
| | - Euphemia Leung
- Maurice Wilkins Centre, Applied Translational Genetics, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Edward Lea
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Caroline Allan
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Lydia Chan
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand
| | - Hilary Longhurst
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Richard Steele
- Department of Clinical Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand; Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Russell Snell
- Maurice Wilkins Centre, Applied Translational Genetics, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Applied Translational Genetics, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Klaus Lehnert
- Maurice Wilkins Centre, Applied Translational Genetics, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand; Applied Translational Genetics, School of Biological Sciences, University of Auckland, Auckland, New Zealand
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Markocsy A, Bobcakova A, Petrovicova O, Kapustova L, Malicherova Jurkova E, Schniederova M, Petriskova J, Cibulka M, Hyblova M, Jesenak M. Association Between Cytometric Biomarkers, Clinical Phenotype, and Complications of Common Variable Immunodeficiency. Cureus 2024; 16:e52941. [PMID: 38406025 PMCID: PMC10894026 DOI: 10.7759/cureus.52941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is a heterogeneous group of immune disorders. The patients are classified according to the clinical manifestation with the infection-only phenotype (CVIDinf) and CVID with immune dysregulation (CVIDid). METHODS We performed a retrospective clinical analysis of 64 CVID patients (34 males, 53.13%; mean age: 41.4 years; SD: ±21.4 years). We divided the patients into subgroups according to the clinical manifestation (CVIDinf and CVIDid) and according to B cell phenotypic profiling after performing flow cytometry with the use of the EUROclass classification. We compared clinical manifestations, selected laboratory parameters, and therapy in these groups. All CVIDid patients were tested after the manifestation of complications associated with immune dysregulation and in eight patients during the immunosuppressive treatment (systemic corticosteroids and hydroxychloroquine). RESULTS Two-thirds of patients in our cohort had symptoms resulting from immune dysregulation. Almost half of the patients had autoimmune complications. A higher proportion of marginal zone B cells was associated with autoimmune complications. A lower percentage of naïve B cells was connected to autoimmunity, whereas a lower proportion of transitional B cells was associated with rheumatic diseases and splenomegaly. Patients with lymphadenopathy had a higher percentage of double-negative T cells and a lower percentage of switched memory B cells. We performed molecular-genetic testing in 28% (n = 17) of patients and found a causal pathogenic variant in 23.5% (n = 4) of this group. CONCLUSION Based on our results, there is an association between specific cytometric parameters, clinical phenotype, and complications of CVID. The use of the subpopulations of B cells can be helpful in the diagnosis of these specific clinical complications in CVID patients and could help to personalise the therapeutic approach.
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Affiliation(s)
- Adam Markocsy
- Department of Paediatrics, Martin University Hospital, Martin, SVK
| | - Anna Bobcakova
- Department of Pulmonology and Phthisiology, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, SVK
| | - Otilia Petrovicova
- Department of Paediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, SVK
| | - Lenka Kapustova
- Department of Paediatrics, Martin University Hospital, Martin, SVK
| | | | - Martina Schniederova
- Department of Clinical Immunology and Allergology, Martin University Hospital, Martin, SVK
| | - Jela Petriskova
- Department of Clinical Immunology and Allergology, Martin University Hospital, Martin, SVK
| | - Michal Cibulka
- Department of Clinical Immunology and Allergology, Martin University Hospital, Martin, SVK
| | | | - Milos Jesenak
- Department of Clinical Immunology and Allergology, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, SVK
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Rolles B, Caballero-Oteyza A, Proietti M, Goldacker S, Warnatz K, Camacho-Ordonez N, Prader S, Schmid JP, Vieri M, Isfort S, Meyer R, Kirschner M, Brümmendorf TH, Beier F, Grimbacher B. Telomere biology disorders may manifest as common variable immunodeficiency (CVID). Clin Immunol 2023; 257:109837. [PMID: 37944684 DOI: 10.1016/j.clim.2023.109837] [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: 07/17/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
Telomere biology disorders (TBD) are caused by germline pathogenic variants in genes related to telomere maintenance and are characterized by critically short telomeres. In contrast to classical dyskeratosis congenita (DC), which is typically diagnosed in infancy, adult or late onset TBD frequently lack the typical DC triad and rather show variable organ manifestations and a cryptic disease course, thus complicating its diagnosis. Common variable immunodeficiency (CVID), on the other hand, is a primary antibody deficiency (PAD) syndrome. PADs are a heterogenous group of diseases characterized by hypogammaglobulinemia which occurs due to dysfunctional B lymphocytes and additional autoimmune and autoinflammatory complications. Genetic screening reveals a monogenic cause in a subset of CVID patients (15-35%). In our study, we screened the exomes of 491 CVID patients for the occurrence of TBD-related variants in 13 genes encoding for telomere/telomerase-associated proteins, which had previously been linked to the disease. We found 110/491 patients (22%) carrying 91 rare candidate variants in these 13 genes. Following the American College of Medical Genetics and Genomics (ACMG) guidelines, we classified two variants as benign, two as likely benign, 64 as variants of uncertain significance (VUS), four as likely pathogenic, and one heterozygous variant in an autosomal recessive disease gene as pathogenic. We performed telomere length measurement in 42 of the 110 patients with candidate variants and CVID. Two of these 42 patients showed significantly shorter telomeres compared to controls in both lymphocytes and granulocytes. Following the evaluation of the published literature and the patient's manifestations, we re-classified two VUS as likely pathogenic variants. Thus, 0.5-1% of all CVID patients in our study carry possibly pathogenic variants in telomere/telomerase-associated genes. Our data adds CVID to the broad clinical spectrum of cryptic adult-onset TBD. As the molecular diagnosis greatly impacts patient management and treatment strategies, we advise inclusion of all TBD-associated genes-despite their low prevalence-into the molecular screening of patients with antibody deficiencies.
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Affiliation(s)
- Benjamin Rolles
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD); Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Andres Caballero-Oteyza
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert Ludwigs University of Freiburg, Germany; Clinic for Rheumatology and Immunology, Hannover Medical University, Germany; RESIST Cluster of Excellence 2155 to Hannover Medical School, Satellite Center Freiburg, Germany
| | - Michele Proietti
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert Ludwigs University of Freiburg, Germany; Clinic for Rheumatology and Immunology, Hannover Medical University, Germany; RESIST Cluster of Excellence 2155 to Hannover Medical School, Satellite Center Freiburg, Germany
| | - Sigune Goldacker
- Clinic for Rheumatology and Clinical Immunology, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert Ludwigs University of Freiburg, Germany
| | - Klaus Warnatz
- Clinic for Rheumatology and Clinical Immunology, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert Ludwigs University of Freiburg, Germany
| | - Nadezhda Camacho-Ordonez
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert Ludwigs University of Freiburg, Germany
| | - Seraina Prader
- Division of Immunology, University Children's Hospital Zürich, Switzerland
| | | | - Margherita Vieri
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD)
| | - Susanne Isfort
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD)
| | - Robert Meyer
- Institute of Human Genetics and Genomic Medicine, Medical Faculty, RWTH Aachen University, Germany
| | - Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD)
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD)
| | - Fabian Beier
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Germany; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD).
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert Ludwigs University of Freiburg, Germany; RESIST Cluster of Excellence 2155 to Hannover Medical School, Satellite Center Freiburg, Germany; Clinic for Rheumatology and Clinical Immunology, Center for Chronic Immunodeficiency (CCI), Medical Center, Faculty of Medicine, Albert Ludwigs University of Freiburg, Germany; DZIF German Center for Infection Research, Satellite Center Freiburg, Germany; CIBSS Centre for Integrative Biological Signaling Studies, Albert Ludwigs University, Germany.
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5
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Park K, Wang Q, Lee RU. Navigating the management complexity in long-term asymptomatic immunodeficiency. Allergy Asthma Proc 2023; 44:436-439. [PMID: 37919850 DOI: 10.2500/aap.2023.44.230054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Background: Common variable immunodeficiency disorder (CVID) is a condition associated with recurrent infections and non-infectious outcomes, including lung disease like bronchiectasis and granulomatous and lymphocytic interstitial lung diseases (GLILD), autoimmune disease, enteropathy, and lymphoma. Treatment involves initiation of replacement immunoglobulin (Ig), which is a lifelong commitment. Prior to Ig replacement, life expectancy for patients with CVID was less than 15 years. With replacement Ig, it has improved to over 50 years. In most cases, patients present to a clinician with a history of recurrent infections, and treatment is indicated. However, in patients with asymptomatic disease, the best timing to start treatment can be difficult to determine. Case: We present a case of an otherwise healthy male who had an incidental diagnosis of CVID. Results: Workup revealed hypogammaglobulinemia for over 30 year. Discussion: Though successful in reducing infections, Ig replacement can come with many side effects, as well as a heavy medical burden to the patient and the healthcare system. It is also a big life adjustment, and can greatly affect a patient's quality of life. In the military, a diagnosis of an immunodeficiency, and the need for monthly intravenous immunoglobulin (IVIG) can be detrimental to deployment readiness, and a patient's military career. Risks and benefits need to be weighed prior to initiating Ig therapy.
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Cabanero-Navalon MD, Garcia-Bustos V, Mira A, Moral Moral P, Salavert-Lleti M, Forner Giner MJ, Núñez Beltrán M, Todolí Parra J, Bracke C, Carda-Diéguez M. Dysimmunity in common variable immunodeficiency is associated with alterations in oral, respiratory, and intestinal microbiota. Clin Immunol 2023; 256:109796. [PMID: 37774905 DOI: 10.1016/j.clim.2023.109796] [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: 03/06/2023] [Revised: 07/10/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency characterized by decreased immunoglobulins and recurrent infections. Its aetiology remains unknown, and some patients present with severe non-infectious autoimmune or inflammatory complications with elevated associated morbimortality. Recently, intestinal dysbiosis has been proposed as a driver of immune dysregulation. In this study, we assessed the oral, respiratory, and gastrointestinal microbiota of 41 CVID patients (24 with dysimmune and 17 with infection complications) and 15 healthy volunteers using 16S rRNA gene sequencing to explore associations between microbiome profiles and CVID phenotypes. Profound differences in the composition of the microbiota in saliva, sputum, and stool were detected between dysimmune CVID patients and healthy individuals. Globally, respiratory species diversity and faecal bacterial richness were lower in CVID individuals with immune complications. Although a single species could not be identified as a robust predictor of dysimmunity, a combination of around 5-7 bacterial species in each type of sample could predict this severe phenotype with an accuracy of around 90% in the study population. Our study provides new insights into these previously unexplored but highly interrelated ecological niches among themselves and with patient profiles. Our data suggest that this disease-related systemic dysbiosis could be implicated in the immune dysregulation associated with severe cases of CVID.
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Affiliation(s)
- Marta Dafne Cabanero-Navalon
- Primary Immune Deficiencies Unit, Department of Internal Medicine, University and Polytechnic Hospital La Fe, Valencia, Spain; Research Group of Chronic Diseases and HIV Infection, Health Research Institute La Fe, Valencia, Spain
| | - Victor Garcia-Bustos
- Primary Immune Deficiencies Unit, Department of Internal Medicine, University and Polytechnic Hospital La Fe, Valencia, Spain; Severe Infection Research Group, Health Research Institute La Fe, Valencia, Spain.
| | - Alex Mira
- Genomics & Health Department, FISABIO Foundation, Valencia, Spain
| | - Pedro Moral Moral
- Primary Immune Deficiencies Unit, Department of Internal Medicine, University and Polytechnic Hospital La Fe, Valencia, Spain; Research Group of Chronic Diseases and HIV Infection, Health Research Institute La Fe, Valencia, Spain
| | - Miguel Salavert-Lleti
- Severe Infection Research Group, Health Research Institute La Fe, Valencia, Spain; Unit of Infectious Diseases, Department of Internal Medicine of the University and Polytechnic Hospital La Fe, Valencia, Spain
| | | | - María Núñez Beltrán
- Primary Immune Deficiencies Unit, Department of Internal Medicine, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - José Todolí Parra
- Primary Immune Deficiencies Unit, Department of Internal Medicine, University and Polytechnic Hospital La Fe, Valencia, Spain; Research Group of Chronic Diseases and HIV Infection, Health Research Institute La Fe, Valencia, Spain
| | - Carme Bracke
- Department of Infectious Diseases, Germans Trias i Pujol Hospital, Badalona, Spain
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Ameratunga R, Leung E, Woon ST, Lea E, Allan C, Chan L, Steele R, Lehnert K, Longhurst H. Selective IgA Deficiency May Be an Underrecognized Risk Factor for Severe COVID-19. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:181-186. [PMID: 36241155 PMCID: PMC9554200 DOI: 10.1016/j.jaip.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
SARS-CoV-2, the agent responsible for COVID-19, has wreaked havoc around the globe. Hundreds of millions of individuals have been infected and well over six million have died from COVID-19. Many COVID-19 survivors have ongoing physical and psychiatric morbidity, which will remain for the rest of their lives. Early in the pandemic, it became apparent that older individuals and those with comorbidities including obesity, diabetes mellitus, coronary artery disease, hypertension, and renal and pulmonary disease were at increased risk of adverse outcomes. It is also clear that some immunodeficient patients, such as those with innate or T cell-immune defects, are at greater risk from COVID-19. Selective IgA deficiency (sIgAD) is generally regarded as a mild disorder in which most patients are asymptomatic because of redundancy in protective immune mechanisms. Recent data indicate that patients with sIgAD may be at high risk of severe COVID-19. SARS-CoV-2 gains entry primarily through the upper respiratory tract mucosa, where IgA has a critical protective role. This may underlie the vulnerability of sIgAD patients to adverse outcomes from COVID-19. This perspective highlights the need for ongoing research into mucosal immunity to improve COVID-19 treatments for patients with sIgAD.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Grafton, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Grafton, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Euphemia Leung
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Auckland, New Zealand,Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Grafton, Auckland, New Zealand,Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Edward Lea
- Department of Clinical Immunology, Auckland Hospital, Grafton, Auckland, New Zealand
| | - Caroline Allan
- Department of Clinical Immunology, Auckland Hospital, Grafton, Auckland, New Zealand
| | - Lydia Chan
- Department of Clinical Immunology, Auckland Hospital, Grafton, Auckland, New Zealand
| | - Richard Steele
- Department of Clinical Immunology, Auckland Hospital, Grafton, Auckland, New Zealand,Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Klaus Lehnert
- Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand,School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Hilary Longhurst
- Department of Clinical Immunology, Auckland Hospital, Grafton, Auckland, New Zealand,Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Díaz-Alberola I, Gutiérrez-Bautista JF, Espuch-Oliver A, García-Aznar JM, Anderson P, Jiménez P, Hidalgo-Tenorio C, López-Nevot MÁ. Incidence, Management Experience and Characteristics of Patients with Giardiasis and Common Variable Immunodeficiency. J Clin Med 2022; 11:jcm11237007. [PMID: 36498582 PMCID: PMC9740678 DOI: 10.3390/jcm11237007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
Common variable immunodeficiency (CVID) is an antibody immunodeficiency with a wide variety of clinical and immunological manifestations, and whose genetic cause is found in about 25% of diagnosed cases. Giardia lamblia is one of the main causes of gastrointestinal infections in CVID. 5-Nitroimidazoles are the most used first-line treatment, but nitroimidazole-refractory giardiasis is increasing. Nevertheless, only a few cases of refractory giardiasis in CVID have been reported. This study aimed to determine the incidence of Giardia infection in our CVID cohort, shows our management experience and describes patients' phenotypic features. Clinical data collection, immunological, immunogenetics and microbiology assays were performed, and previous cases of giardiasis in CVID were reviewed. The incidence of symptomatic giardiasis was 12.9%. The main immunological features were undetectable or decreased IgA levels and reduced switched memory B cells. A probable PTEN pathogenic variant was detected in one. Three patients responded to metronidazole but suffered reinfections, and one was a refractory giardiasis eradicated with innovative quinacrine plus paromomycin combination. This work could contribute to the decision-making and therapeutic management of future patients with CVID and giardiasis, highlighting the importance of the early detection and treatment of infections in patients with CVID to ensure a good quality of life.
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Affiliation(s)
- Irene Díaz-Alberola
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Programa de Doctorado en Biomedicina, University of Granada, 10816 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
- Correspondence:
| | | | - Andrea Espuch-Oliver
- Servicio de Reproducción Asistida, Hospital Universitario de Torrecárdenas, 04009 Almería, Spain
| | | | - Per Anderson
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
- Departamento Bioquímica, Biología Molecular e Inmunología III, University of Granada, 18071 Granada, Spain
| | - Pilar Jiménez
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
| | - Carmen Hidalgo-Tenorio
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
- Unidad de Enfermedades Infecciosas, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
| | - Miguel Ángel López-Nevot
- Servicio de Análisis Clínicos e Inmunología, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain
- Departamento Bioquímica, Biología Molecular e Inmunología III, University of Granada, 18071 Granada, Spain
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Ameratunga R, Leung E, Woon ST, Chan L, Steele R, Lehnert K, Longhurst H. SARS-CoV-2 Omicron: Light at the End of the Long Pandemic Tunnel or Another False Dawn for Immunodeficient Patients? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2267-2273. [PMID: 35752434 PMCID: PMC9220855 DOI: 10.1016/j.jaip.2022.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022]
Abstract
COVID-19 has had a disastrous impact on the world. Apart from at least 6 million deaths, countless COVID-19 survivors are suffering long-term physical and psychiatric morbidity. Hundreds of millions have been plunged into poverty caused by economic misery, particularly in developing nations. Early in the pandemic, it became apparent certain groups of individuals such as the elderly and those with comorbidities were more likely to suffer severe disease. In addition, patients with some forms of immunodeficiency, including those with T-cell and innate immune defects, were at risk of poor outcomes. Patients with immunodeficiencies are also disadvantaged as they may not respond optimally to COVID-19 vaccines and often have pre-existing lung damage. SARS-CoV-2 Omicron (B.1.529) and its subvariants (BA.1, BA.2, etc) have emerged recently and are dominating COVID-19 infections globally. Omicron is associated with a reduced risk of hospitalization and appears to have a lower case fatality rate compared with previous SARS-CoV-2 variants. Omicron has offered hope the pandemic may finally be coming to an end, particularly for vaccinated, healthy individuals. The situation is less clear for individuals with vulnerabilities, particularly immunodeficient patients. This perspective offers insight into potential implications of the SARS-CoV-2 Omicron variant for patients with immunodeficiencies.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical immunology, Auckland Hospital, Auckland, New Zealand; Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. E%
| | - Euphemia Leung
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Auckland, New Zealand; Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Lydia Chan
- Department of Clinical immunology, Auckland Hospital, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand; Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Klaus Lehnert
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Auckland, New Zealand; School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Hilary Longhurst
- Department of Clinical immunology, Auckland Hospital, Auckland, New Zealand; Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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10
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Guevara-Hoyer K, Fuentes-Antrás J, de la Fuente-Muñoz E, Fernández-Arquero M, Solano F, Pérez-Segura P, Neves E, Ocaña A, Pérez de Diego R, Sánchez-Ramón S. Genomic crossroads between non-Hodgkin’s lymphoma and common variable immunodeficiency. Front Immunol 2022; 13:937872. [PMID: 35990641 PMCID: PMC9390007 DOI: 10.3389/fimmu.2022.937872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/07/2022] [Indexed: 12/03/2022] Open
Abstract
Common variable immunodeficiency (CVID) represents the largest group of primary immunodeficiencies that may manifest with infections, inflammation, autoimmunity, and cancer, mainly B-cell non-Hodgkin’s lymphoma (NHL). Indeed, NHL may result from chronic or recurrent infections and has, therefore, been recognized as a clinical phenotype of CVID, although rare. The more one delves into the mechanisms involved in CVID and cancer, the stronger the idea that both pathologies can be a reflection of the same primer events observed from different angles. The potential effects of germline variants on specific somatic modifications in malignancies suggest that it might be possible to anticipate critical events during tumor development. In the same way, a somatic alteration in NHL could be conditioning a similar response at the transcriptional level in the shared signaling pathways with genetic germline alterations in CVID. We aimed to explore the genomic substrate shared between these entities to better characterize the CVID phenotype immunodeficiency in NHL. By means of an in-silico approach, we interrogated the large, publicly available datasets contained in cBioPortal for the presence of genes associated with genetic pathogenic variants in a panel of 50 genes recurrently altered in CVID and previously described as causative or disease-modifying. We found that 323 (25%) of the 1,309 NHL samples available for analysis harbored variants of the CVID spectrum, with the most recurrent alteration presented in NHL occurring in PIK3CD (6%) and STAT3 (4%). Pathway analysis of common gene alterations showed enrichment in inflammatory, immune surveillance, and defective DNA repair mechanisms similar to those affected in CVID, with PIK3R1 appearing as a central node in the protein interaction network. The co-occurrence of gene alterations was a frequent phenomenon. This study represents an attempt to identify common genomic grounds between CVID and NHL. Further prospective studies are required to better know the role of genetic variants associated with CVID and their reflection on the somatic pathogenic variants responsible for cancer, as well as to characterize the CVID-like phenotype in NHL, with the potential to influence early CVID detection and therapeutic management.
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Affiliation(s)
- Kissy Guevara-Hoyer
- Cancer Immunomonitoring and Immuno-Mediated Pathologies Support Unit, IdSSC, Department of Clinical Immunology, San Carlos Clinical Hospital, Madrid, Spain
- Department of Clinical Immunology, IML and IdSSC, San Carlos Clinical Hospital, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
- *Correspondence: Kissy Guevara-Hoyer,
| | - Jesús Fuentes-Antrás
- Oncology Department, San Carlos Clinical Hospital, Madrid, Spain
- Experimental Therapeutics and Translational Oncology Unit, Medical Oncology Department, San Carlos University Hospital, Madrid, Spain
| | - Eduardo de la Fuente-Muñoz
- Cancer Immunomonitoring and Immuno-Mediated Pathologies Support Unit, IdSSC, Department of Clinical Immunology, San Carlos Clinical Hospital, Madrid, Spain
- Department of Clinical Immunology, IML and IdSSC, San Carlos Clinical Hospital, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Miguel Fernández-Arquero
- Cancer Immunomonitoring and Immuno-Mediated Pathologies Support Unit, IdSSC, Department of Clinical Immunology, San Carlos Clinical Hospital, Madrid, Spain
- Department of Clinical Immunology, IML and IdSSC, San Carlos Clinical Hospital, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Fernando Solano
- Department of Hematology, General University Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
| | | | - Esmeralda Neves
- Department of Immunology, Centro Hospitalar e Universitário do Porto, Porto, Portugal
- Unit for Multidisciplinary Research in Biomedicine (UMIB), Hospital and University Center of Porto, Porto, Portugal
| | - Alberto Ocaña
- Oncology Department, San Carlos Clinical Hospital, Madrid, Spain
- Experimental Therapeutics and Translational Oncology Unit, Medical Oncology Department, San Carlos University Hospital, Madrid, Spain
| | - Rebeca Pérez de Diego
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
- Laboratory of Immunogenetics of Human Diseases, IdiPAZ Institute for Health Research, Madrid, Spain
| | - Silvia Sánchez-Ramón
- Cancer Immunomonitoring and Immuno-Mediated Pathologies Support Unit, IdSSC, Department of Clinical Immunology, San Carlos Clinical Hospital, Madrid, Spain
- Department of Clinical Immunology, IML and IdSSC, San Carlos Clinical Hospital, Madrid, Spain
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
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11
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Common variable immunodeficiency and its inflammatory neurological manifestations: a case report and literature review. Mult Scler Relat Disord 2022; 67:104086. [DOI: 10.1016/j.msard.2022.104086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/26/2022] [Accepted: 07/31/2022] [Indexed: 11/19/2022]
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12
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Mørup SB, Nazaryan-Petersen L, Gabrielaite M, Reekie J, Marquart HV, Hartling HJ, Marvig RL, Katzenstein TL, Masmas TN, Lundgren J, Murray DD, Helleberg M, Borgwardt L. Added Value of Reanalysis of Whole Exome- and Whole Genome Sequencing Data From Patients Suspected of Primary Immune Deficiency Using an Extended Gene Panel and Structural Variation Calling. Front Immunol 2022; 13:906328. [PMID: 35874679 PMCID: PMC9302041 DOI: 10.3389/fimmu.2022.906328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background Knowledge of the genetic variation underlying Primary Immune Deficiency (PID) is increasing. Reanalysis of genome-wide sequencing data from undiagnosed patients with suspected PID may improve the diagnostic rate. Methods We included patients monitored at the Department of Infectious Diseases or the Child and Adolescent Department, Rigshospitalet, Denmark, for a suspected PID, who had been analysed previously using a targeted PID gene panel (457 PID-related genes) on whole exome- (WES) or whole genome sequencing (WGS) data. A literature review was performed to extend the PID gene panel used for reanalysis of single nucleotide variation (SNV) and small indels. Structural variant (SV) calling was added on WGS data. Results Genetic data from 94 patients (86 adults) including 36 WES and 58 WGS was reanalysed a median of 23 months after the initial analysis. The extended gene panel included 208 additional PID-related genes. Genetic reanalysis led to a small increase in the proportion of patients with new suspicious PID related variants of uncertain significance (VUS). The proportion of patients with a causal genetic diagnosis was constant. In total, five patients (5%, including three WES and two WGS) had a new suspicious PID VUS identified due to reanalysis. Among these, two patients had a variant added due to the expansion of the PID gene panel, and three patients had a variant reclassified to a VUS in a gene included in the initial PID gene panel. The total proportion of patients with PID related VUS, likely pathogenic, and pathogenic variants increased from 43 (46%) to 47 (50%), as one patient had a VUS detected in both initial- and reanalysis. In addition, we detected new suspicious SNVs and SVs of uncertain significance in PID candidate genes with unknown inheritance and/or as heterozygous variants in genes with autosomal recessive inheritance in 8 patients. Conclusion These data indicate a possible diagnostic gain of reassessing WES/WGS data from patients with suspected PID. Reasons for the possible gain included improved knowledge of genotype-phenotype correlation, expanding the gene panel, and adding SV analyses. Future studies of genotype-phenotype correlations may provide additional knowledge on the impact of the new suspicious VUSs.
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Affiliation(s)
- Sara Bohnstedt Mørup
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lusine Nazaryan-Petersen
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Migle Gabrielaite
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joanne Reekie
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hanne V. Marquart
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hans Jakob Hartling
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rasmus L. Marvig
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Terese L. Katzenstein
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tania N. Masmas
- The Child and Adolescent Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Lundgren
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniel D. Murray
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marie Helleberg
- Centre of Excellence for Health, Immunity, and Infections, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Line Borgwardt
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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13
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Nguyen A, Martin-Silva N, de Boysson H, Deshayes S, Gac AC, Reboursière E, Damaj G, Aouba A. Low total gamma globulin level discovery at diffuse large B-cell lymphoma diagnosis predicts high risk of infection-related death: data from a monocentric retrospective study. Swiss Med Wkly 2022; 152:w30143. [PMID: 35704942 DOI: 10.4414/smw.2022.w30143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Diffuse large B-cell lymphoma can complicate the course of B-cell primary immunodeficiencies or induce lowering of total gamma globulin levels, whose clinical status as an effective secondary immunodeficiency remains unspecified. This study aimed to assess the frequency, and clinical and prognostic relevance of the low total gamma-globulin levels discovered at diagnosis of diffuse large B-cell lymphoma. RESULTS In a 2-year monocentric retrospective study, 96 patients diagnosed with diffuse large B-cell lymphoma who had a serum electrophoresis were included. Patients were divided into those with lower (L-TGL and higher (H-TGL) total gamma-globulin levels (total gamma-globulin levels ≤5.5 g/l and >5.5 g/l) and compared for outcomes, including fatal infectious events. Twelve (12.5%; 8 males; age median 68 years, range 55-82 years) exhibited L-TGL. There was no difference between the both groups regarding demographics, Ann Arbor lymphoma stage, inflammatory parameters or chemotherapy regimen. However, overall death rates (10/12, 83.3% versus 22/96, 26.2%; p = 0.03) and infection-related death rates (10/12, 83% versus 6/96, 6.2%; p <0.001) were significantly higher in the L-TGL group. CONCLUSION We demonstrate for the first time the strong negative impact of L-TGL on overall and infection-related mortality in diffuse large B-cell lymphoma. Prospective studies should distinguish immunodeficiencies secondary to the lymphoma from pre-existing humoral primary immunodeficiencies, using biomolecular testing and post-treatment total gamma-globulin level monitoring, to determine the best management strategy for infectious risk during diffuse large B-cell lymphoma treatment in the context of L-TGL.
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Affiliation(s)
- Alexandre Nguyen
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Nicolas Martin-Silva
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Anne-Claire Gac
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Emilie Reboursière
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Gandhi Damaj
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
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14
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Clinical and Phenotypic Characterization of Common Variable Immunodeficiency Diagnosed in Younger and Older Adults. J Clin Immunol 2022; 42:1270-1279. [PMID: 35588029 DOI: 10.1007/s10875-022-01290-w] [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: 02/24/2022] [Accepted: 05/06/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Common variable immunodeficiency (CVID) is the most prevalent symptomatic immunodeficiency in adults. Little is known about the manifestations of CVID presenting in older adults. Herein, we performed a phenotypic characterization of patients diagnosed older than age 40. METHODS A retrospective chart review of 79 patients seen at UF Health between 2006 and 2020 with a verified diagnosis of CVID per the ICON 2016 criteria was conducted. Patients were classified according to four phenotypes: no-disease-related complications, autoimmune cytopenias, polyclonal lymphoproliferation, and unexplained enteropathy. Patients diagnosed with CVID from age 2 to 40 (n = 41, "younger cohort") were compared to patients diagnosed with CVID age 41 and older (n = 38, "older cohort"). RESULTS Among the younger cohort, pathologic genetic variants, positive family history for immunodeficiency, autoimmunity (49% vs 24%, p = 0.03), and splenomegaly (46% vs 16%, p = 0.004) were more common, as was the "autoimmune cytopenias" phenotype (24% vs 3%, p = 0.007). Among the older cohort, lymphoma (11% vs 0%, p = 0.049) and the "no disease-related complications" phenotype (79% vs 57%, p = 0.03) were more commonly seen. Comorbidities such as bronchiectasis (27% vs 21%, p = 0.61), GI involvement (34% vs 24%, p = 0.33), and GLILD (5% vs 8%, p = 0.67) were equally present among both the younger and older cohorts, respectively. CONCLUSION The lower incidence of autoimmunity and splenomegaly, as well as overlapping clinical features with immunosenescence, may make diagnosing CVID in older patients more challenging; however, the disease is not more indolent as the risks for lymphoma, bronchiectasis, and GLILD are similar to those of younger patients.
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15
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Ameratunga R, Woon ST, Steele R, Lehnert K, Leung E, Brooks AES. Severe COVID-19 is a T cell immune dysregulatory disorder triggered by SARS-CoV-2. Expert Rev Clin Immunol 2022; 18:557-565. [PMID: 35510369 DOI: 10.1080/1744666x.2022.2074403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION COVID-19 has had a calamitous impact on the global community. Apart from at least 6M deaths, hundreds of millions have been infected and a much greater number have been plunged into poverty. Vaccines have been effective but financial and logistical challenges have hampered their rapid global deployment. Vaccine disparities have allowed the emergence of new SARS-CoV-2 variants including delta and omicron, perpetuating the pandemic. AREAS COVERED The immunological response to SARS-CoV-2 has been the subject of intense study and is now better understood. Many of the clinical manifestations of severe disease are a consequence of immune dysregulation triggered by the virus. This may explain the lack of efficacy of antiviral treatments such as convalescent plasma infusions, given later in the disease. EXPERT OPINION T cells play a crucial role in both the outcome of COVID-19 as well as the protective response to vaccines. Vaccines do not prevent infection but reduce the risk of a chaotic and destructive cellular immune response to the virus. Severe COVID-19 should be considered a virus-induced secondary immune dysregulatory disorder of cellular immunity, with broad host susceptibility. This perspective of COVID-19 will lead to better diagnostic tests, vaccines and therapeutic strategies in the future.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland New Zealand.,Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Park Rd, Grafton 1010, Auckland, New Zealand.,Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand Wilkins Centre, University of Auckland
| | - Euphemia Leung
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand Wilkins Centre, University of Auckland.,Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Anna E S Brooks
- School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Symonds St, Auckland, New Zealand Wilkins Centre, University of Auckland
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16
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Janssen LMA, Reijnen ICGM, Milito C, Edgar D, Chapel H, de Vries E. Protocol for the unclassified primary antibody deficiency (unPAD) study: Characterization and classification of patients using the ESID online Registry. PLoS One 2022; 17:e0266083. [PMID: 35333892 PMCID: PMC9045688 DOI: 10.1371/journal.pone.0266083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background Primary antibody deficiencies (PADs) without an identified monogenetic origin
form the largest and most heterogeneous group of primary immunodeficiencies.
These patients often remain undiagnosed for years and many present to
medical attention in adulthood after several infections risking structural
complications. Not much is known about their treatment, comorbidities, or
prognosis, nor whether the various immunological forms (decreased total IgG,
IgG subclass(es), IgM, IgA, specific antibody responses, alone or in
combination(s)) should be considered as separate, clearly definable
subgroups. The unclassified primary antibody deficiency (unPAD) study aims
to describe in detail all PAD patients without an
identified specific monogenetic defect regarding their demographical,
clinical, and immunological characteristics at presentation and during
follow-up. In constructing these patterns, the unPAD study aims to reduce
the number of missed and unidentified PAD patients in the future. In
addition, this study will focus on subclassifying unPAD to support the
identification of patients at higher risk for infection or immune
dysregulation related complications, enabling the development of
personalized follow-up and treatment plans. Methods and analysis We present a protocol for a multicenter observational cohort study using the
ESID online Registry. Patients of all ages who have given informed consent
for participation in the ESID online Registry and fulfill the ESID Clinical
Working Definitions for ‘unclassified antibody deficiency’, ‘deficiency of
specific IgG’, ‘IgA with IgG subclass deficiency’, ‘isolated IgG subclass
deficiency’, ‘selective IgM deficiency’, ‘selective IgA deficiency’ or
‘common variable immunodeficiency’ will be included. For all patients, basic
characteristics can be registered at first registration and yearly
thereafter in level 1 forms. Detailed characteristics of the patients can be
registered in level 2 forms. Consecutive follow-up forms can be added
indefinitely. To ensure the quality of the collected data, all data will be
fully monitored before they are exported from the ESID online Registry for
analysis. Outcomes will be the clinical and immunological characteristics of
unPAD at presentation and during follow-up. Subgroup analyses will be made
based on demographical, clinical and immunological characteristics.
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Affiliation(s)
- Lisanne M. A. Janssen
- Department of Tranzo, TSB, Tilburg University, Tilburg, the
Netherlands
- Department of Pediatrics, Amalia Children’s hospital, Nijmegen, the
Netherlands
| | | | - Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome,
Italy
| | - David Edgar
- Department of Immunology, St James’s Hospital, Dublin & (ii) Trinity
College, Dublun, Ireland
| | - Helen Chapel
- Primary Immunodeficiency Unit, Nuffield Department of Medicine,
University of Oxford, Oxford, United Kingdom
| | - Esther de Vries
- Department of Tranzo, TSB, Tilburg University, Tilburg, the
Netherlands
- Laboratory of Medical Microbiology and Immunology, Elisabeth-Tweesteden
Hospital, Tilburg, the Netherlands
- * E-mail:
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17
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Rasul TF, Bergholz DR, Faiz A. The Diagnosis of Common Variable Immunodeficiency After Multisystem Dysfunction. Cureus 2022; 14:e21624. [PMID: 35228973 PMCID: PMC8874879 DOI: 10.7759/cureus.21624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Common variable immunodeficiency (CVID) is a primary immunodeficiency caused by the lack of B cell differentiation into plasma cells, thereby leading to decreased serum immunoglobulins. Patients with this condition are predisposed to recurrent infections and are more likely to develop certain cancers and autoimmune diseases. We report the case of a 53-year-old female suffering from recurrent pulmonary infections and a history of non-Hodgkin lymphoma (NHL) who had a poor response to the measles, mumps, and rubella (MMR) and varicella vaccines as a child, and was infected with coronavirus disease 2019 (COVID-19) twice in 2020. Testing of her antibody titers in order to determine suitability for Streptococcus pneumoniae (S. pneumoniae) vaccination found an overall decrease in major immunoglobulin classes (IgG, IgM, and IgA) and B cells with normal morphology. The diagnosis of CVID was made, and prompt treatment with intravenous immunoglobulins (IVIG) brought her IgG levels up from 282 to 680 mg/dL within three months. This case highlights the importance for providers to keep immunological dysfunction on their differentials for patients with atypical presentations involving multiple organ systems.
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18
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Ameratunga R, Woon ST, Steele R, Lehnert K, Leung E, Edwards ESJ, Brooks AES. Common Variable Immunodeficiency Disorders as a Model for Assessing COVID-19 Vaccine Responses in Immunocompromised Patients. Front Immunol 2022; 12:798389. [PMID: 35116031 PMCID: PMC8805700 DOI: 10.3389/fimmu.2021.798389] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/22/2021] [Indexed: 01/27/2023] Open
Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Auckland, New Zealand
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
- Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- *Correspondence: Rohan Ameratunga, E
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
- Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
- Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Euphemia Leung
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Auckland, New Zealand
- Auckland Cancer Society Research Centre, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Emily S. J. Edwards
- Allergy and Clinical Immunology Laboratory, Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Anna E. S. Brooks
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, School of Biological Sciences, University of Auckland, Auckland, New Zealand
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19
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Ameratunga R, Longhurst H, Lehnert K, Steele R, Edwards ESJ, Woon ST. Are All Primary Immunodeficiency Disorders Inborn Errors of Immunity? Front Immunol 2021; 12:706796. [PMID: 34367167 PMCID: PMC8335567 DOI: 10.3389/fimmu.2021.706796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/01/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland Hospital, Auckland, New Zealand.,Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Hilary Longhurst
- Department of Clinical Immunology, Auckland Hospital, Auckland, New Zealand.,Department of Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
| | - Emily S J Edwards
- B Cell Differentiation Laboratory, Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland Hospital, Auckland, New Zealand
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20
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Ameratunga R, Longhurst H, Steele R, Woon ST. Comparison of Diagnostic Criteria for Common Variable Immunodeficiency Disorders (CVID) in the New Zealand CVID Cohort Study. Clin Rev Allergy Immunol 2021; 61:236-244. [PMID: 34236581 DOI: 10.1007/s12016-021-08860-7] [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] [Accepted: 05/11/2021] [Indexed: 11/28/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are the most frequent symptomatic primary immune deficiencies in adults and children. In addition to recurrent and severe infections, patients with CVID are susceptible to autoimmune and inflammatory complications. The aetiologies of these uncommon conditions are, by definition, unknown. When the causes of complex disorders are uncertain, diagnostic criteria may offer valuable guidance to the management of patients. Over the last two decades, there have been four sets of diagnostic criteria for CVID in use. The original 1999 European Society for Immunodeficiencies and Pan-American Society for Immunodeficiency (ESID/PAGID) criteria are less commonly used than the three newer criteria: Ameratunga et al (Clin Exp Immunol 174:203-211, 2013), ESID (J Allergy Clin Immunol Pract, 2019) and ICON (J Allergy Clin Immunol Pract 4:38-59, 2016) criteria. The primary aim of the present study was to compare the utility of diagnostic criteria in a well-characterised cohort of CVID patients. The New Zealand CVID cohort study (NZCS) commenced in 2006 and currently comprises one hundred and thirteen patients, which represents approximately 70% of all known CVID patients in NZ. Many patients have been on subcutaneous or intravenous (SCIG/IVIG) immunoglobulin treatment for decades. Patients were given a clinical diagnosis of CVID as most were diagnosed before the advent of newer diagnostic criteria. Application of the three commonly used CVID diagnostic criteria to the NZCS showed relative sensitivities as follows: Ameratunga et al (Clin Exp Immunol 174:203-211, 2013), possible and probable CVID, 88.7%; ESID (J Allergy Clin Immunol Pract, 2019), 48.3%; and ICON (J Allergy Clin Immunol Pract 4:38-59, 2016), 47.1%. These differences were mostly due to the low rates of diagnostic vaccination challenges in patients prior to commencing SCIG/IVIG treatment and mirror similar findings in CVID cohorts from Denmark and Finland. Application of the Ameratunga et al (Clin Exp Immunol 174:203-211, 2013) CVID diagnostic criteria to patients on SCIG/IVIG may obviate the need to stop treatment for vaccine studies, to confirm the diagnosis.
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Affiliation(s)
- Rohan Ameratunga
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand. .,Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand. .,Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand.
| | - Hilary Longhurst
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Steele
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
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21
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Mushino T, Hiroi T, Yamashita Y, Suzaki N, Mishima H, Ueno M, Kinoshita A, Minami K, Imai K, Yoshiura KI, Sonoki T, Tamura S. Progressive Massive Splenomegaly in an Adult Patient with Kabuki Syndrome Complicated with Immune Thrombocytopenic Purpura. Intern Med 2021; 60:1927-1933. [PMID: 33518579 PMCID: PMC8263171 DOI: 10.2169/internalmedicine.6694-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Kabuki syndrome is characterized by multiple systemic anomalies and intellectual disability. It is complicated with immunodeficiencies and autoimmune disorders. The syndrome is caused by a mutation in the KMT2D gene. We herein report a case of a Kabuki syndrome with developing immune thrombocytopenic purpura (ITP) and progressive splenomegaly. Laparoscopic splenectomy was performed and the patients' symptoms quickly disappeared with platelet recovery. After this operation, the patient had no severe complications. A sequence analysis of the KMT2D gene identified a pathogenic mutation frequently associated with ITP. Laparoscopic splenectomy is therefore considered to be a good therapeutic option for recurrent ITP and symptomatic splenomegaly with Kabuki syndrome.
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Affiliation(s)
- Toshiki Mushino
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Takayuki Hiroi
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Yusuke Yamashita
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Norihiko Suzaki
- Second Department of Surgery, Wakayama Medical University, Japan
| | - Hiroyuki Mishima
- Department of Human Genetics, Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Masaki Ueno
- Second Department of Surgery, Wakayama Medical University, Japan
| | - Akira Kinoshita
- Department of Human Genetics, Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Koichi Minami
- Department of Pediatrics, Wakayama Medical University, Japan
| | - Kohsuke Imai
- Department of Pediatrics, Tokyo Medical and Dental University, Japan
| | - Ko-Ichiro Yoshiura
- Department of Human Genetics, Graduate School of Biomedical Sciences, Nagasaki University, Japan
| | - Takashi Sonoki
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Shinobu Tamura
- Department of Hematology/Oncology, Wakayama Medical University, Japan
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22
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Bosák J, Lexa M, Fiedorová K, Gadara DC, Micenková L, Spacil Z, Litzman J, Freiberger T, Šmajs D. Patients With Common Variable Immunodeficiency (CVID) Show Higher Gut Bacterial Diversity and Levels of Low-Abundance Genes Than the Healthy Housemates. Front Immunol 2021; 12:671239. [PMID: 34054845 PMCID: PMC8163231 DOI: 10.3389/fimmu.2021.671239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/26/2021] [Indexed: 12/19/2022] Open
Abstract
Common variable immunodeficiency (CVID) is a clinically and genetically heterogeneous disorder with inadequate antibody responses and low levels of immunoglobulins including IgA that is involved in the maintenance of the intestinal homeostasis. In this study, we analyzed the taxonomical and functional metagenome of the fecal microbiota and stool metabolome in a cohort of six CVID patients without gastroenterological symptomatology and their healthy housemates. The fecal microbiome of CVID patients contained higher numbers of bacterial species and altered abundance of thirty-four species. Hungatella hathewayi was frequent in CVID microbiome and absent in controls. Moreover, the CVID metagenome was enriched for low-abundance genes likely encoding nonessential functions, such as bacterial motility and metabolism of aromatic compounds. Metabolomics revealed dysregulation in several metabolic pathways, mostly associated with decreased levels of adenosine in CVID patients. Identified features have been consistently associated with CVID diagnosis across the patients with various immunological characteristics, length of treatment, and age. Taken together, this initial study revealed expansion of bacterial diversity in the host immunodeficient conditions and suggested several bacterial species and metabolites, which have potential to be diagnostic and/or prognostic CVID markers in the future.
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Affiliation(s)
- Juraj Bosák
- Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Matej Lexa
- Faculty of Informatics, Masaryk University, Brno, Czechia
| | - Kristýna Fiedorová
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Department of Clinical Immunology and Allergology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Darshak C. Gadara
- RECETOX Center, Faculty of Science, Masaryk University, Brno, Czechia
| | - Lenka Micenková
- RECETOX Center, Faculty of Science, Masaryk University, Brno, Czechia
| | - Zdenek Spacil
- RECETOX Center, Faculty of Science, Masaryk University, Brno, Czechia
| | - Jiří Litzman
- Department of Clinical Immunology and Allergology, Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Clinical Immunology and Allergology, St. Anne’s University Hospital in Brno, Brno, Czechia
| | - Tomáš Freiberger
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Department of Clinical Immunology and Allergology, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - David Šmajs
- Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czechia
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23
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Fliegauf M, Krüger R, Steiner S, Hanitsch LG, Büchel S, Wahn V, von Bernuth H, Grimbacher B. A Pathogenic Missense Variant in NFKB1 Causes Common Variable Immunodeficiency Due to Detrimental Protein Damage. Front Immunol 2021; 12:621503. [PMID: 33995346 PMCID: PMC8115018 DOI: 10.3389/fimmu.2021.621503] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 04/01/2021] [Indexed: 12/14/2022] Open
Abstract
In common variable immunodeficiency (CVID), heterozygous damaging NFKB1 variants represent the most frequent monogenic cause. NFKB1 encodes the precursor p105, which undergoes proteasomal processing to generate the mature NF-κB transcription factor subunit p50. The majority of NFKB1 sequence changes comprises missense variants of uncertain significance (VUS), each requiring functional evaluation to assess causality, particularly in families with multiple affected members presenting with different phenotypes. In four affected members of a German family, all diagnosed with CVID, we identified a previously uncharacterized heterozygous NFKB1 missense variant (c.1049A>G; p.Tyr350Cys). The clinical phenotypes varied markedly regarding onset, frequency and severity of infections. Consistent immunologic findings were hypogammaglobulinemia with normal specific antibody response to protein- and polysaccharide-based vaccinations, reduced switched memory B cells and decreased lymphocyte proliferation upon stimulation with the B cell mitogen SAC. To assess the pathogenicity of the NFKB1 missense variant, we employed immunophenotyping and functional analyses in a routine in vitro cell culture model. Following site-directed mutagenesis to introduce the variant into overexpression vectors encoding EGFP-fused p105 or p50, we analyzed transiently transfected HEK293T cells by confocal imaging and Western blotting. The cytoplasmic p105-Tyr350Cys precursor gained only weak expression levels indicating accelerated decay. The missense change disabled processing of the precursor to prevent the generation of mutant p50. Unlike the wildtype p50, the overexpressed mutant p50-Tyr350Cys was also not sustainable and showed a conspicuous subnuclear mislocalization with accumulation in dense aggregates instead of a homogenous distribution. Electrophoretic mobility shift assays, fluorescence-based reporter gene analyses and co-transfection experiments however demonstrated, that the DNA-binding activity of p50-Tyr350Cys and the interaction with RelA(p65), IκBα and wildtype p50 were preserved. Mutation carriers had reduced p105 and p50 levels, indicating insufficient protein amounts as the most likely primary defect. In conclusion, the missense variant c.1049A>G caused a detrimental defect, preventing the persistent expression of both, the p105-Tyr350Cys precursor and the mature p50-Tyr350Cys. The variable clinical phenotypes among affected family members sharing an identical pathogenic NFKB1 variant support a disease mechanism provoked by a p105/p50 (haplo)insufficient condition.
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Affiliation(s)
- Manfred Fliegauf
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany
| | - Renate Krüger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie Steiner
- Department of Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Leif Gunnar Hanitsch
- Department of Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Büchel
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker Wahn
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Horst von Bernuth
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Immunology, Labor Berlin Charité - Vivantes GmbH, Berlin, Germany.,Berlin Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,CIBSS - Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany.,DZIF - German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany.,RESIST - Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
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24
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Ameratunga R, Jordan A, Cavadino A, Ameratunga S, Hills T, Steele R, Hurst M, McGettigan B, Chua I, Brewerton M, Kennedy N, Koopmans W, Ahn Y, Barker R, Allan C, Storey P, Slade C, Baker A, Huang L, Woon ST. Bronchiectasis is associated with delayed diagnosis and adverse outcomes in the New Zealand Common Variable Immunodeficiency Disorders cohort study. Clin Exp Immunol 2021; 204:352-360. [PMID: 33755987 DOI: 10.1111/cei.13595] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/19/2021] [Accepted: 03/13/2021] [Indexed: 02/06/2023] Open
Abstract
Common variable immunodeficiency disorders (CVID) are multi-system disorders where target organ damage is mediated by infective, autoimmune and inflammatory processes. Bronchiectasis is probably the most common disabling complication of CVID. The risk factors for bronchiectasis in CVID patients are incompletely understood. The New Zealand CVID study (NZCS) is a nationwide longitudinal observational study of adults, which commenced in 2006. In this analysis, the prevalence and risk factors for bronchiectasis were examined in the NZCS. After informed consent, clinical and demographic data were obtained with an interviewer-assisted questionnaire. Linked electronic clinical records and laboratory results were also reviewed. Statistical methods were applied to determine if variables such as early-onset disease, delay in diagnosis and increased numbers of infections were associated with greater risk of bronchiectasis. One hundred and seven adult patients with a diagnosis of CVID are currently enrolled in the NZCS, comprising approximately 70% of patients known to have CVID in New Zealand. Fifty patients (46·7%) had radiologically proven bronchiectasis. This study has shown that patients with compared to those without bronchiectasis have an increased mortality at a younger age. CVID patients with bronchiectasis had a greater number of severe infections consequent to early-onset disease and delayed diagnosis. Indigenous Māori have a high prevalence of CVID and a much greater burden of bronchiectasis compared to New Zealand Europeans. Diagnostic latency has not improved during the study period. Exposure to large numbers of infections because of early-onset disease and delayed diagnosis was associated with an increased risk of bronchiectasis. Earlier diagnosis and treatment of CVID may reduce the risk of bronchiectasis and premature death in some patients.
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Affiliation(s)
- R Ameratunga
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
| | - A Jordan
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - A Cavadino
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - S Ameratunga
- School of Population Health, University of Auckland, Auckland, New Zealand.,Population Health Directorate, Counties Manukau Health, Auckland, New Zealand
| | - T Hills
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - R Steele
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - M Hurst
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - B McGettigan
- Department of Clinical Immunology, Fiona Stanley Hospital, Perth, WA, Australia
| | - I Chua
- Department of Clinical Immunology, Christchurch Hospital, Christchurch, New Zealand
| | - M Brewerton
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - N Kennedy
- Department of Respiratory Medicine, Wellington Hospital, Wellington, New Zealand
| | - W Koopmans
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Y Ahn
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - R Barker
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - C Allan
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - P Storey
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - C Slade
- Walter and Eliza Hall Institute, Melbourne, VIC, Australia
| | - A Baker
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand
| | - L Huang
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - S-T Woon
- Department of Clinical Immunology, Auckland City Hospital, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
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25
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Ameratunga R, Allan C, Lehnert K, Woon ST. Perspective: Application of the American College of Medical Genetics Variant Interpretation Criteria to Common Variable Immunodeficiency Disorders. Clin Rev Allergy Immunol 2021; 61:226-235. [PMID: 33818703 DOI: 10.1007/s12016-020-08828-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 02/05/2023]
Abstract
Common variable immunodeficiency disorders (CVIDs) are rare primary immunodeficiency diseases (PIDs) mostly associated with late onset antibody failure leading to immune system failure. Patients with CVID are predisposed to disabling complications such as bronchiectasis and systemic autoimmunity. In recent years a large number of genetic defects have become associated with these disorders. Patients with a causative mutation are deemed to have CVID-like disorders, while those with mutations predisposing to or modifying disease severity remain within the spectrum of CVID as defined by current diagnostic criteria. Next-generation sequencing (NGS) allows simultaneous analysis of multiple genes. Potential mutations identified from NGS are commonly evaluated with the American College of Medical Genetics (ACMG) variant interpretation criteria to determine their pathogenicity (causality). Patients with CVID and CVID-like disorders have marked genetic, allelic, and phenotypic heterogeneity. Although all patients with a CVID phenotype should undergo genetic testing, the complexity of the genetics associated with these disorders is challenging. Variants of unknown significance (VUS) remain a significant barrier to realising the full potential of NGS in CVID and CVID-like disorders. Here we explore the nuances of applying the ACMG criteria to patients with CVID and CVID-like disorders. Close collaboration between the clinician, bioinformatics, and genetics professionals will improve the diagnostic yield from genetic testing and reduce the frequency of VUS.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, 1010, New Zealand. .,Department of Clinical Immunology, Auckland City Hospital, Auckland, 1010, New Zealand. .,Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1010, New Zealand.
| | - Caroline Allan
- Department of Virology and Immunology, Auckland City Hospital, Auckland, 1010, New Zealand
| | - Klaus Lehnert
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, 1010, New Zealand.,Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1010, New Zealand
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26
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Janssen LMA, van der Flier M, de Vries E. Lessons Learned From the Clinical Presentation of Common Variable Immunodeficiency Disorders: A Systematic Review and Meta-Analysis. Front Immunol 2021; 12:620709. [PMID: 33833753 PMCID: PMC8021796 DOI: 10.3389/fimmu.2021.620709] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/24/2021] [Indexed: 12/22/2022] Open
Abstract
Background Diagnostic delay in common variable immunodeficiency disorders (CVID) is considerable. There is no generally accepted symptom-recognition framework for its early detection. Objective To systematically review all existing data on the clinical presentation of CVID. Methods PubMed, EMBASE and Cochrane were searched for cohort studies, published January/1999-December/2019, detailing the clinical manifestations before, at and after the CVID-diagnosis. Results In 51 studies (n=8521 patients) 134 presenting and 270 total clinical manifestations were identified. Recurrent upper and/or lower respiratory infections were present at diagnosis in 75%. Many patients had suffered severe bacterial infections (osteomyelitis 4%, meningitis 6%, septicemia 8%, mastoiditis 8%). Bronchiectasis (28%), lymphadenopathy (27%), splenomegaly (13%), inflammatory bowel disease (11%), autoimmune cytopenia (10%) and idiopathic thrombocytopenia (6%) were also frequently reported. A bimodal sex distribution was found, with male predominance in children (62%) and female predominance in adults (58%). 25% of CVID-patients developed other manifestations besides infections in childhood, this percentage was much higher in adults (62%). Immune-dysregulation features, such as granulomatous-lymphocytic interstitial lung disease and inflammatory bowel disease, were more prominent in adults. Conclusions The shift from male predominance in childhood to female predominance in adults suggests differences in genetic and environmental etiology in CVID and has consequences for pathophysiologic studies. We confirm the high frequency of respiratory infections at presentation, but also show a high incidence of severe bacterial infections such as sepsis and meningitis, and immune dysregulation features including lymphoproliferative, gastrointestinal and autoimmune manifestations. Early detection of CVID may be improved by screening for antibody deficiency in patients with these manifestations.
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Affiliation(s)
- Lisanne M A Janssen
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Department of Pediatrics, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Michiel van der Flier
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Esther de Vries
- Department of Tranzo, Tilburg University, Tilburg, Netherlands.,Laboratory of Medical Microbiology and Immunology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
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27
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Primary Humoral Immune Deficiencies: Overlooked Mimickers of Chronic Immune-Mediated Gastrointestinal Diseases in Adults. Int J Mol Sci 2020; 21:ijms21155223. [PMID: 32718006 PMCID: PMC7432083 DOI: 10.3390/ijms21155223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 12/12/2022] Open
Abstract
In recent years, the incidence of immune-mediated gastrointestinal disorders, including celiac disease (CeD) and inflammatory bowel disease (IBD), is increasingly growing worldwide. This generates a need to elucidate the conditions that may compromise the diagnosis and treatment of such gastrointestinal disorders. It is well established that primary immunodeficiencies (PIDs) exhibit gastrointestinal manifestations and mimic other diseases, including CeD and IBD. PIDs are often considered pediatric ailments, whereas between 25 and 45% of PIDs are diagnosed in adults. The most common PIDs in adults are the selective immunoglobulin A deficiency (SIgAD) and the common variable immunodeficiency (CVID). A trend to autoimmunity occurs, while gastrointestinal disorders are common in both diseases. Besides, the occurrence of CeD and IBD in SIgAD/CVID patients is significantly higher than in the general population. However, some differences concerning diagnostics and management between enteropathy/colitis in PIDs, as compared to idiopathic forms of CeD/IBD, have been described. There is an ongoing discussion whether CeD and IBD in CVID patients should be considered a true CeD and IBD or just CeD-like and IBD-like diseases. This review addresses the current state of the art of the most common primary immunodeficiencies in adults and co-occurring CeD and IBD.
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28
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Ameratunga R, Allan C, Woon ST. Defining Common Variable Immunodeficiency Disorders in 2020. Immunol Allergy Clin North Am 2020; 40:403-420. [PMID: 32654689 DOI: 10.1016/j.iac.2020.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are the most frequent symptomatic primary immune deficiency in adults. Because there is no known cause for these conditions, there is no single clinical feature or laboratory test that can confirm the diagnosis with certainty. If a causative mutation is identified, patients are deemed to have a CVID-like disorder caused by a specific primary immunodeficiency/inborn error of immunity. In the remaining patients, the explanation for these disorders remains unclear. The understanding of CVID continues to evolve and the authors review recent studies, which have addressed some of these uncertainties.
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Affiliation(s)
- Rohan Ameratunga
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand; Auckland Healthcare Services, Park Road, Grafton, Auckland 1010, New Zealand; Clinical Immunology, Auckland City Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Caroline Allan
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand
| | - See-Tarn Woon
- Department of Virology and Immunology, Auckland City Hospital, Auckland, New Zealand; Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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29
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Jablonka A, Etemadi H, Adriawan IR, Ernst D, Jacobs R, Buyny S, Witte T, Schmidt RE, Atschekzei F, Sogkas G. Peripheral Blood Lymphocyte Phenotype Differentiates Secondary Antibody Deficiency in Rheumatic Disease from Primary Antibody Deficiency. J Clin Med 2020; 9:jcm9041049. [PMID: 32272789 PMCID: PMC7230453 DOI: 10.3390/jcm9041049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
The phenotype of primary immunodeficiency disorders (PID), and especially common variable immunodeficiency (CVID), may be dominated by symptoms of autoimmune disorders. Furthermore, autoimmunity may be the first manifestation of PID, frequently preceding infections and the diagnosis of hypogammaglobulinemia, which occurs later on. In this case, distinguishing PID from hypogammaglobulinemia secondary to anti-inflammatory treatment of autoimmunity may become challenging. The aim of this study was to evaluate the diagnostic accuracy of peripheral blood lymphocyte phenotyping in resolving the diagnostic dilemma between primary and secondary hypogammaglobulinemia. Comparison of B and T cell subsets from patients with PID and patients with rheumatic disease, who developed hypogammaglobulinemia as a consequence of anti-inflammatory regimes, revealed significant differences in proportion of naïve B cells, class-switched memory B cells and CD21low B cells among B cells as well as in CD4+ memory T cells and CD4+ T follicular cells among CD4+ T cells. Identified differences in B cell and T cell subsets, and especially in the proportion of class-switched memory B cells and CD4+ T follicular cells, display a considerable diagnostic efficacy in distinguishing PID from secondary hypogammaglobulinemia due to anti-inflammatory regimens for rheumatic disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Faranaz Atschekzei
- Correspondence: (F.A.); (G.S.); Tel.: +49-(0)-511-532-3871 (F.A.); +49-(0)-511-532-3799 (G.S.)
| | - Georgios Sogkas
- Correspondence: (F.A.); (G.S.); Tel.: +49-(0)-511-532-3871 (F.A.); +49-(0)-511-532-3799 (G.S.)
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