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Gazzin A, Pala F, Bosticardo M, Niemela J, Stoddard J, Biasin E, Quarello P, Carli D, Ferroni F, Delmonte OM, Montin D, Rosenzweig SD, Licciardi F, Notarangelo LD. Mulibrey nanism and immunological complications: a comprehensive case report and literature review. Front Immunol 2023; 14:1303251. [PMID: 38116000 PMCID: PMC10728670 DOI: 10.3389/fimmu.2023.1303251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
Introduction Mulibrey nanism (MUL) is a rare disorder caused by TRIM37 gene variants characterized by growth failure, dysmorphic features, congestive heart failure (CHF), and an increased risk of Wilms' tumor. Although immune system impairment has been documented in MUL, the underlying mechanisms remain poorly understood. Methods We present a case of MUL with progressive lymphopenia and review similar cases from the literature. Results Our patient presented with prenatal onset growth restriction, characteristic dysmorphic features, and Wilms' tumor. She developed progressive lymphopenia starting at 10 years of age, leading to the initiation of intravenous immunoglobulin (IVIG) replacement therapy and infection prophylaxis. Genetic analysis detected a likely pathogenic variant on the maternal allele and copy number loss on the paternal allele in TRIM37. Subsequently a cardiac magnetic resonance imaging was conducted revealing signs of pericardial constriction raising concerns for intestinal lymphatic losses. The cessation of IVIG therapy did not coincide with any increase in the rate of infections. The patient exhibited a distinct immunological profile, characterized by hypogammaglobulinemia, impaired antibody responses, and skewed T-cell subsets with an altered CD4+/CD8+ ratio, consistent with previous reports. Normal thymocyte development assessed by artificial thymic organoid platform ruled out an early hematopoietic intrinsic defect of T-cell development. Discussion The immunological profile of MUL patients reported so far shares similarities with that described in protein-losing enteropathy secondary to CHF in Fontan circulation and primary intestinal lymphangiectasia. These similarities include hypogammaglobulinemia, significant T-cell deficiency with decreased CD4+ and CD8+ counts, altered CD4+/CD8+ ratios, and significantly modified CD4+ and CD8+ T-cell phenotypes toward effector and terminal differentiated T cells, accompanied by a loss of naïve CD45RA+ T lymphocytes. In MUL, CHF is a cardinal feature, occurring in a significant proportion of patients and influencing prognosis. Signs of CHF or constrictive pericarditis have been evident in the case reported here and in all cases of MUL with documented immune dysfunction reported so far. These observations raise intriguing connections between these conditions. However, further investigation is warranted to in-depth define the immunological defect, providing valuable insights into the pathophysiology and treatment strategies for this condition.
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Affiliation(s)
- Andrea Gazzin
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
- Postgraduate School of Pediatrics, University of Torino, Turin, Italy
| | - Francesca Pala
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
| | - Marita Bosticardo
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
| | - Julie Niemela
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Jennifer Stoddard
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Eleonora Biasin
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children’s Hospital, Turin, Italy
| | - Paola Quarello
- Pediatric Onco-Hematology, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children’s Hospital, Turin, Italy
| | - Diana Carli
- Immunogenetics and Transplant Biology Unit, Città della Salute e della Scienza University Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesca Ferroni
- Department of Pediatric Cardiology, City of Health and Science University Hospital, Turin, Italy
| | - Ottavia M. Delmonte
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
| | - Davide Montin
- Department of Public Health and Pediatrics, University of Turin, Pediatria Specialistica U, “Regina Margherita” Children Hospital, Turin, Italy
| | - Sergio D. Rosenzweig
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Francesco Licciardi
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Immune Deficiency Genetics Section, National Institutes of Health, Bethesda, MD, United States
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Sivunen J, Karlberg S, Kivisaari R, Lohi J, Karlberg N, Jokinen E, Sarkola T, Jahnukainen T, Lipsanen‐Nyman M, Jalanko H. Liver pathology and biochemistry in patients with mutations in TRIM37 gene (Mulibrey nanism). Liver Int 2022; 42:1369-1378. [PMID: 35220664 PMCID: PMC9545472 DOI: 10.1111/liv.15213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/01/2022] [Accepted: 02/16/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Mulibrey nanism (MUL) is a multiorgan disease caused by recessive mutations in the TRIM37 gene. Chronic heart failure and hepatopathy are major determinants of prognosis in MUL patients, which prompted us to study liver biochemistry and pathology in a national cohort of MUL patients. METHODS Clinical, laboratory and imaging data were collected in a cross-sectional survey and retrospectively from hospital records. Liver histology and immunohistochemistry for 10 biomarkers were assessed. RESULTS Twenty-one MUL patients (age 1-51 years) with tumour suspicion showed moderate congestion, steatosis and fibrosis in liver biopsies and marginally elevated levels of serum GGT, AST, ALT and AST to platelet ratio index (APRI) in 20%-66%. Similarly, GGT, AST, ALT and APRI levels were moderately elevated in 12%-69% of 17 MUL patients prior to pericardiectomy. In a cross-sectional evaluation of 36 MUL outpatients, GGT, total bilirubin and galactose half-life (Gal½) correlated with age (r = 0.45, p = .017; r = 0.512, p = .007; r = 0.44, p = .03 respectively). The frequency of clearly abnormal serum values of 15 parameters analysed, however, was low even in patients with signs of restrictive cardiomyopathy. Transient elastography (TE) of the liver revealed elevated levels in 50% of patients with signs of heart failure and TE levels correlated with several biochemistry parameters. Biomarkers of fibrosis, sinusoidal capillarization and hepatocyte metaplasia showed increased expression in autopsy liver samples from 15 MUL patients. CONCLUSION Liver disease in MUL patients was characterized by sinusoidal dilatation, steatosis and fibrosis with individual progression to cirrhosis and moderate association of histology with cardiac function, liver biochemistry and elastography.
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Affiliation(s)
- Johanna Sivunen
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Susann Karlberg
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland,Folkhälsan Research CenterHelsinkiFinland
| | - Reetta Kivisaari
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland,Department of Pediatric Radiology, HUS Medical Imaging CentreUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Jouko Lohi
- Department of PathologyUniversity of HelsinkiHelsinkiFinland
| | - Niklas Karlberg
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Eero Jokinen
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Taisto Sarkola
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland,Minerva Foundation Institute for Medical ResearchHelsinkiFinland
| | - Timo Jahnukainen
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Marita Lipsanen‐Nyman
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - Hannu Jalanko
- Children´s Hospital, University of Helsinki and Helsinki University HospitalHelsinkiFinland
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