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Rao VK, Kulm E, Grossman J, Buchbinder D, Chong H, Bradt J, Webster S, Šedivá A, Dalm VA, Uzel G. Long-term treatment with selective PI3Kδ inhibitor leniolisib in adults with activated PI3Kδ syndrome. Blood Adv 2024; 8:3092-3108. [PMID: 38593221 DOI: 10.1182/bloodadvances.2023011000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 03/27/2024] [Accepted: 03/27/2024] [Indexed: 04/11/2024] Open
Abstract
ABSTRACT Activated phosphoinositide 3-kinase delta (PI3Kδ) syndrome (APDS) is an inborn error of immunity that manifests as immune deficiency and dysregulation; symptoms include frequent infections and lymphoproliferation. In our dose-finding and phase 3 placebo-controlled trials, treatment with the selective PI3Kδ inhibitor leniolisib reduced lymphoproliferation and normalized lymphocyte subsets. Here, we present 6 years of follow-up from the 6 adult patients in the original dose-finding trial receiving leniolisib. We used data from the ongoing open-label extension study, which was supplemented at later time points by investigators, including health-related quality of life (HRQoL) assessed through a clinician-reported questionnaire. We observed improvements in HRQoL: 5 of 6 patients experienced an increase in physical capabilities and socialization, and a decrease in prescribed medications. Immune subsets improved in all patients: mean transitional B-cell levels decreased from 38.17% to 2.47% and the CD4:CD8 T-cell ratio normalized to 1.11. Manifestations seen before and within the first year of leniolisib exposure, such as infections and gastrointestinal conditions, attenuated after year 2, with few new conditions emerging out to year 6. Thrombocytopenia or lymphopenia remained present in half of patients at year 6. Of 83 adverse events through year 5, 90.36% were grade 1; none were grade 4/5 nor deemed leniolisib related. Collectively, we saw an enhancement in HRQoL as well as durable changes in lymphocyte subsets and clinical manifestations, further supporting the use of leniolisib as a long-term therapeutic option for the treatment of APDS. This trial was registered at www.ClinicalTrials.gov as #NCT02859727.
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Affiliation(s)
- V Koneti Rao
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Elaine Kulm
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Bethesda, MD
| | | | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, CA
| | - Hey Chong
- Division of Allergy and Immunology, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Sharon Webster
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Anna Šedivá
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Virgil A Dalm
- Division of Allergy and Clinical Immunology and Department of Immunology, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Gulbu Uzel
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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Hitchcock I, Skrobanski H, Matter E, Munro E, Whalen J, Nolthenius JT, Crocker-Buque A, Harrington A, Vandenberghe D, Acaster S, Williams K. A qualitative study to explore the burden of disease in activated phosphoinositide 3-kinase delta syndrome (APDS). Orphanet J Rare Dis 2024; 19:203. [PMID: 38760658 PMCID: PMC11102230 DOI: 10.1186/s13023-024-03215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 05/10/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Activated phosphoinositide 3-kinase delta syndrome (APDS) is an ultra-rare primary immunodeficiency, with only 256 cases reported globally. This study aimed to explore the disease burden of APDS from the perspective of individuals with APDS and their caregivers. METHODS Qualitative interviews were conducted with healthcare providers (HCPs), individuals with APDS and caregivers, to explore the symptoms and health-related quality of life (HRQoL) impact of APDS. Some individuals and caregivers also completed a narrative account exercise. All interviews were audio recorded and transcribed. Data were analysed using thematic analysis and saturation was recorded. RESULTS Semi-structured qualitative interviews were conducted with healthcare providers (HCPs), individuals with APDS and caregivers. Individuals and caregivers had the option of completing a narrative account exercise. Six HCPs participated in an interview. Seven participants completed the narrative account exercise (N = 5 caregivers and N = 2 individuals with APDS) and 12 took part in an interview (N = 4 caregivers and N = 8 individuals with APDS). Themes identified from HCPs interviews included symptoms, clinical manifestations, HRQoL impacts and treatments/management of APDS. The narrative account exercise identified similar themes, but with the addition to the journey to diagnosis. These themes were explored during the individual/caregiver interviews. Reported clinical manifestations and symptoms of APDS included susceptibility to infections, lymphoproliferation, gastrointestinal (GI) disorders, fatigue, bodily pain, and breathing difficulties. HRQoL impacts of living with APDS included negative impacts to daily activities, including work, education and social and leisure activities, physical functioning, as well as emotional well-being, such as concern for the future, and interpersonal relationships. Impacts to caregiver HRQoL included negative impacts to physical health, work, emotional well-being, interpersonal relationships and family life and holidays. The management of APDS included the use of healthcare services and medications including immunoglobulin replacement therapy (IRT), rapamycin, prophylactic antibiotics, leniolisib, as well as medical procedures due to complications. CONCLUSIONS APDS has a high disease burden and there is an unmet need for licensed, more targeted treatments which modify disease progression. This study was the first to describe the day-to-day experience and HRQoL impact of APDS from the perspective of individuals living with the condition, caregivers and treating physicians.
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Affiliation(s)
| | | | | | - Ewen Munro
- Pharming Group N.V, Leiden, The Netherlands
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Mallick R, Solomon G, Bassett P, Zhang X, Patel P, Lepeshkina O. Subcutaneous immunoglobulin replacement therapy in patients with immunodeficiencies - impact of drug packaging and administration method on patient reported outcomes. BMC Immunol 2024; 25:18. [PMID: 38378441 PMCID: PMC10880328 DOI: 10.1186/s12865-024-00608-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/07/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Here, the perspective of patients with primary and secondary immunodeficiency receiving subcutaneous immunoglobulin (SCIg) via introductory smaller size pre-filled syringes (PFS) or vials were compared. METHODS An online survey was conducted in Canada by the Association des Patients Immunodéficients du Québec (APIQ) (10/2020-03/2021). Survey questions included: reasons for choosing SCIg packaging and administration methods, training experiences, infusion characteristics, and switching methods. The survey captured structured patient-reported outcomes: treatment satisfaction and its sub-domains, symptom state, general health perception, and physical and mental function. Respondents using PFS were compared with vial users, overall and stratified by their administration method (pump or manual push). RESULTS Of the 132 total respondents, 66 respondents used vials, with 38 using a pump and 28 using manual push. PFS (5 and 10 mL sizes) were being used by 120 respondents, with 38 using a pump and 82 using manual push. PFS users were associated with a 17% lower median (interquartile range) SCIg dose (10 [8, 12] vs. 12 [9, 16] g/week, respectively), a significantly shorter infusion preparation time (15 [10, 20] vs. 15 [10, 30] mins, respectively), and a trend for shorter length of infusion (60 [35, 90] vs. 70 [48, 90] mins, respectively) compared with those on vials. Patient-reported treatment satisfaction scores were overall similar between vial and PFS users (including on the domains of effectiveness and convenience), except for a higher score for vials over PFS on the domain of global satisfaction (p=0.02). CONCLUSIONS Consistent with prescribing that reflects a recognition of less wastage, PFS users were associated with a significantly lower SCIg dose compared with vial users. PFS users were also associated with shorter pre-infusion times, reflecting simpler administration mechanics compared with vial users. Higher global satisfaction with treatment among vial users compared with PFS users was consistent with users being limited to smaller PFS size options in Canada during the study period. Patient experience on PFS is expected to improve with the introduction of larger PFS sizes. Overall, treatment satisfaction for SCIg remains consistently high with the introduction of PFS packaging compared with vials.
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Affiliation(s)
- R Mallick
- CSL Behring, King of Prussia, PA, USA.
| | - G Solomon
- Association des Patients Immunodeficients du Québec, Québec, Canada
| | - P Bassett
- Meridian HealthComms Ltd, Manchester, UK
| | - X Zhang
- CSL Behring, King of Prussia, PA, USA
| | - P Patel
- Formerly of CSL Behring, King of Prussia, PA, USA
| | - O Lepeshkina
- Centre hospitalier de l'Université Laval, Québec, Canada
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Papanastasiou G, Yang G, Fotiadis DI, Dikaios N, Wang C, Huda A, Sobolevsky L, Raasch J, Perez E, Sidhu G, Palumbo D. Large-scale deep learning analysis to identify adult patients at risk for combined and common variable immunodeficiencies. COMMUNICATIONS MEDICINE 2023; 3:189. [PMID: 38123736 PMCID: PMC10733406 DOI: 10.1038/s43856-023-00412-8] [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: 02/17/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Primary immunodeficiency (PI) is a group of heterogeneous disorders resulting from immune system defects. Over 70% of PI is undiagnosed, leading to increased mortality, co-morbidity and healthcare costs. Among PI disorders, combined immunodeficiencies (CID) are characterized by complex immune defects. Common variable immunodeficiency (CVID) is among the most common types of PI. In light of available treatments, it is critical to identify adult patients at risk for CID and CVID, before the development of serious morbidity and mortality. METHODS We developed a deep learning-based method (named "TabMLPNet") to analyze clinical history from nationally representative medical claims from electronic health records (Optum® data, covering all US), evaluated in the setting of identifying CID/CVID in adults. Further, we revealed the most important CID/CVID-associated antecedent phenotype combinations. Four large cohorts were generated: a total of 47,660 PI cases and (1:1 matched) controls. RESULTS The sensitivity/specificity of TabMLPNet modeling ranges from 0.82-0.88/0.82-0.85 across cohorts. Distinctive combinations of antecedent phenotypes associated with CID/CVID are identified, consisting of respiratory infections/conditions, genetic anomalies, cardiac defects, autoimmune diseases, blood disorders and malignancies, which can possibly be useful to systematize the identification of CID and CVID. CONCLUSIONS We demonstrated an accurate method in terms of CID and CVID detection evaluated on large-scale medical claims data. Our predictive scheme can potentially lead to the development of new clinical insights and expanded guidelines for identification of adult patients at risk for CID and CVID as well as be used to improve patient outcomes on population level.
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Affiliation(s)
| | - Guang Yang
- National Heart and Lung Institute, Imperial College London, London, UK
- Cardiovascular Research Centre, Royal Brompton Hospital, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Dimitris I Fotiadis
- Department of Biomedical Research, Institute of Molecular Biology and Biotechnology, FORTH, Ioannina, Greece
- Unit of Medical Technology and Intelligent Information Systems, University of Ioannina, Ioannina, Greece
| | | | - Chengjia Wang
- School of Mathematical and Computer Sciences, Heriot Watt, Edinburgh, UK
- Edinburgh Centre for Robotics, Edinburgh, UK
| | | | | | | | - Elena Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, FL, USA
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Layton JB, Ritchey ME, Huang Z, Chavan S, Ay H, Souayah N, Anderson-Smits C. Intravenous Immunoglobulin Initiation in Patients with Chronic Inflammatory Demyelinating Polyradiculoneuropathy: A US Claims-based Cohort Study. Neurol Ther 2023; 12:1171-1186. [PMID: 37195408 PMCID: PMC10310640 DOI: 10.1007/s40120-023-00479-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/05/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Intravenous immunoglobulin (IVIG) is recommended as first-line therapy for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), an immune-mediated neuropathy. The clinical profile of patients with CIDP newly initiating IVIG is poorly characterized. This claims-based cohort study describes characteristics of US patients with CIDP initiating IVIG treatment. METHODS Adult immunoglobulin (IG)-naïve patients with CIDP diagnosed between 2008 and 2018 and a subgroup of patients subsequently initiating IVIG were identified in the Merative MarketScan Research Databases. Demographics, clinical characteristics, and diagnostic procedures were described for patients initiating IVIG. RESULTS Of 32,090 patients with CIDP identified, 3975 (mean age 57 years) subsequently initiated IVIG. In the 6 months prior to IVIG initiation, diagnoses of comorbidities including neuropathy (75%), hypertension (62%), and diabetes (33%) were frequent, as were CIDP features/symptoms/markers of functional status including chronic pain (80%), difficulty walking (30%), and weakness (30%). CIDP-related laboratory/diagnostic procedures were performed in approximately 20- > 40% of patients in the 3 months prior to IVIG initiation (63.7% underwent electrodiagnostic/nerve conduction testing in the 6 months prior to IVIG initiation). Patient characteristics by initial IVIG product differed only in IVIG initiation year, US geographic region, and insurance type. Comorbidities, CIDP severity or functional status markers, and other clinical variables were generally well balanced across initial IVIG product groups. CONCLUSION A heavy burden of symptoms, comorbidities, and diagnostic testing exists in patients with CIDP initiating IVIG. Characteristics of patients with CIDP initiating different IVIG products are well balanced, suggesting an absence of clinical or demographic determinants underlying IVIG selection.
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Affiliation(s)
| | - Mary E Ritchey
- RTI Health Solutions, Research Triangle Park, NC, USA
- Center for Pharmacoepidemiology and Treatment Sciences, Rutgers University, New Brunswick, NJ, USA
| | - Zhongwen Huang
- Takeda Development Center Americas, Inc., 650 E. Kendall St., Cambridge, MA, 02142, USA
| | - Shailesh Chavan
- Takeda Development Center Americas, Inc., 650 E. Kendall St., Cambridge, MA, 02142, USA
| | - Hakan Ay
- Takeda Development Center Americas, Inc., 650 E. Kendall St., Cambridge, MA, 02142, USA
| | - Nizar Souayah
- Department of Neurology, Rutgers University, Newark, NJ, USA
| | - Colin Anderson-Smits
- Takeda Development Center Americas, Inc., 650 E. Kendall St., Cambridge, MA, 02142, USA.
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Vanselow S, Wahn V, Schuetz C. Activated PI3Kδ syndrome - reviewing challenges in diagnosis and treatment. Front Immunol 2023; 14:1208567. [PMID: 37600808 PMCID: PMC10432830 DOI: 10.3389/fimmu.2023.1208567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/04/2023] [Indexed: 08/22/2023] Open
Abstract
Activated PI3Kδ syndrome (APDS) is a rare inborn error of immunity (IEI) characterized primarily by frequent infections, lymphoproliferation and autoimmunity. Since its initial description in 2013, APDS has become part of the growing group of nearly 500 IEIs affecting various components of the immune system. The two subtypes of APDS - APDS1 and APDS2 - are caused by variants in the PIK3CD and PIK3R1 genes, respectively. Due to the rarity of the disease and the heterogeneous clinical picture, many patients are not diagnosed until years after symptom onset. Another challenge is the large number of PIK3CD and PIK3R1 variants whose functional significance for developing APDS is inconclusive. Treatment of APDS has so far been mostly symptom-oriented with immunoglobulin replacement therapy, immunosuppressive therapies and antibiotic or antiviral prophylaxes. Additionally, allogeneic stem cell transplantation as well as new targeted therapies are options targeting the root cause that may improve patients' quality of life and life expectancy. However, the clinical course of the disease is difficult to predict which complicates the choice of appropriate therapies. This review article discusses diagnostic procedures and current and future treatment options, and highlights the difficulties that physicians, patients and their caretakers face in managing this complex disease. This article is based on cohort studies, the German and US guidelines on the management of primary immunodeficiencies as well as on published experience with diagnosis and compiled treatment experience for APDS.
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Affiliation(s)
- Sven Vanselow
- Infill Healthcare Communication, Königswinter, Germany
| | - Volker Wahn
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine at Charité University Hospital Berlin, Berlin, Germany
| | - Catharina Schuetz
- Medical Faculty of The Technical University (TU) Dresden, Department of Pediatrics, University Hospital Carl Gustav Carus, Dresden, Germany
- University Center for Rare Diseases, University Hospital Carl Gustav Carus, Dresden, Germany
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Ažukaitis K, Puronaitė R, Vaitkevičienė GE, Trinkūnas J, Jankauskienė A, Jankauskienė D. Integrated Collection of Patient-Reported Outcomes and Experiences in Children with Kidney and Hematological Diseases: A Pilot Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1245. [PMID: 37508742 PMCID: PMC10377830 DOI: 10.3390/children10071245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023]
Abstract
We aimed to explore the feasibility and potential relevance of integrated electronic collection of patient-reported outcome and experience measures (PROM and PREM) in children with special healthcare needs (CSHCN) by using the example of children with kidney and hematological diseases. We performed a cross-sectional, single-center study of children <18 years of age. Children (≥10 years) and their parents received Generic PedsQL Core Scale 4.0 and custom PREM surveys to their email addresses via the REDCap platform, and the results were integrated into the hospital's electronic health records system. A total of 192 patients (98 with kidney diseases and 94 with hematological diseases) were enrolled. The overall response rate was 51%, and the median time for completion of each proxy questionnaire was approximately three minutes. The lowest PROM scores were observed in the emotional and school functioning dimensions. More favorable experiences in the diagnosis establishment process were associated with higher scores in physical, social, school functioning, and total PROM scores. A better evaluation of the hospital's environment was associated with higher social functioning, while better information provision correlated with higher physical functioning and total PROM scores. Our data indicates that integrated electronic collection of PROMs and PREMs in the population of CSHCN is feasible, but efforts to increase the response rate are needed. The associations between PROMs and PREMs suggest that future studies exploring targeted interventions at the healthcare service level to improve subjective patient outcomes are needed.
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Affiliation(s)
- Karolis Ažukaitis
- Clinic of Pediatrics, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
| | - Roma Puronaitė
- Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
| | - Goda Elizabeta Vaitkevičienė
- Clinic of Pediatrics, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
| | - Justas Trinkūnas
- Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
- Faculty of Fundamental Sciences, Vilnius Gediminas Technical University, 10223 Vilnius, Lithuania
| | - Augustina Jankauskienė
- Clinic of Pediatrics, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
- Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania
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Dorsey MJ, Condino-Neto A. Improving Access to Therapy for Patients With Inborn Errors of Immunity: A Call to Action. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1698-1702. [PMID: 37119982 DOI: 10.1016/j.jaip.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/01/2023]
Abstract
Breakthroughs in sequencing technology, targeted immunotherapy, and immune reconstituting treatment have increased the pool of patients with inborn errors of immunity, requiring expertise from clinical immunologists. A growing category of immunodeficiency, presenting as primary immune regulatory disorder and secondary immunodeficiency due to targeted immune therapy for cancer and autoimmunity, has added to the growing burden of patients needing access to immune-supportive therapy. The confluence of a growing population of patients needing a clinical immunologist, complex payer structures, and inadequate health care representation will exacerbate current problems with access to therapy. Patients, health care providers, researchers, public and private payers, and industry must come together to find solutions to improve access to therapy. In this article, we reviewed the major topics regarding access to therapy for patients with immunodeficiency.
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Affiliation(s)
- Morna J Dorsey
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, Calif
| | - Antonio Condino-Neto
- Department of Immunology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil.
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Md Nawawi NH, Abdul Kadir A, Mat Yudin Z. Primary immunodeficiency disease in children: A significant but rare cause of failure to thrive. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/13001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
This case illustrates the rare cause of failure to thrive (FTT) that initially presented with recurrent ear discharge. A five-year-old boy with a history of recurrent ear infections for the past year was treated for acute symptoms during each visit. He later was diagnosed with acute mastoiditis secondary to otitis media by a private otorhinolaryngologist and was referred to a tertiary hospital for admission and parenteral antibiotic commencement. The anthropometric evaluation noted he fell under the group of FTT and had an incidental finding of lower tract respiratory infection that turned out to be tuberculosis infection. Multiple complications occurred during his admission, including candidemia, disseminated tuberculosis, and deep-seated collections. Hence, he was worked up for primary immunodeficiency and was given extensive supportive treatment.
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Affiliation(s)
- Noorfaizahtul Hanim Md Nawawi
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, MALAYSIA
- Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, Kelantan, MALAYSIA
| | - Azidah Abdul Kadir
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, MALAYSIA
- Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, Kelantan, MALAYSIA
| | - Zainab Mat Yudin
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, MALAYSIA
- Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, Kelantan, MALAYSIA
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De Almeida BI, Smith TL, Delic A, Esquibel L, Galli J, Millsap L, Paz Soldán MM, Cortez MM, Rose J, Greenlee JE, Gundlapalli AV, Hill HR, Wong KH, Clardy SL. Neurologic Manifestations of Common Variable Immunodeficiency: Impact on Quality of Life. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/3/e200088. [PMID: 36797058 PMCID: PMC9936420 DOI: 10.1212/nxi.0000000000200088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/01/2022] [Indexed: 02/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Common variable immunodeficiency is a systemic disease and not solely a disease of humoral immunity. Neurologic symptoms associated with common variable immunodeficiency are underrecognized and warrant further study. This work aimed to characterize the neurologic symptoms reported by people living with common variable immunodeficiency. METHODS We conducted a single academic medical center study of neurologic symptoms reported by adults previously diagnosed with common variable immunodeficiency. We used a survey of common neurologic symptoms to determine the prevalence of these symptoms in a population with common variable immunodeficiency and further assessed these patient-reported symptoms with validated questionnaires and compared symptom burden with other neurologic conditions. RESULTS A volunteer sample of adults (aged 18 years or older) previously diagnosed with common variable immunodeficiency at the University of Utah Clinical Immunology/Immune Deficiency Clinic who were able to read and comprehend English and willing and able to answer survey-based questions were recruited. Of 148 eligible participants identified, 80 responded and 78 completed the surveys. The mean age of respondents was 51.3 years (range 20-78 years); 73.1% female and 94.8% White. Patients with common variable immunodeficiency reported many common neurologic symptoms (mean 14.6, SD 5.9, range 1-25), with sleep issues, fatigue, and headache reported by more than 85%. Validated questionnaires addressing specific neurologic symptoms supported these results. T-scores on Neuro QoL questionnaires for sleep (mean 56.4, SD 10.4) and fatigue (mean 54.1, SD 11) were higher, indicating more dysfunction, than in the reference clinical population (p < 0.005). The Neuro QoL questionnaire for cognitive function showed a lower T-score (mean 44.8, SD 11.1) than that in the reference general population (p < 0.005), indicating worse function in this domain. DISCUSSION Among survey respondents, there is a marked burden of neurologic symptoms. Given the impact of neurologic symptoms on health-related quality-of-life measures, clinicians should screen patients with common variable immunodeficiency for the presence of these symptoms and offer referral to neurologists and/or symptomatic treatment when indicated. Frequently prescribed neurologic medications may also affect the immune system, and neurologists should consider screening patients for immune deficiency before prescribing them.
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Affiliation(s)
- Bruno Ivo De Almeida
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Tammy L Smith
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Alen Delic
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lawanda Esquibel
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Jonathan Galli
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Leah Millsap
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - M Mateo Paz Soldán
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Melissa M Cortez
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - John Rose
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - John E Greenlee
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Adi V Gundlapalli
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Harry R Hill
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Ka-Ho Wong
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City
| | - Stacey L Clardy
- From the Université de Bordeaux (B.I.D.A.), U de Biologie, France; Department of Neurology (B.I.D.A., T.L.S., A.D., L.E., J.G., M.M.P.S., M.M.C., J.R., J.E.G., K.-H.W., S.L.C.), University of Utah School of Medicine, Salt Lake City; George E. Wahlen Department of Veterans Affairs Medical Center (T.L.S., J.G., M.M.P.S., J.R., J.E.G., S.L.C.), Salt Lake City, UT; University of Utah School of Medicine (L.M.); Department of Internal Medicine, (A.V.G.), University of Utah School of Medicine; and Divisions of Immunology and Infectious Disease (H.R.H.), Departments of Pathology, Pediatrics and Medicine, University of Utah School of Medicine, Salt Lake City.
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A validated artificial intelligence-based pipeline for population-wide primary immunodeficiency screening. J Allergy Clin Immunol 2023; 151:272-279. [PMID: 36243223 DOI: 10.1016/j.jaci.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/21/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Identification of patients with underlying inborn errors of immunity and inherent susceptibility to infection remains challenging. The ensuing protracted diagnostic odyssey for such patients often results in greater morbidity and suboptimal outcomes, underscoring a need to develop systematic methods for improving diagnostic rates. OBJECTIVE The principal aim of this study is to build and validate a generalizable analytical pipeline for population-wide detection of infection susceptibility and risk of primary immunodeficiency. METHODS This prospective, longitudinal cohort study coupled weighted rules with a machine learning classifier for risk stratification. Claims data were analyzed from a diverse population (n = 427,110) iteratively over 30 months. Cohort outcomes were enumerated for new diagnoses, hospitalizations, and acute care visits. This study followed TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) standards. RESULTS Cohort members initially identified as high risk were proportionally more likely to receive a diagnosis of primary immunodeficiency compared to those at low-medium risk or those without claims of interest respectively (9% vs 1.5% vs 0.2%; P < .001, chi-square test). Subsequent machine learning stratification enabled an annualized individual snapshot of complexity for triaging referrals. This study's top-performing machine learning model for visit-level prediction used a single dense layer neural network architecture (area under the receiver-operator characteristic curve = 0.98; F1 score = 0.98). CONCLUSIONS A 2-step analytical pipeline can facilitate identification of individuals with primary immunodeficiency and accurately quantify clinical risk.
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Mallick R, Solomon G, Bassett P, Zhang X, Patel P, Lepeshkina O. Immunoglobulin replacement therapy in patients with immunodeficiencies: impact of infusion method on patient-reported outcomes. Allergy Asthma Clin Immunol 2022; 18:110. [PMID: 36566213 PMCID: PMC9789520 DOI: 10.1186/s13223-022-00746-3] [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] [Received: 08/24/2022] [Accepted: 11/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Understanding the impact of different immunoglobulin (Ig) infusion methods (intravenous [IVIg] and subcutaneous [SCIg]) upon treatment experience can potentially facilitate optimization of patient outcomes. Here, the perspective of patients with primary and secondary immunodeficiency diseases (PID and SID, respectively) receiving IVIg and SCIg was evaluated, in terms of treatment satisfaction, accounting for treatment history, using Association des Patients Immunodéficients du Québec (APIQ) survey data. METHODS The online APIQ survey (shared October 2020-March 2021) of patients with immunodeficiencies in Canada contained 101 questions on: Ig use, history, and detailed infusion characteristics; as well as structured patient-reported outcomes such as treatment satisfaction (via TSQM-9), symptom state (via PASS), general health perception (via GHP), and physical and mental function (via PROMIS). Adult respondents (≥ 18 years old) currently using Ig were compared by their current Ig infusion method (IVIg or SCIg cohort) overall, and in a sub-analysis, the IVIg cohort was compared with the SCIg cohort after stratification by respondents who started SCIg when naïve to Ig ('SCIg naïve') or with previous IVIg experience ('SCIg switch'). RESULTS In total, 54 respondents currently used IVIg and 242 used SCIg. The average duration per infusion of a weekly SCIg infusion was significantly shorter compared with the average duration of a 3-4 weekly IVIg infusion (p < 0.001). The SCIg cohort was associated with significantly higher scores for the TSQM-9 effectiveness domain compared with the IVIg cohort. The scores for TSQM-9 convenience and global satisfaction domains were similar in the two cohorts. The SCIg cohort was also associated with a significantly higher proportion of respondents who were in an acceptable symptom state and a lower proportion who reported very poor or poor perception of health compared with the IVIg cohort. Further, the SCIg naïve subgroup was associated with significantly higher TSQM-9 effectiveness and convenience domain scores compared with the IVIg cohort, while there was no significant difference between the SCIg switch subgroup and the IVIg cohort in terms of convenience. CONCLUSIONS A better understanding of how different IgRT administration methods impact treatment experience and satisfaction may assist with informed treatment decision making and ultimately further improvements in patient outcomes.
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Affiliation(s)
- Rajiv Mallick
- grid.428413.80000 0004 0524 3511CSL Behring, King of Prussia, PA USA
| | | | | | - Xiang Zhang
- grid.428413.80000 0004 0524 3511CSL Behring, King of Prussia, PA USA
| | - Palak Patel
- grid.428413.80000 0004 0524 3511Formerly of CSL Behring, King of Prussia, PA USA
| | - Oleksandra Lepeshkina
- grid.411065.70000 0001 0013 6651Centre Hospitalier de l’Université Laval, Québec, Canada
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Mauracher AA, Henrickson SE. Leveraging Systems Immunology to Optimize Diagnosis and Treatment of Inborn Errors of Immunity. FRONTIERS IN SYSTEMS BIOLOGY 2022; 2:910243. [PMID: 37670772 PMCID: PMC10477056 DOI: 10.3389/fsysb.2022.910243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Inborn errors of immunity (IEI) are monogenic disorders that can cause diverse symptoms, including recurrent infections, autoimmunity and malignancy. While many factors have contributed, the increased availability of next-generation sequencing has been central in the remarkable increase in identification of novel monogenic IEI over the past years. Throughout this phase of disease discovery, it has also become evident that a given gene variant does not always yield a consistent phenotype, while variants in seemingly disparate genes can lead to similar clinical presentations. Thus, it is increasingly clear that the clinical phenotype of an IEI patient is not defined by genetics alone, but is also impacted by a myriad of factors. Accordingly, we need methods to amplify our current diagnostic algorithms to better understand mechanisms underlying the variability in our patients and to optimize treatment. In this review, we will explore how systems immunology can contribute to optimizing both diagnosis and treatment of IEI patients by focusing on identifying and quantifying key dysregulated pathways. To improve mechanistic understanding in IEI we must deeply evaluate our rare IEI patients using multimodal strategies, allowing both the quantification of altered immune cell subsets and their functional evaluation. By studying representative controls and patients, we can identify causative pathways underlying immune cell dysfunction and move towards functional diagnosis. Attaining this deeper understanding of IEI will require a stepwise strategy. First, we need to broadly apply these methods to IEI patients to identify patterns of dysfunction. Next, using multimodal data analysis, we can identify key dysregulated pathways. Then, we must develop a core group of simple, effective functional tests that target those pathways to increase efficiency of initial diagnostic investigations, provide evidence for therapeutic selection and contribute to the mechanistic evaluation of genetic results. This core group of simple, effective functional tests, targeting key pathways, can then be equitably provided to our rare patients. Systems biology is thus poised to reframe IEI diagnosis and therapy, fostering research today that will provide streamlined diagnosis and treatment choices for our rare and complex patients in the future, as well as providing a better understanding of basic immunology.
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Affiliation(s)
- Andrea A. Mauracher
- Division of Allergy and Immunology, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarah E. Henrickson
- Division of Allergy and Immunology, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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