Primary Immunodeficiency and the Gut

Dietary intakes and nutritional issues in inborn errors of immunity: a systematic review

Introduction

Inborn errors of immunity (IEI) are characterized by an inherited dysregulation or absence of immune system components that can manifest clinically in complications that predispose an individual to feeding difficulties or impaired swallowing, digestion, and absorption. Treatment side-effects or altered requirements may further impair nutritional status. While adequate nutrition is necessary for optimal growth and immune function, little is known about nutritional intakes in IEI, and best practice nutrition guidelines are limited. This review aimed to synthesize current evidence on the dietary intakes, anthropometry and nutritional biochemistry in individuals with an IEI.

Methods

A systematic review of literature published from database inception to March 2023 was conducted in accordance with the PRISMA guidelines. Articles eligible for inclusion reported anthropometric, biochemical, or dietary intake-related measures in pediatric or adult patients with a diagnosed IEI. Identified articles were screened for eligibility; data was synthesized descriptively.

Results

A total of 4488 studies were retrieved of which 34 were included. Across studies, 2894 IEI individuals were included (age range 4 weeks to 83y), predominantly focusing on ataxia telangiectasia (AT) and common variable immunodeficiency (CVID). A significant association between inadequate energy intakes and IEI was identified (n=6 studies); however, there was significant variability in adequacy of macro- and micronutrients across studies. Patients with IEI were at risk of malnutrition (range 30% to 70%); although anthropometric assessment measures were not consistent across studies. Biochemical assessments found patients were also at risk of micronutrient deficiencies including vitamin D.

Discussion

This review identified few studies assessing dietary intakes, anthropometry and nutritional biochemistry in patients with IEI, with considerable heterogeneity across studies. Future longitudinal studies using consistent validated dietary assessment tools and anthropometric measures in diverse IEI patient populations are needed. This review reinforces the need for dietetic input in people with an IEI and the development evidence-based clinical practice guidelines for people with an IEI.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023412365.

Gastrointestinal system involvement in patients with primary immunodeficiency: a single center experience

AIM

Primary immunodeficiencies (PIDs) are a heterogeneous disorder group characterized by an impaired immune system, leading to an increased susceptibility to infections and a wide range of clinical manifestations, including gastrointestinal (GI) complications. This study aimed to assess the GI manifestations of PID patients and highlight the significance of atypical gastrointestinal symptoms in the early diagnosis of these patients.

METHODS

A retrospective analysis was conducted on pediatric patients diagnosed with PIDs at Selcuk University Medical Faculty from 2011 to 2021. The study focused on demographic data, clinical presentation, genetic mutations, and GI manifestations, including endoscopic evaluation. Patients were categorized according to the International Union of Immunological Societies (IUIS) PID classifications. Statistical analyses were performed to identify significant associations between PID types and GI manifestations.

RESULTS

The cohort comprised 101 patients, with 46% presenting with GI symptoms, including malnutrition and chronic diarrhea, as the most common findings. Primary antibody deficiency (PAD) emerged as the most prevalent PID with GI involvement, followed by combined immunodeficiencies (CID) with associated or syndromic features. Endoscopic evaluations revealed inflammatory bowel disease (IBD)-like colitis in a significant subgroup of patients. The analysis showed that some GI symptoms were more common in specific PID categories, highlighting the importance of early gastroenterological assessment in PID patients.

CONCLUSION

Recognition of common GI symptoms in pediatric patients with PIDs may facilitate early diagnosis and prompt multidisciplinary management, potentially improving patient outcomes. The study highlights the necessity of considering PIDs in diagnosing persistent or severe GI symptoms in children.

Primary Immunodeficiencies in Children Initially Admitted with Gastrointestinal/Liver Manifestations

Purpose

The gastrointestinal system is the most commonly affected organ, followed by the lungs, in patients with primary immunodeficiency disease (PID). Hence, it is common for children with PIDs to present with gastrointestinal symptoms. We aimed to analyze the clinical and histopathological findings of patients who were initially admitted to pediatric gastroenterology/hepatology clinics and subsequently diagnosed with PIDs to identify the clinical clues for PIDs.

Methods

The demographic, laboratory, and histopathological findings, treatment modality, and outcomes of patients initially admitted to the pediatric gastroenterology/hepatology unit and subsequently diagnosed with PIDs were recorded.

Results

The study included 24 patients (58.3% male; median age [range]: 29 [0.5-204] months). Common clinical presentations included chronic diarrhea (n=8), colitis (n=6), acute hepatitis (n=4), and acute liver failure (n=2). The association of autoimmune diseases, development of malignant diseases, and severe progression of viral diseases was observed in 20.8%, 8.3%, and 16.6% of the patients, respectively. Antibody deficiency was predominantly diagnosed in 29.2% of patients, combined immunodeficiency in 20.8%, immune dysregulation in 12.5%, defects in intrinsic and innate immunity in 4.2%, autoinflammatory disorders in 8.3%, and congenital defects of phagocytes in 4.2%. Five patients remained unclassified (20.8%).

Conclusion

Patients with PIDs may initially experience gastrointestinal or liver problems. It is recommended that the association of autoimmune or malignant diseases or severe progression of viral diseases provide pediatric gastroenterologists some suspicion of PIDs. After screening using basic laboratory tests, genetic analysis is mandatory for a definitive diagnosis.

Nutritional status and prognosis in children with immunodeficiencies undergoing hematopoietic stem cell transplantation

BACKGROUND

Primary immunodeficiencies (PID) are diseases resulting from genetic dysfunctions in the immune system, which can result in recurrent infections, autoimmunity and even malignancy. It is estimated that approximately one-third of the PID described have gastrointestinal components or symptoms involved and may present an increased risk of weight loss and failure to thrive. It is also known that, in patients with other diagnoses, malnutrition may be associated with worse outcomes after hematopoietic stem cell transplantation (HSCT).

OBJECTIVE

to characterize the nutritional status of pediatric patients with PID at the time of admission for HSCT and to establish the relationship between baseline nutritional status measures and post-HSCT clinical outcomes.

METHODS

a retrospective analytical observational study, based on data from pediatric patients, of both sexes and all ethnicities, with PID, submitted to HSCT in the period from 2004 to 2019. The risk factors analyzed were the Z-scores of weights for age (W/A), height for age (H/A), BMI for age (BMI/A) and Sum score, obtained by through the sum of the W/A and H/A scores. The primary outcomes were overall survival at 6 months, occurrence of acute Graft Versus Host Disease (aGVHD) at 6 months, and occurrence of chronic Graft Versus Host Disease (cGVHD) at 1 year. Secondary outcomes were occurrence and degree of mucositis, length of stay, and total number of infectious episodes. As statistical analysis, the ANOVA model, the Tukey test, ROC curves and Kaplan Meier and Log-Rank analysis were used. Multivariate survival and logistic regression models were also performed.

RESULTS

The study showed important indicators of malnutrition in patients with PID, especially those diagnosed with Severe Combined Immunodeficiency Syndrome (SCID) and Hemophagocytic Syndromes (HS). Among those with SCID, 60% had low or very low weight for their age, 52% had low or very short stature for their age, and 44% were classified as being thin or very thin. Among patients with HS, 75% had short or very short stature for their age. Multivariate analysis only demonstrated association between W/A score with extensive cGVHD, controlling for diagnosis, compatibility, conditioning and immunoprophylaxis. Lower W/A values were associated with higher occurrences of these events. Although W/A was only associated with cGVHD and H/A had no association with chronic or acute GVHD, when Sum scores were used, the lower values the higher rates of severe aGVHD and total cGVHD according to multivariate controlled models for diagnosis, compatibility, conditioning and immunoprophylaxis.

CONCLUSIONS

Our study characterized the nutritional status of children with PID undergoing HSCT and found alarming rates of underweight and short stature in patients with SCID and HS. We also demonstrated a relationship between anthropometric parameters and outcomes such as mortality, the occurrence of GVHD and severe mucositis after HSCT. In this sense, W/A and Sum score measures would be good prognostic methods for these outcomes. Henceforth, prospective studies are needed to confirm these findings and establish new nutritional assessment criteria for this population.

Multisystem Autoimmune Inflammatory Disease, Including Colitis, Due to Inborn Error of Immunity

Our understanding of inflammatory bowel disease is changing as we identify genetic variants associated with immune dysregulation. Inflammatory bowel disease undetermined, even when diagnosed in older children and adolescents, in the setting of multiple inflammatory and infectious diseases should raise the suspicion of complex immune dysregulation with a monogenic basis. We report a case of inflammatory bowel disease undetermined triggered by exposure to a nonsteroidal antiinflammatory drug in a 16-year-old girl with a background history of juvenile idiopathic arthritis, cytopenias, recurrent respiratory tract and middle ear infections, and esophageal candidiasis. Immunologic assessment included measurement of immunoglobulin levels, lymphocyte immunophenotyping, B-cell functional tests, and whole-exome sequencing. Laboratory investigation revealed defects of humoral immunity, including mild persistent hypogammaglobulinemia affecting all 3 isotypes and absent isohemagglutinins. Whole exome sequencing revealed a heterozygous TNFRSF13B (Tumor Necrosis Factor Receptor Superfamily Member 13B, or Transmembrane Activator and Calcium-modulating cyclophilin ligand Interactor, TACI) gene variant, which is associated with common variable immunodeficiency and the development of autoimmune diseases. In conclusion, a clinical history of recurrent infections, atypical histologic features of inflammatory bowel disease, additional autoimmune manifestations, and an inadequate response to conventional therapy should prompt the physician to refer to an immunologist with the query of inborn error of immunity. We report how extensive immune evaluation and genetic diagnosis can individualize care and facilitate a multidisciplinary team approach.

Needs for Increased Awareness of Gastrointestinal Manifestations in Patients With Human Inborn Errors of Immunity

The gastrointestinal (GI) tract is frequently affected by inborn errors of immunity (IEI), and GI manifestations can be present in IEI patients before a diagnosis is confirmed. We aimed to investigate clinical features, endoscopic and histopathologic findings in IEI patients. This was a retrospective cohort study conducted from 1995 to 2020. Eligible patients were diagnosed with IEI and had GI manifestations that were enough to require endoscopies. IEI was classified according to the International Union of Immunological Societies classification. Of 165 patients with IEI, 55 (33.3%) had GI manifestations, and 19 (11.5%) underwent endoscopy. Among those 19 patients, nine (47.4%) initially presented with GI manifestations. Thirteen patients (68.4%) were male, and the mean age of patients 11.5 ± 7.9 years (range, 0.6 – 26.6) when they were consulted and evaluated with endoscopy. The most common type of IEI with severe GI symptoms was “Disease of immune dysregulation” (31.6%) followed by “Phagocyte defects” (26.3%), according to the International Union of Immunological Societies classification criteria. Patients had variable GI symptoms such as chronic diarrhea (68.4%), hematochezia (36.8%), abdominal pain (31.6%), perianal disease (10.5%), and recurrent oral ulcers (10.5%). During the follow-up period, three patients developed GI tract neoplasms (early gastric carcinoma, mucosa associated lymphoid tissue lymphoma of colon, and colonic tubular adenoma, 15.8%), and 12 patients (63.2%) were diagnosed with inflammatory bowel disease (IBD)-like colitis. Investigating immunodeficiency in patients with atypical GI symptoms can provide an opportunity for correct diagnosis and appropriate disease-specific therapy. Gastroenterologists and immunologists should consider endoscopy when atypical GI manifestations appear in IEI patients to determine if IBD-like colitis or neoplasms including premalignant and malignant lesions have developed. Also, if physicians in various fields are better educated about IEI-specific complications, early diagnosis and disease-specific treatment for IEI will be made possible.

Selenium-related nutritional status in patients with common variable immunodeficiency: association with oxidative stress and atherosclerosis risk

Background

Common variable immunodeficiency (CVID) is an inborn errors of immunity, that leads to recurrent chronic infections and autoimmune/ inflammatory diseases and neoplasms. It is considered that these condition is related to persistent this immune-inflammatory stimulation and increased oxidative stress. A positive impact on the survival of patients with an inborn error of immunity was observed with advanced clinical care protocols, thus raising concerns about the risk of developing other associated chronic diseases, such as atherosclerosis. Studies suggest that selenium (Se) is a protective trace element against damage caused by oxidative stress. Thus, it is postulated that adequate consumption reduces the risk of some chronic diseases.

Results

Se median levels (ug/L) [45.6 (37.3–56.2) vs. 57.8 (46.0–66.0); p = 0.004] and GPX activity (U/L) [7682 (6548–8446) vs. 9284(8440–10,720); p = 0,002) were significantly lower in patients compared to controls. Inadequacy of Se levels was observed in 50% of the patients. There was a higher percentage of high values of C-reactive protein in the group of CVID patients compared to controls [8 (36.4%) vs. 2 (11.1%); p = 0.082]. Higher concentrations of oxidized LDL (45.3 mg/dL vs. 33.3 mg/dL; p = 0.016) and lower concentrations of Apo A-1 (98.5 mg/dL) vs. 117.0 mg/dL; p = 0.008) were observed in the CVID group compared to the control. There was a significant and positive correlation between Se plasma levels and apolipoprotein A-1 concentrations in CVID group (rho = 0.577; p = 0.001). Se values less than 46 μg / L (OR = 3.590; 95% CI 1.103 to 11.687; p = 0.034) and GPX activity below the 4th quartile (OR = 21.703; 95% CI 2.534 to 185.914; p = 0.005) were independently associated, after adjustment for age, overweight and dyslipidemia, with the CVID group (Table 5).

Conclusion

This study showed an higher percentage of high us-CRP, lower values of plasma Se and GPX activity, higher concentrations of LDLox and lower levels of Apo A-1 in CVID patients in comparison to controls, suggesting oxidative stress and cardiovascular risk.These data point to the importance of assessing the Se status and cardiovascular risk in these patients.

Failure of immunological competence: when to suspect?

OBJECTIVES

To draw physicians' attention to the different warning signs of diseases of inborn errors of immunity.

DATA SOURCES

A non-systematic review of the literature was carried out in the PubMed, LILACS, and SciELO databases, in addition to consultation of reference textbooks.

SUMMARY OF THE FINDINGS

It is known that the lack of immunological competence observed in patients with inborn errors of immunity diseases causes particularly serious and/or recurrent infections. However, manifestations related to autoimmunity, inflammation, allergies, and malignancy can also occur. Aiming at the early identification of these patients, a list of warning signs for inborn errors of immunity was created, in which the need for intravenous antibiotics or prolonged antibiotics use to control infection, failure to thrive, and positive family history for this group of diseases are considered the most sensitive. Regarding non-infectious manifestations, early onset, difficulty in controlling with the usual treatments, atypical presentations or association with other warning signs are noteworthy, and investigation for inborn errors of immunity in these situations is recommended.

CONCLUSIONS

This article highlights the importance of considering this group of diseases even in the face of patients with non-infectious manifestations. Disclosure of inborn errors of immunity diseases, especially to non-specialists, is essential for early diagnosis and, consequently, for the reduction of these patients' morbidity and mortality.

Primary Humoral Immune Deficiencies: Overlooked Mimickers of Chronic Immune-Mediated Gastrointestinal Diseases in Adults

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.

Diagnosis of primary immunodeficiency diseases in the developing world: the need for education and networking with the developed world

PURPOSE OF REVIEW

Even with the evident improvement in knowledge about clinical and molecular aspects and the technology used to diagnose primary immunodeficiency diseases (PIDs), there is still a significant delay in recognition of these diseases in the developing world, specifically in Latin America. In this review, the goal is to outline the challenges that need to overcome for the diagnosis of PIDs and the optimization of resources available based on our experience.

RECENT FINDINGS

We describe the advances achieved in the past decade in Latin America in terms of recognition of PIDs, as well as the need for improvement. We outline the need for continued medical education, the lack of resources for laboratory testing, and how genetic testing through next-generation sequencing (that is becoming a day-to-day tool) can be achieved in the developing world.

SUMMARY

We aim to gather information about the limitations and challenges for the diagnosis of PIDs in a low-resource environment and the opportunities to benefit from the available advanced tools for diagnosis.