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Yakici N, Kreins AY, Catak MC, Babayeva R, Erman B, Kenney H, Gungor HE, Cea PA, Kawai T, Bosticardo M, Delmonte OM, Adams S, Fan YT, Pala F, Turkyilmaz A, Howley E, Worth A, Kot H, Sefer AP, Kara A, Bulutoglu A, Bilgic-Eltan S, Altunbas MY, Bayram Catak F, Karakus IS, Karatay E, Tekeoglu SD, Eser M, Albayrak D, Citli S, Kiykim A, Karakoc-Aydiner E, Ozen A, Ghosh S, Gohlke H, Orhan F, Notarangelo LD, Davies EG, Baris S. Expanding the clinical and immunological phenotypes of PAX1-deficient SCID and CID patients. Clin Immunol 2023; 255:109757. [PMID: 37689091 PMCID: PMC10958138 DOI: 10.1016/j.clim.2023.109757] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/13/2023] [Accepted: 09/02/2023] [Indexed: 09/11/2023]
Abstract
Paired box 1 (PAX1) deficiency has been reported in a small number of patients diagnosed with otofaciocervical syndrome type 2 (OFCS2). We described six new patients who demonstrated variable clinical penetrance. Reduced transcriptional activity of pathogenic variants confirmed partial or complete PAX1 deficiency. Thymic aplasia and hypoplasia were associated with impaired T cell immunity. Corrective treatment was required in 4/6 patients. Hematopoietic stem cell transplantation resulted in poor immune reconstitution with absent naïve T cells, contrasting with the superior recovery of T cell immunity after thymus transplantation. Normal ex vivo differentiation of PAX1-deficient CD34+ cells into mature T cells demonstrated the absence of a hematopoietic cell-intrinsic defect. New overlapping features with DiGeorge syndrome included primary hypoparathyroidism (n = 5) and congenital heart defects (n = 2), in line with PAX1 expression during early embryogenesis. Our results highlight new features of PAX1 deficiency, which are relevant to improving early diagnosis and identifying patients requiring corrective treatment.
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Affiliation(s)
- Nalan Yakici
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Alexandra Y Kreins
- Great Ormond Street Institute of Child Health, Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, United Kingdom; Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
| | - Mehmet Cihangir Catak
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Royala Babayeva
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Baran Erman
- Institute of Child Health, Hacettepe University, Ankara, Turkey; Can Sucak, Research Laboratory for Translational Immunology, Center for Genomics and Rare Diseases, Hacettepe University, Ankara, Turkey
| | - Heather Kenney
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Hatice Eke Gungor
- Division of Pediatric Allergy and Immunology, Erciyes City Hospital, Turkey
| | - Pablo A Cea
- Institute for Pharmaceutical and Medicinal Chemistry, Heinrich Heine University, Düsseldorf, Germany
| | - Tomoki Kawai
- Shizuoka Children's Hospital, Shizuoka, Department of Allergy and Clinical Immunology, Japan
| | - Marita Bosticardo
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Ottavia Maria Delmonte
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Stuart Adams
- SIHMDS-Haematology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Yu-Tong Fan
- Great Ormond Street Institute of Child Health, Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, United Kingdom
| | - Francesca Pala
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Ayberk Turkyilmaz
- Department of Medical Genetics, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Evey Howley
- Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Austen Worth
- Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hakan Kot
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Asena Pinar Sefer
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Altan Kara
- TUBITAK Marmara Research Center, Gene Engineering and Biotechnology Institute, Gebze, Turkey
| | - Alper Bulutoglu
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Sevgi Bilgic-Eltan
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Melek Yorgun Altunbas
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Feyza Bayram Catak
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | | | - Emrah Karatay
- Department of Radiology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Sidem Didar Tekeoglu
- Can Sucak, Research Laboratory for Translational Immunology, Center for Genomics and Rare Diseases, Hacettepe University, Ankara, Turkey; Department of Pediatric Immunology, Hacettepe University, Ankara, Turkey
| | - Metin Eser
- Department of Medical Genetics, Umraniye Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Davut Albayrak
- Department of Pediatrics, Division of Pediatric Hematology, Medicalpark Hospital, Samsun, Turkey
| | - Senol Citli
- Department of Medical Genetics, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ayca Kiykim
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Ahmet Ozen
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey
| | - Sujal Ghosh
- Department for Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich Heine University, Düsseldorf, Germany
| | - Holger Gohlke
- Institute for Pharmaceutical and Medicinal Chemistry, Heinrich Heine University, Düsseldorf, Germany; Institute of Bio- and Geosciences (IBG-4: Bioinformatics), Forschungszentrum Jülich GmbH, Jülich, Germany
| | - Fazil Orhan
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Faculty of Medicine, Karadeniz Technical University Trabzon, Turkey
| | - Luigi D Notarangelo
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - E Graham Davies
- Great Ormond Street Institute of Child Health, Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, United Kingdom; Department of Immunology and Gene therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Safa Baris
- Division of Pediatric Allergy and Immunology, School of Medicine, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul, Turkey.
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Chitty-Lopez M, Duff C, Vaughn G, Trotter J, Monforte H, Lindsay D, Haddad E, Keller MD, Oshrine BR, Leiding JW. Case Report: Unmanipulated Matched Sibling Donor Hematopoietic Cell Transplantation In TBX1 Congenital Athymia: A Lifesaving Therapeutic Approach When Facing a Systemic Viral Infection. Front Immunol 2022; 12:721917. [PMID: 35095830 PMCID: PMC8794793 DOI: 10.3389/fimmu.2021.721917] [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] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/19/2021] [Indexed: 11/13/2022] Open
Abstract
Congenital athymia can present with severe T cell lymphopenia (TCL) in the newborn period, which can be detected by decreased T cell receptor excision circles (TRECs) on newborn screening (NBS). The most common thymic stromal defect causing selective TCL is 22q11.2 deletion syndrome (22q11.2DS). T-box transcription factor 1 (TBX1), present on chromosome 22, is responsible for thymic epithelial development. Single variants in TBX1 causing haploinsufficiency cause a clinical syndrome that mimics 22q11.2DS. Definitive therapy for congenital athymia is allogeneic thymic transplantation. However, universal availability of such therapy is limited. We present a patient with early diagnosis of congenital athymia due to TBX1 haploinsufficiency. While evaluating for thymic transplantation, she developed Omenn Syndrome (OS) and life-threatening adenoviremia. Despite treatment with anti-virals and cytotoxic T lymphocytes (CTLs), life threatening adenoviremia persisted. Given the imminent need for rapid establishment of T cell immunity and viral clearance, the patient underwent an unmanipulated matched sibling donor (MSD) hematopoietic cell transplant (HCT), ultimately achieving post-thymic donor-derived engraftment, viral clearance, and immune reconstitution. This case illustrates that because of the slower immune recovery that occurs following thymus transplantation and the restricted availability of thymus transplantation globally, clinicians may consider CTL therapy and HCT to treat congenital athymia patients with severe infections.
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Affiliation(s)
- Maria Chitty-Lopez
- Division of Pediatric Allergy and Immunology, University of South Florida, Tampa, FL, United States
| | - Carla Duff
- Division of Pediatric Allergy and Immunology, University of South Florida, Tampa, FL, United States
| | - Gretchen Vaughn
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Cancer and Blood Disorders Institute at Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States
| | - Jessica Trotter
- Division of Pediatric Allergy and Immunology, University of South Florida, Tampa, FL, United States
| | - Hector Monforte
- Department of Pathology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States
| | - David Lindsay
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States
- Division of Immuno-Allergy and Rheumatology, The Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Elie Haddad
- Division of Immuno-Allergy and Rheumatology, The Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Division of Allergy and Immunology, Children’s National Hospital, Washington, DC, United States
| | - Michael D. Keller
- Division of Allergy and Immunology, Children’s National Hospital, Washington, DC, United States
| | - Benjamin R. Oshrine
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Cancer and Blood Disorders Institute at Johns Hopkins All Children’s Hospital, St. Petersburg, FL, United States
| | - Jennifer W. Leiding
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States
- Infectious Diseases and Immunology Division. Arnold Palmer Hospital for Children, Orlando, FL, United States
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Cooper MA, Zimmerman O, Nataraj R, Wynn RF. Lifelong Immune Modulation Versus Hematopoietic Cell Therapy for Inborn Errors of Immunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:628-639. [PMID: 33551038 DOI: 10.1016/j.jaip.2020.11.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
Advances in diagnosis of inborn errors of immunity (IEI) and an understanding of the molecular and immunologic mechanisms of these disorders have led to both the development of new therapies and improved approaches to hematopoietic cell transplantation (HCT). For example, monoclonal antibodies (mAbs) and small molecules, such as Janus tyrosine kinase inhibitors, that can modulate immunologic pathways have been designed for or repurposed for management of IEI. A better understanding of molecular mechanisms of IEI has led to use of drugs typically considered "immunosuppressive" to modulate the immune response, such as mammalian target of rapamycin inhibitors in disorders of phosphoinositide 3-kinase gain of function. Since the first HCT in a patient with severe combined immunodeficiency (SCID) in 1968, transplantation strategies have improved, with more than 90% probability of survival after allogeneic HCT in SCID and hence HCT is now the therapeutic standard for SCID and many other IEI. When tailoring treatment for IEI, multiple disease-specific and individual factors should be considered. In diseases such as SCID or agammaglobulinemia, the choice between HCT or medical management is straightforward. However, in many IEI, the choice between the options is challenging. This review focuses on the factors that should be taken into account in the quest for the optimal treatment for patients with IEI.
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Affiliation(s)
- Megan A Cooper
- Department of Pediatrics, Division of Rheumatology/Immunology, Washington University in St Louis, St Louis, Mo.
| | - Ofer Zimmerman
- Department of Medicine, Division of Allergy/Immunology, Washington University in St Louis, St Louis, Mo
| | - Ramya Nataraj
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Robert F Wynn
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, United Kingdom.
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4
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Kreins AY, Bonfanti P, Davies EG. Current and Future Therapeutic Approaches for Thymic Stromal Cell Defects. Front Immunol 2021; 12:655354. [PMID: 33815417 PMCID: PMC8012524 DOI: 10.3389/fimmu.2021.655354] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022] Open
Abstract
Inborn errors of thymic stromal cell development and function lead to impaired T-cell development resulting in a susceptibility to opportunistic infections and autoimmunity. In their most severe form, congenital athymia, these disorders are life-threatening if left untreated. Athymia is rare and is typically associated with complete DiGeorge syndrome, which has multiple genetic and environmental etiologies. It is also found in rare cases of T-cell lymphopenia due to Nude SCID and Otofaciocervical Syndrome type 2, or in the context of genetically undefined defects. This group of disorders cannot be corrected by hematopoietic stem cell transplantation, but upon timely recognition as thymic defects, can successfully be treated by thymus transplantation using cultured postnatal thymic tissue with the generation of naïve T-cells showing a diverse repertoire. Mortality after this treatment usually occurs before immune reconstitution and is mainly associated with infections most often acquired pre-transplantation. In this review, we will discuss the current approaches to the diagnosis and management of thymic stromal cell defects, in particular those resulting in athymia. We will discuss the impact of the expanding implementation of newborn screening for T-cell lymphopenia, in combination with next generation sequencing, as well as the role of novel diagnostic tools distinguishing between hematopoietic and thymic stromal cell defects in facilitating the early consideration for thymus transplantation of an increasing number of patients and disorders. Immune reconstitution after the current treatment is usually incomplete with relatively common inflammatory and autoimmune complications, emphasizing the importance for improving strategies for thymus replacement therapy by optimizing the current use of postnatal thymus tissue and developing new approaches using engineered thymus tissue.
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Affiliation(s)
- Alexandra Y. Kreins
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Paola Bonfanti
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Epithelial Stem Cell Biology & Regenerative Medicine Laboratory, The Francis Crick Institute, London, United Kingdom
- Institute of Immunity & Transplantation, University College London, London, United Kingdom
| | - E. Graham Davies
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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5
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Buchbinder D, Walter JE, Butte MJ, Chan WY, Chitty Lopez M, Dimitriades VR, Dorsey MJ, Nugent DJ, Puck JM, Singh J, Collins CA. When Screening for Severe Combined Immunodeficiency (SCID) with T Cell Receptor Excision Circles Is Not SCID: a Case-Based Review. J Clin Immunol 2021; 41:294-302. [PMID: 33411155 PMCID: PMC8179373 DOI: 10.1007/s10875-020-00931-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022]
Abstract
Newborn screening efforts focusing on the quantification of T cell receptor excision circles (TRECs), as a biomarker for abnormal thymic production of T cells, have allowed for the identification and definitive treatment of severe combined immunodeficiency (SCID) in asymptomatic neonates. With the adoption of TREC quantification in Guthrie cards across the USA and abroad, typical, and atypical SCID constitutes only ~ 10% of cases identified with abnormal TRECs associated with T cell lymphopenia. Several other non-SCID-related conditions may be identified by newborn screening in a term infant. Thus, it is important for physicians to recognize that other factors, such as prematurity, are often associated with low TRECs initially, but often improve with age. This paper focuses on a challenge that immunologists face: the diagnostic evaluation and management of cases in which abnormal TRECs are associated with variants of T cell lymphopenia in the absence of a genetically defined form of typical or atypical SCID. Various syndromes associated with T cell impairment, secondary forms of T cell lymphopenia, and idiopathic T cell lymphopenia are identified using this screening approach. Yet there is no consensus or guidelines to assist in the evaluation and management of these newborns, despite representing 90% of the patients identified, resulting in significant work for the clinical teams until a diagnosis is made. Using a case-based approach, we review pearls relevant to the evaluation of these newborns, as well as the management dilemmas for the families and team related to the resolution of genetic ambiguities.
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Affiliation(s)
- David Buchbinder
- Department of Hematology, Children's Hospital of Orange County, Orange, CA, USA.
- Department of Pediatrics, University of California at Irvine, Orange, CA, USA.
| | - Jolan E Walter
- Division of Pediatric, University of South Florida at Johns Hopkins All Children's Hospital, Allergy/ Immunology, St. Petersburg, FL, USA
- Division of Pediatric Allergy and Immunology, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Manish J Butte
- Division of Immunology, Allergy, and Rheumatology, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Wan-Yin Chan
- Department of Allergy & Immunology, Children's Hospital of Orange County, Orange, CA, USA
| | - Maria Chitty Lopez
- Division of Pediatric, University of South Florida at Johns Hopkins All Children's Hospital, Allergy/ Immunology, St. Petersburg, FL, USA
| | - Victoria R Dimitriades
- Division of Allergy, Immunology & Rheumatology, Department of Pediatrics, Sacramento, CA, USA
| | - Morna J Dorsey
- Department of Allergy & Immunology, University of California, San Francisco, CA, USA
| | - Diane J Nugent
- Department of Hematology, Children's Hospital of Orange County, Orange, CA, USA
- Department of Pediatrics, University of California at Irvine, Orange, CA, USA
| | - Jennifer M Puck
- Department of Allergy & Immunology, University of California, San Francisco, CA, USA
| | - Jasjit Singh
- Department of Infectious Disease, Children's Hospital of Orange County, Orange, CA, USA
| | - Cathleen A Collins
- Department of Pediatrics, Division of Allergy Immunology, University of California at San Diego, La Jolla, CA, USA
- Department of Pediatrics, Division of Allergy Immunology, Rady Children's Hospital, San Diego, CA, USA
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6
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Kreins AY, Maio S, Dhalla F. Inborn errors of thymic stromal cell development and function. Semin Immunopathol 2020; 43:85-100. [PMID: 33257998 PMCID: PMC7925491 DOI: 10.1007/s00281-020-00826-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/09/2020] [Indexed: 12/31/2022]
Abstract
As the primary site for T cell development, the thymus is responsible for the production and selection of a functional, yet self-tolerant T cell repertoire. This critically depends on thymic stromal cells, derived from the pharyngeal apparatus during embryogenesis. Thymic epithelial cells, mesenchymal and vascular elements together form the unique and highly specialised microenvironment required to support all aspects of thymopoiesis and T cell central tolerance induction. Although rare, inborn errors of thymic stromal cells constitute a clinically important group of conditions because their immunological consequences, which include autoimmune disease and T cell immunodeficiency, can be life-threatening if unrecognised and untreated. In this review, we describe the molecular and environmental aetiologies of the thymic stromal cell defects known to cause disease in humans, placing particular emphasis on those with a propensity to cause thymic hypoplasia or aplasia and consequently severe congenital immunodeficiency. We discuss the principles underpinning their diagnosis and management, including the use of novel tools to aid in their identification and strategies for curative treatment, principally transplantation of allogeneic thymus tissue.
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Affiliation(s)
- Alexandra Y Kreins
- UCL Great Ormond Street Institute of Child Health, London, UK.,Department of Immunology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stefano Maio
- Developmental Immunology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Fatima Dhalla
- Developmental Immunology, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK. .,Department of Clinical Immunology, Oxford University Hospitals, Oxford, UK.
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Abstract
PURPOSE OF REVIEW Transplantation of cultured postnatal allogeneic thymus has been successful for treating athymia, mostly associated with complete DiGeorge syndrome, for more than 20 years. Advances in molecular genetics provide opportunities for widening the range of athymic conditions that can be treated while advances in cell culture and organ/tissue regeneration may offer the prospect of alternative preparations of thymic tissue. There are potential broader applications of this treatment outside congenital athymia. RECENT FINDINGS At the same time as further characterization of the cultured thymus product in terms of thymic epithelial cells and lymphoid composition, preclinical studies have looked at de-novo generation of thymic epithelial cells from stem cells and explored scaffolds for delivering these as three-dimensional structures. In the era of newborn screening for T-cell lymphopaenia, a broadening range of defects leading to athymia is being recognized and new assays should allow differentiation of these from haematopoietic cell defects, pending their genetic/molecular characterization. Evidence suggests that the tolerogenic effect of transplanted thymus could be exploited to improve outcomes after solid organ transplantation. SUMMARY Thymus transplantation, the accepted standard treatment for complete DiGeorge syndrome is also appropriate for other genetic defects leading to athymia. Improved strategies for generating thymus may lead to better outcomes and broader application of this treatment.
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8
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Giardino G, Borzacchiello C, De Luca M, Romano R, Prencipe R, Cirillo E, Pignata C. T-Cell Immunodeficiencies With Congenital Alterations of Thymic Development: Genes Implicated and Differential Immunological and Clinical Features. Front Immunol 2020; 11:1837. [PMID: 32922396 PMCID: PMC7457079 DOI: 10.3389/fimmu.2020.01837] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/08/2020] [Indexed: 02/06/2023] Open
Abstract
Combined Immunodeficiencies (CID) are rare congenital disorders characterized by defective T-cell development that may be associated with B- and NK-cell deficiency. They are usually due to alterations in genes expressed in hematopoietic precursors but in few cases, they are caused by impaired thymic development. Athymia was classically associated with DiGeorge Syndrome due to TBX1 gene haploinsufficiency. Other genes, implicated in thymic organogenesis include FOXN1, associated with Nude SCID syndrome, PAX1, associated with Otofaciocervical Syndrome type 2, and CHD7, one of the genes implicated in CHARGE syndrome. More recently, chromosome 2p11.2 microdeletion, causing FOXI3 haploinsufficiency, has been identified in 5 families with impaired thymus development. In this review, we will summarize the main genetic, clinical, and immunological features related to the abovementioned gene mutations. We will also focus on different therapeutic approaches to treat SCID in these patients.
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Affiliation(s)
- Giuliana Giardino
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Carla Borzacchiello
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Martina De Luca
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Roberta Romano
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Rosaria Prencipe
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Emilia Cirillo
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences, Pediatric Section, Federico II University of Naples, Naples, Italy
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9
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Bhalla P, Wysocki CA, van Oers NSC. Molecular Insights Into the Causes of Human Thymic Hypoplasia With Animal Models. Front Immunol 2020; 11:830. [PMID: 32431714 PMCID: PMC7214791 DOI: 10.3389/fimmu.2020.00830] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/14/2020] [Indexed: 12/30/2022] Open
Abstract
22q11.2 deletion syndrome (DiGeorge), CHARGE syndrome, Nude/SCID and otofaciocervical syndrome type 2 (OTFCS2) are distinct clinical conditions in humans that can result in hypoplasia and occasionally, aplasia of the thymus. Thymic hypoplasia/aplasia is first suggested by absence or significantly reduced numbers of recent thymic emigrants, revealed in standard-of-care newborn screens for T cell receptor excision circles (TRECs). Subsequent clinical assessments will often indicate whether genetic mutations are causal to the low T cell output from the thymus. However, the molecular mechanisms leading to the thymic hypoplasia/aplasia in diverse human syndromes are not fully understood, partly because the problems of the thymus originate during embryogenesis. Rodent and Zebrafish models of these clinical syndromes have been used to better define the underlying basis of the clinical presentations. Results from these animal models are uncovering contributions of different cell types in the specification, differentiation, and expansion of the thymus. Cell populations such as epithelial cells, mesenchymal cells, endothelial cells, and thymocytes are variably affected depending on the human syndrome responsible for the thymic hypoplasia. In the current review, findings from the diverse animal models will be described in relation to the clinical phenotypes. Importantly, these results are suggesting new strategies for regenerating thymic tissue in patients with distinct congenital disorders.
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Affiliation(s)
- Pratibha Bhalla
- Department of Immunology, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Christian A Wysocki
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nicolai S C van Oers
- Department of Immunology, The University of Texas Southwestern Medical Center, Dallas, TX, United States.,Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, United States.,Department of Microbiology, The University of Texas Southwestern Medical Center, Dallas, TX, United States
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10
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Sullivan KE. Chromosome 22q11.2 deletion syndrome and DiGeorge syndrome. Immunol Rev 2019; 287:186-201. [PMID: 30565249 DOI: 10.1111/imr.12701] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/30/2018] [Indexed: 12/19/2022]
Abstract
Chromosome 22q11.2 deletion syndrome is the most common microdeletion syndrome in humans. The effects are protean and highly variable, making a unified approach difficult. Nevertheless, commonalities have been identified and white papers with recommended evaluations and anticipatory guidance have been published. This review will cover the immune system in detail and discuss both the primary features and the secondary features related to thymic hypoplasia. A brief discussion of the other organ system involvement will be provided for context. The immune system, percolating throughout the body can impact the function of other organs through allergy or autoimmune disease affecting organs in deleterious manners. Our work has shown that the primary effect of thymic hypoplasia is to restrict T cell production. Subsequent homeostatic proliferation and perhaps other factors drive a Th2 polarization, most obvious in adulthood. This contributes to atopic risk in this population. Thymic hypoplasia also contributes to low regulatory T cells and this may be part of the overall increased risk of autoimmunity. Collectively, the effects are complex and often age-dependent. Future goals of improving thymic function or augmenting thymic volume may offer a direct intervention to ameliorate infections, atopy, and autoimmunity.
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Affiliation(s)
- Kathleen E Sullivan
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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11
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Kuo CY, Signer R, Saitta SC. Immune and Genetic Features of the Chromosome 22q11.2 Deletion (DiGeorge Syndrome). Curr Allergy Asthma Rep 2018; 18:75. [PMID: 30377837 DOI: 10.1007/s11882-018-0823-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW This review provides an update on the progress in identifying the range of immunological dysfunction seen in DiGeorge syndrome and on more recent diagnostic and treatment approaches. RECENT FINDINGS Clinically, the associated thymic hypoplasia/aplasia is well known and can have profound effects on T cell function. Further, the humoral arm of the immune system can be affected, with hypogammaglobulinemia and poor vaccine-specific antibody response. Additionally, genetic testing utilizing chromosomal microarray demonstrates a small but significant number of 22q11 deletions that are not detectable by standard FISH testing. The recent addition of a TREC assay to newborn screening can identify a subset of infants whose severe immune defects may result from 22q11 deletion. This initial presentation now also places the immunologist in the role of "first responder" with regard to diagnosis and management of these patients. DiGeorge syndrome reflects a clinical phenotype now recognized by its underlying genetic diagnosis, chromosome 22q11.2 deletion syndrome, which is associated with multisystem involvement and variable immune defects among patients. Updated genetic and molecular techniques now allow for earlier identification of immune defects and confirmatory diagnoses, in this disorder with life-long clinical issues.
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Affiliation(s)
- Caroline Y Kuo
- Department of Pediatrics, Division of Allergy and Immunology and Rheumatology, Mattel Children's Hospital, UCLA School of Medicine, Los Angeles, CA, USA
| | - Rebecca Signer
- Department of Pediatrics, Division of Medical Genetics, Mattel Children's Hospital, UCLA School of Medicine, Los Angeles, CA, USA
| | - Sulagna C Saitta
- Department of Pathology, Division of Genomic Medicine, Children's Hospital Los Angeles, USC Keck School of Medicine, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA. .,Center for Personalized Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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12
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Morsheimer M, Brown Whitehorn TF, Heimall J, Sullivan KE. The immune deficiency of chromosome 22q11.2 deletion syndrome. Am J Med Genet A 2017. [PMID: 28627729 DOI: 10.1002/ajmg.a.38319] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The syndrome originally described by Dr. Angelo DiGeorge had immunodeficiency as a central component. When a 22q11.2 deletion was identified as the cause in the majority of patients with DiGeorge syndrome, the clinical features of 22q11.2 deletion syndrome became so expansive that the immunodeficiency became less prominent in our thinking about the syndrome. This review will focus on the immune system and the changes in our understanding over the past 50 years. Initially characterized as a pure defect in T cell development, we now appreciate that many of the clinical features related to the immunodeficiency are well downstream of the limitation imposed by a small thymus. Dysfunctional B cells presumed to be secondary to compromised T cell help, issues related to T cell exhaustion, and high rates of atopy and autoimmunity are aspects of management that require consideration for optimal clinical care and for designing a cogent monitoring approach. New data on atopy are presented to further demonstrate the association.
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Affiliation(s)
- Megan Morsheimer
- Nemours Children's Health System, DuPont Hospital for Children, Wilmington, Delaware
| | - Terri F Brown Whitehorn
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Jennifer Heimall
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Kathleen E Sullivan
- The Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
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13
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Jyonouchi S, Jongco AM, Puck J, Sullivan KE. Immunodeficiencies Associated with Abnormal Newborn Screening for T Cell and B Cell Lymphopenia. J Clin Immunol 2017; 37:363-374. [PMID: 28353166 DOI: 10.1007/s10875-017-0388-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
Newborn screening for SCID has revealed the association of low T cells with a number of unexpected syndromes associated with low T cells, some of which were not appreciated to have this feature. This review will discuss diagnostic approaches and the features of some of the syndromes likely to be encountered following newborn screening for immune deficiencies.
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Affiliation(s)
- Soma Jyonouchi
- Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Artemio M Jongco
- Division of Allergy and Immunology, Cohen Children's Medical Center of New York, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Jennifer Puck
- Division of Allergy, Immunology and Blood and Marrow Transplantation, Department of Pediatrics, University of California San Francisco, and UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Kathleen E Sullivan
- Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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14
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Abstract
Severe combined immunodeficiency disorders represent pediatric emergencies due to absence of adaptive immune responses to infections. The conditions result from either intrinsic defects in T-cell development (ie, severe combined immunodeficiency disease [SCID]) or congenital athymia (eg, complete DiGeorge anomaly). Hematopoietic stem cell transplant provides the only clinically approved cure for SCID, although gene therapy research trials are showing significant promise. For greatest survival, patients should undergo transplant before 3.5 months of age and before the onset of infections. Newborn screening programs have yielded successful early identification and treatment of infants with SCID and congenital athymia in the United States.
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15
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Kojima D, Muramatsu H, Okuno Y, Kataoka S, Murakami N, Tanahashi Y, Suzuki K, Kato T, Sekiya Y, Kawashima N, Narita A, Nishio N, Hama A, Imai K, Nonoyama S, Takahashi Y, Kojima S. Successful T-cell reconstitution after unrelated cord blood transplantation in a patient with complete DiGeorge syndrome. J Allergy Clin Immunol 2016; 138:1471-1473.e4. [PMID: 27444175 DOI: 10.1016/j.jaci.2016.04.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/30/2016] [Accepted: 04/25/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Daiei Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Muramatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Okuno
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan; Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Shinsuke Kataoka
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norihiro Murakami
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihiro Tanahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kyogo Suzuki
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tamaki Kato
- Department of Pediatrics, National Defense Medical College, Tokorozawa, Japan
| | - Yuko Sekiya
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nozomu Kawashima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Narita
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuhiro Nishio
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan; Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Asahito Hama
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kohsuke Imai
- Department of Pediatrics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shigeaki Nonoyama
- Department of Pediatrics, National Defense Medical College, Tokorozawa, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seiji Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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16
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Bonilla FA, Khan DA, Ballas ZK, Chinen J, Frank MM, Hsu JT, Keller M, Kobrynski LJ, Komarow HD, Mazer B, Nelson RP, Orange JS, Routes JM, Shearer WT, Sorensen RU, Verbsky JW, Bernstein DI, Blessing-Moore J, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller D, Spector SL, Tilles S, Wallace D. Practice parameter for the diagnosis and management of primary immunodeficiency. J Allergy Clin Immunol 2015; 136:1186-205.e1-78. [PMID: 26371839 DOI: 10.1016/j.jaci.2015.04.049] [Citation(s) in RCA: 400] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 04/18/2015] [Accepted: 04/23/2015] [Indexed: 02/07/2023]
Abstract
The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma & Immunology (ACAAI) have jointly accepted responsibility for establishing the "Practice parameter for the diagnosis and management of primary immunodeficiency." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
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17
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Mikkers HM, Freund C, Mummery CL, Hoeben RC. Cell replacement therapies: is it time to reprogram? Hum Gene Ther 2014; 25:866-74. [PMID: 25141889 DOI: 10.1089/hum.2014.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Hematopoietic stem cell transplantations have become a very successful therapeutic approach to treat otherwise life-threatening blood disorders. It is thought that stem cell transplantation may also become a feasible treatment option for many non-blood-related diseases. So far, however, the limited availability of human leukocyte antigen-matched donors has hindered development of some cell replacement therapies. The Nobel-prize rewarded finding that pluripotency can be induced in somatic cells via expression of a few transcription factors has led to a revolution in stem cell biology. The possibility to change the fate of somatic cells by expressing key transcription factors has been used not only to generate pluripotent stem cells, but also for directly converting somatic cells into fully differentiated cells of another lineage or more committed progenitor cells. These approaches offer the prospect of generating cell types with a specific genotype de novo, which would circumvent the problems associated with allogeneic cell transplantations. This technology has generated a plethora of new disease-specific research efforts, from studying disease pathogenesis to therapeutic interventions. Here we will discuss the opportunities in this booming field of cell biology and summarize how the scientists in the Netherlands have joined efforts in one area to exploit the new technology.
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Affiliation(s)
- Harald M Mikkers
- 1 Department of Molecular Cell Biology, Leiden University Medical Center , 2300RC Leiden, The Netherlands
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18
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Maggadottir SM, Sullivan KE. The diverse clinical features of chromosome 22q11.2 deletion syndrome (DiGeorge syndrome). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:589-94. [PMID: 24565705 DOI: 10.1016/j.jaip.2013.08.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/24/2013] [Accepted: 08/06/2013] [Indexed: 01/15/2023]
Abstract
A 2-year-old boy with chromosome 22q11.2 deletion syndrome was referred for recurrent sinopulmonary infections. He was diagnosed shortly after birth by a fluorescence in situ hybridization test that was performed due to interrupted aortic arch type B. He had no hypocalcemia, and his recovery from cardiac repair was uneventful. He had difficulty feeding and gained weight slowly, but, otherwise, there were no concerns during his first year of life. At 15 months of age, he began to develop significant otitis media and bronchitis. He was hospitalized once for pneumonia at 18 months of age and has never been off antibiotics for more than 1 week since then. He has not had any previous immunologic evaluation. Recurrent sinopulmonary infections in a child with chromosome 22q11.2 deletion syndrome can have the same etiologies as in any other child. Atopy, anatomic issues, cystic fibrosis, and new environmental exposures could be considered in this setting. Early childhood can be problematic for patients with chromosome 22q11.2 deletion syndrome due to unfavorable drainage of the middle ear and sinuses. Atopy occurs at a higher frequency in 22q11.2 deletion syndrome, and these children also have a higher rate of gastroesophageal reflux and aspiration than the general population. As would be appropriate for any child who presents with recurrent infections at 2 years of age, an immunologic evaluation should be performed. In this review, we will highlight recent findings and new data on the management of children and adults with chromosome 22q11.2 deletion syndrome.
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Affiliation(s)
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pa.
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19
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Ip W, Zhan H, Gilmour KC, Davies EG, Qasim W. 22q11.2 deletion syndrome with life-threatening adenovirus infection. J Pediatr 2013; 163:908-10. [PMID: 23660376 DOI: 10.1016/j.jpeds.2013.03.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 02/14/2013] [Accepted: 03/25/2013] [Indexed: 12/17/2022]
Abstract
Adenovirus causes significant morbidity and mortality in immunocompromised children. We report how an infusion of HLA-matched sibling donor T lymphocytes rapidly eradicated life-threatening, high-level adenoviremia in a child with complete DiGeorge syndrome (22q11.2 deletion) who went on to reconstitute a diverse, donor-derived, postthymic T-cell repertoire.
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Affiliation(s)
- Winnie Ip
- Molecular Immunology Unit, Institute of Child Health, University College London, London, United Kingdom.
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20
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Kobayashi D, Sallaam S, Humes RA. Tetralogy of Fallot with complete DiGeorge syndrome: report of a case and a review of the literature. CONGENIT HEART DIS 2012; 8:E119-26. [PMID: 22883347 DOI: 10.1111/j.1747-0803.2012.00694.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2012] [Indexed: 12/11/2022]
Abstract
Complete DiGeorge syndrome (CDGS) has a severe T-cell immunodeficiency and is fatal without thymus or bone marrow transplantation. Associated congenital heart disease (CHD) further complicates the clinical management. We report an infant with tetralogy of Fallot, confluent and hypoplastic pulmonary arteries, right aortic arch, and aberrant left subclavian artery. He was athymic with no CD3+ T cells. CDGS was diagnosed with 22q11.2 deletion. The patient underwent central aortopulmonary shunt at 12 days of age. The patient died at 5 weeks of age awaiting thymus transplantation. We performed a review of the literature regarding CDGS and CHD. We found 43 cases including conotruncal defects (20) and nonconotruncal defects (23). The overall mortality rate was 67%. Among 30 cases undergoing transplantation (bone marrow 16 and thymus 12, bone marrow + thymus 2), the mortality rate was 53%. The patients with conotruncal defects were more likely to die before transplantation (45% vs. 16%, P =.04). The main cause of death was infection before and after transplantation. We conclude that children with CDGS and CHD have a high mortality. Bone marrow and thymus transplantation can improve the survival, but the overall management of these high risk patients remains challenging.
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Affiliation(s)
- Daisuke Kobayashi
- Section of Pediatric Cardiology, Children's Hospital of Michigan, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48201-2119, USA
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21
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McDonald-McGinn DM, Sullivan KE. Chromosome 22q11.2 deletion syndrome (DiGeorge syndrome/velocardiofacial syndrome). Medicine (Baltimore) 2011; 90:1-18. [PMID: 21200182 DOI: 10.1097/md.0b013e3182060469] [Citation(s) in RCA: 268] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Chromosome 22q11.2 deletion syndrome is a common syndrome also known as DiGeorge syndrome and velocardiofacial syndrome. It occurs in approximately 1:4000 births, and the incidence is increasing due to affected parents bearing their own affected children. The manifestations of this syndrome cross all medical specialties, and care of the children and adults can be complex. Many patients have a mild to moderate immune deficiency, and the majority of patients have a cardiac anomaly. Additional features include renal anomalies, eye anomalies, hypoparathyroidism, skeletal defects, and developmental delay. Each child's needs must be tailored to his or her specific medical problems, and as the child transitions to adulthood, additional issues will arise. A holistic approach, addressing medical and behavioral needs, can be very helpful.
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22
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Colarusso G, Gambineri E, Lapi E, Casini T, Tucci F, Lippi F, Azzari C. Evans syndrome and antibody deficiency: an atypical presentation of chromosome 22q11.2 deletion syndrome. Pediatr Rep 2010; 2:e13. [PMID: 21589826 PMCID: PMC3094001 DOI: 10.4081/pr.2010.e13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 05/20/2010] [Accepted: 05/25/2010] [Indexed: 12/21/2022] Open
Abstract
We report a case of an 8-year-old male patient with Evans syndrome and severe hypogammaglobulinemia, subsequently in whom the 22q11.2 deletion syndrome (22q11.2 DS) was diagnosed. No other clinical sign of 22q11.2 DS was present with the exception of slight facial dysmorphism. The case is of particular interest because it suggests the need to research chromosome 22q11.2 deletion in patients who present with autoimmune cytopenia and peculiar facial abnormalities, which could be an atypical presentation of an incomplete form of 22q11.2 DS.
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23
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De Ravin SS, Cowen EW, Zarember KA, Whiting-Theobald NL, Kuhns DB, Sandler NG, Douek DC, Pittaluga S, Poliani PL, Lee YN, Notarangelo LD, Wang L, Alt FW, Kang EM, Milner JD, Niemela JE, Fontana-Penn M, Sinal SH, Malech HL. Hypomorphic Rag mutations can cause destructive midline granulomatous disease. Blood 2010; 116:1263-71. [PMID: 20489056 PMCID: PMC2938237 DOI: 10.1182/blood-2010-02-267583] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 04/17/2010] [Indexed: 01/08/2023] Open
Abstract
Destructive midline granulomatous disease characterized by necrotizing granulomas of the head and neck is most commonly caused by Wegener granulomatosis, natural killer/T-cell lymphomas, cocaine abuse, or infections. An adolescent patient with myasthenia gravis treated with thymectomy subsequently developed extensive granulomatous destruction of midface structures, palate, nasal septum, airways, and epiglottis. His lymphocyte numbers, total immunoglobulin G level, and T-cell receptor (TCR) repertoire appeared normal. Sequencing of Recombination activating gene-1 (Rag1) showed compound heterozygous Rag1 mutations; a novel deletion with no recombinase activity and a missense mutation resulting in 50% Rag activity. His thymus was dysplastic and, although not depleted of T cells, showed a notable absence of autoimmune regulator (AIRE) and Foxp3(+) regulatory T cells. This distinct Rag-deficient phenotype characterized by immune dysregulation with granulomatous hyperinflammation and autoimmunity, with relatively normal T and B lymphocyte numbers and a diverse TCR repertoire expands the spectrum of presentation in Rag deficiency. This study was registered at www.clinicaltrials.gov as #NCT00128973.
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Affiliation(s)
- Suk See De Ravin
- Laboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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24
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Inoue H, Takada H, Kusuda T, Goto T, Ochiai M, Kinjo T, Muneuchi J, Takahata Y, Takahashi N, Morio T, Kosaki K, Hara T. Successful cord blood transplantation for a CHARGE syndrome with CHD7 mutation showing DiGeorge sequence including hypoparathyroidism. Eur J Pediatr 2010; 169:839-44. [PMID: 20052490 DOI: 10.1007/s00431-009-1126-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 12/01/2009] [Indexed: 01/29/2023]
Abstract
It is rare that coloboma, heart anomalies, choanal atresia, retarded growth and development, and genital and ear anomalies (CHARGE) syndrome patients have DiGeorge sequence showing severe immunodeficiency due to the defect of the thymus. Although the only treatment to achieve immunological recovery for these patients in countries where thymic transplantation is not ethically approved would be hematopoietic cell transplantation, long-term survival has not been obtained in most patients. On the other hand, it is still not clarified whether hypoparathyroidism is one of the manifestations of CHARGE syndrome. We observed a CHARGE syndrome patient with chromodomain helicase DNA-binding protein 7 mutation showing DiGeorge sequence including the defect of T cells accompanied with the aplasia of the thymus, severe hypoparathyroidism, and conotruncal cardiac anomaly. He received unrelated cord blood transplantation without conditioning at 4 months of age. Recovery of T cell number and of proliferative response against mitogens was achieved by peripheral expansion of mature T cells in cord blood without thymic output. Although he is still suffering from severe hypoparathyroidism, he is alive without serious infections for 10 months.
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Affiliation(s)
- Hirosuke Inoue
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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25
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Multicenter survey on the outcome of transplantation of hematopoietic cells in patients with the complete form of DiGeorge anomaly. Blood 2010; 116:2229-36. [PMID: 20530285 DOI: 10.1182/blood-2010-03-275966] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Seventeen patients transplanted with hematopoietic cells to correct severe T lymphocyte immunodeficiency resulting from complete DiGeorge anomaly were identified worldwide, and retrospective data were obtained using a questionnaire-based survey. Patients were treated at a median age of 5 months (range, 2-53 months) between 1995 and 2006. Bone marrow was used in 11 procedures in 9 cases: 6 from matched unrelated donors, 4 from human leukocyte antigen (HLA)-identical siblings, and one haploidentical parent with T-cell depletion. Unmobilized peripheral blood was used in 8 cases: 5 from HLA-identical siblings, one from a matched unrelated donor, one from an HLA-identical parent, and one unrelated matched cord blood. Conditioning was used in 5 patients and graft-versus-host disease prophylaxis in 11 patients. Significant graft-versus-host disease occurred in 9 patients, becoming chronic in 3. Median length of follow-up was 13 months, with transplantation from HLA-matched sibling showing the best results. Median survival among deceased patients (10 patients) was 7 months after transplantation (range, 2-18 months). The overall survival rate was 41%, with a median follow-up of 5.8 years (range, 4-11.5 years). Among survivors, median CD3 and CD4 counts were 806 (range, 644-1224) and 348 (range, 225-782) cells/mm(3), respectively, CD4(+)/CD45RA(+) cells remained very low, whereas mitogen responses were normalized.
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26
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Abstract
Adoptive transfer of mature T cells (ATMTC) through bone marrow (BM) transplantation, first attempted over 20 years ago, has recently emerged as a successful therapy for complete 22q deletion syndrome (22qDS). This provides a potential option to thymic transplantation (TT) for immune reconstitution in 22qDS. Compared to thymic transplant, ATMTC is an easier procedure to accomplish and is available at more centers. However, there are differences in the nature of the T-cell reconstitution that results. Predictably, more naïve T cells and recent thymic emigrants are present in patients treated with thymus transplant. There are no significant differences in mortality between the two procedures, but the number of patients is too limited to conclude that the procedures are equally effective. Adoptive transfer should be pursued as a reasonable treatment for 22qDS patients requiring immune reconstitution when thymus transplant is not available.
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27
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Primary immunodeficiencies. J Allergy Clin Immunol 2009; 125:S182-94. [PMID: 20042228 DOI: 10.1016/j.jaci.2009.07.053] [Citation(s) in RCA: 298] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 07/27/2009] [Accepted: 07/30/2009] [Indexed: 12/14/2022]
Abstract
In the last years, advances in molecular genetics and immunology have resulted in the identification of a growing number of genes causing primary immunodeficiencies (PIDs) in human subjects and a better understanding of the pathophysiology of these disorders. Characterization of the molecular mechanisms of PIDs has also facilitated the development of novel diagnostic assays based on analysis of the expression of the protein encoded by the PID-specific gene. Pilot newborn screening programs for the identification of infants with severe combined immunodeficiency have been initiated. Finally, significant advances have been made in the treatment of PIDs based on the use of subcutaneous immunoglobulins, hematopoietic cell transplantation from unrelated donors and cord blood, and gene therapy. In this review we will discuss the pathogenesis, diagnosis, and treatment of PIDs, with special attention to recent advances in the field.
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28
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Renner E, Rieber N, Klein C, Albert M. Angeborene Immundefekte als Multisystemerkrankungen. Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-009-1987-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Advances in basic and clinical immunology in 2007. J Allergy Clin Immunol 2008; 122:36-41. [DOI: 10.1016/j.jaci.2008.04.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Accepted: 04/25/2008] [Indexed: 12/20/2022]
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Daguindau N, Decot V, Nzietchueng R, Ferrand C, Picard C, Latger-Cannard V, Gregoire MJ, Beri M, Salmon A, Stoltz JF, Bordigoni P, Bensoussan D. Immune constitution monitoring after PBMC transplantation in complete DiGeorge syndrome: an eight-year follow-up. Clin Immunol 2008; 128:164-71. [PMID: 18515186 DOI: 10.1016/j.clim.2008.03.524] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 03/13/2008] [Accepted: 03/30/2008] [Indexed: 12/24/2022]
Abstract
A young boy with a confirmed complete DiGeorge Syndrome (cDGS) underwent a peripheral blood mononuclear cell transplantation (PBMCT) from his HLA-identical sister at 4.5 years of age, without a conditioning regimen. Eight years later, he is healthy with good immunological functions in the presence of a stable mixed T-cell chimerism. Absence of recent thymic emigrants is confirmed. We observe an inverted CD4+/CD8+ ratio, related to the CD8 subset expansion, a skewing of the TCR repertoire, especially on the CD8+ subset and a telomere loss on the CD8+ cells compared to the donor. However, these anomalies do not seem to have an impact on functional immunity. PBMCT in cDGS using an HLA-matched sibling donor provides good long-lasting immunity and is an easy alternative to bone marrow transplantation and to thymic transplantation.
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Affiliation(s)
- Nicolas Daguindau
- CHU de Nancy, Unité de Thérapie cellulaire et Tissus, Vandoeuvre-lès-Nancy, F-54511-France
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Land MH, Garcia-Lloret MI, Borzy MS, Stiehm ER. Reply. J Allergy Clin Immunol 2008. [DOI: 10.1016/j.jaci.2007.12.1182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Markert ML. Treatment of infants with complete DiGeorge anomaly. J Allergy Clin Immunol 2008; 121:1063; author reply 1063-4. [PMID: 18289653 DOI: 10.1016/j.jaci.2007.12.1181] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 12/03/2007] [Indexed: 10/22/2022]
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Shearer WT, Malech HL, Puck JM. Primary immunodeficiency: meeting the challenges. J Allergy Clin Immunol 2007; 120:753-5. [PMID: 17931558 DOI: 10.1016/j.jaci.2007.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Revised: 09/04/2007] [Accepted: 09/05/2007] [Indexed: 12/19/2022]
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