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Perez-Perez D, Santos-Argumedo L, Rodriguez-Alba JC, Lopez-Herrera G. Analysis of LRBA pathogenic variants and the association with functional protein domains and clinical presentation. Pediatr Allergy Immunol 2024; 35:e14179. [PMID: 38923448 DOI: 10.1111/pai.14179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/29/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024]
Abstract
LRBA is a cytoplasmic protein that is ubiquitously distributed. Almost all LRBA domains have a scaffolding function. In 2012, it was reported that homozygous variants in LRBA are associated with early-onset hypogammaglobulinemia. Since its discovery, more than 100 pathogenic variants have been reported. This review focuses on the variants reported in LRBA and their possible associations with clinical phenotypes. In this work LRBA deficiency cases reported more than 11 years ago have been revised. A database was constructed to analyze the type of variants, age at onset, clinical diagnosis, infections, autoimmune diseases, and cellular and immunoglobulin levels. The review of cases from 2012 to 2023 showed that LRBA deficiency was commonly diagnosed in patients with a clinical diagnosis of Common Variable Immunodeficiency, followed by enteropathy, neonatal diabetes mellitus, ALPS, and X-linked-like syndrome. Most cases show early onset of presentation at <6 years of age. Most cases lack protein expression, whereas hypogammaglobulinemia is observed in half of the cases, and IgG and IgA levels are isotypes reported at low levels. Patients with elevated IgG levels exhibited more than one autoimmune manifestation. Patients carrying pathogenic variants leading to a premature stop codon show a severe phenotype as they have an earlier onset of disease presentation, severe autoimmune manifestations, premature death, and low B cells and regulatory T cell levels. Missense variants were more common in patients with low IgG levels and cytopenia. This work lead to the conclusion that the type of variant in LRBA has association with disease severity, which leads to a premature stop codon being the ones that correlates with severe disease.
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Affiliation(s)
- D Perez-Perez
- Doctorate Program in Biological Sciences, Autonomous National University of Mexico, Mexico City, Mexico
- Immunodeficiencies Laboratory, National Institute of Pediatrics (INP), Mexico City, Mexico
| | - L Santos-Argumedo
- Biomedicine Department, Center for Research and Advanced Studies of the National Polytechnic Institute (CINVESTAV), Mexico City, Mexico
| | - J C Rodriguez-Alba
- Neuroimmunology and Neurooncology Unit, The National Institute of Neurology and Neurosurgery (NINN), Mexico City, Mexico
- Medicine and Surgery Faculty, Autonomous University Benito Juarez from Oaxaca, Oaxaca, Mexico
| | - G Lopez-Herrera
- Immunodeficiencies Laboratory, National Institute of Pediatrics (INP), Mexico City, Mexico
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Globa E, Zelinska N, Johnson MB, Flanagan SE, De Franco E. Neonatal and early-onset diabetes in Ukraine: Atypical features and mortality. Diabet Med 2023; 40:e15013. [PMID: 36398453 PMCID: PMC10946703 DOI: 10.1111/dme.15013] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 10/27/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022]
Abstract
AIMS The aim of this study is to elucidate the aetiology and clinical features of neonatal and early-onset diabetes in a large database for pediatric diabetes patients in Ukraine. METHODS We established a Pediatric Diabetes Register to identify patients diagnosed with diabetes before 9 months of age. Genetic testing was undertaken for 66 patients from 65 unrelated families with diabetes diagnosed within the first 6 months of life (neonatal diabetes, n = 36) or between 6 and 9 months (early-onset diabetes, n = 30). RESULTS We determined the genetic aetiology in 86.1% of patients (31/36) diagnosed before 6 months and in 20% (6/30) diagnosed between 6 and 9 months. Fourteen individuals (37.8% of those with a genetic cause identified) had activating heterozygous variants in ABCC8 or KCNJ11. An additional 10 individuals had pathogenic variants in the INS or GCK genes, while 4 had 6q24 transient neonatal diabetes. Rare genetic subtypes (including pathogenic variants in EIF2AK3, GLIS3, INSR, PDX1, LRBA, RFX6 and FOXP3) were identified in nine probands (24.3% of solved cases), 6 of whom died. In total, eight individuals died between infancy and childhood, all of them were diagnosed before 6 months and had received a genetic diagnosis. CONCLUSIONS In the last decade, the increased availability of comprehensive genetic testing has resulted in increased recognition of the contribution of rare genetic subtypes within pediatric diabetes cohorts. In our study, we identified a high mortality rate among these patients.
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Affiliation(s)
- Evgenia Globa
- Ukrainian Scientific and Practical Center of Endocrine SurgeryTransplantation of Endocrine Organs and Tissues of the Ministry of Health of UkraineKyivUkraine
| | - Nataliya Zelinska
- Ukrainian Scientific and Practical Center of Endocrine SurgeryTransplantation of Endocrine Organs and Tissues of the Ministry of Health of UkraineKyivUkraine
| | - Matthew B. Johnson
- Institute of Biomedical and Clinical Science, Faculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Sarah E. Flanagan
- Institute of Biomedical and Clinical Science, Faculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Elisa De Franco
- Institute of Biomedical and Clinical Science, Faculty of Health and Life SciencesUniversity of ExeterExeterUK
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3
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Tuğcu GD, Eryılmaz Polat S, Metin A, Orhan D, Cinel G. Interstitial Lung Disease in an Adolescent Girl with Lipopolysaccharide-Responsive Beige-Like Anchor Deficiency. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:133-138. [PMID: 36121783 DOI: 10.1089/ped.2022.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background: Previously, lipopolysaccharide-responsive beige-like anchor (LRBA) deficiency was categorized as a subtype of common variable immune deficiency. Research shows that LRBA deficiency is caused by dysregulation of T cell activation and expansion; it is placed under the category of immune dysregulation with cytotoxic T lymphocyte-associated protein 4 (CTLA-4) haploinsufficiency. Cohort studies have revealed a broad spectrum of clinical manifestations and variable phenotype expression, including immune dysregulation [enteropathy, autoimmune cytopenia, interstitial lung disease (ILD), etc.] on 1 hand and immune deficiency (hypogammaglobulinemia, recurrent infections, bronchiectasis, etc.) on the other hand. Chronic lung disease is frequently seen in LRBA deficiency and is associated with poor outcomes. Case Presentation: This case report evaluates a female who presented with recurrent pneumonia and bronchiectasis but did not respond to treatment; she was lastly diagnosed with ILD with detailed clinical, radiological, and pathological workup. Conclusions: The respiratory characteristics of patients with LRBA deficiency should be investigated, monitored, and treated from the time of its diagnosis. The awareness and involvement of pulmonologists to pulmonary morbidity of patients with LRBA deficiency in workup and clinical decision making are crucial.
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Affiliation(s)
- Gökçen Dilşa Tuğcu
- Department of Pediatric Pulmonology, University of Health Science, Ankara City Hospital, Çankaya, Turkey
| | - Sanem Eryılmaz Polat
- Department of Pediatric Pulmonology, University of Health Science, Ankara City Hospital, Çankaya, Turkey
| | - Ayşe Metin
- Department of Pediatric İmmunology, University of Health Science, Ankara City Hospital, Çankaya, Turkey
| | - Diclehan Orhan
- Department of Pediatric Pathology, Ihsan Dogramacı Children's Hospital, Hacettepe University, Ankara, Turkey
| | - Güzin Cinel
- Department of Pediatric Pulmonology, Ankara City Hospital, Yıldırım Beyazıt University, Çankaya, Turkey
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Kedar P, Dongerdiye R, Chandrakala S, Bargir UA, Madkaikar M. Targeted next-generation sequencing revealed a novel homozygous mutation in the LRBA gene causes severe haemolysis associated with Inborn Errors of Immunity in an Indian family. Hematology 2022; 27:441-448. [PMID: 35413226 DOI: 10.1080/16078454.2022.2058736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES LPS-responsive beige-like anchor protein (LRBA) deficiency abolishes LRBA protein expression due to biallelic mutations in the LRBA gene that lead to autoimmune manifestations, inflammatory bowel disease, hypogammaglobulinemia in early stages, and variable clinical manifestations. MATERIALS AND METHODS Mutational analysis of the LRBA gene was performed in Indian patients using targeted Next Generation Sequencing (t-NGS) and confirmed by Sanger sequencing using specific primers of exons 53. Then, bioinformatics analysis and protein modeling for the novel founded mutations were also performed. The genotype, phenotype correlation was done according to the molecular findings and clinical features. RESULTS We report an unusual case of a female patient born of a consanguineous marriage, presented with severe anaemia and jaundice with a history of multiple blood transfusions of unknown cause up to the age of 5 yrs. She had hepatosplenomegaly with recurrent viral and bacterial infections. Tests for hemoglobinopathies, enzymopathies, and hereditary spherocytosis were within the normal limits. The t-NGS revealed a novel homozygous missense variation in exon 53 of the LRBA gene (chr4:151231464C > T; c.7799G > A) (p.C2600Y), and the parents were heterozygous. The further immunological analysis is suggestive of hypogammaglobulinaemia and autoimmune haemolytic anaemia. The bioinformatics tools are suggestive of deleterious and disease-causing variants. CONCLUSION This study concludes the importance of a timely decision of targeted exome sequencing for the molecular diagnostic tool of unexplained haemolytic anaemia with heterogeneous clinical phenotypes.
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Affiliation(s)
- Prabhakar Kedar
- Department of Haematogenetics, ICMR- National Institute of Immunohaematology, Parel, Mumbai, India
| | - Rashmi Dongerdiye
- Department of Haematogenetics, ICMR- National Institute of Immunohaematology, Parel, Mumbai, India
| | | | - Umair Ahmed Bargir
- Department of Pediatric Immunology and Leukocyte Biology, ICMR- National Institute of Immunohaematology, Parel, Mumbai, India
| | - Manisha Madkaikar
- Department of Pediatric Immunology and Leukocyte Biology, ICMR- National Institute of Immunohaematology, Parel, Mumbai, India
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Yao J, Gu H, Mou W, Chen Z, Ma J, Ma H, Li N, Zhang R, Wang T, Jiang J, Wu R. Various phenotypes of LRBA gene with compound heterozygous variation: A case series report of pediatric cytopenia patients. Int J Immunopathol Pharmacol 2022; 36:3946320221125591. [PMID: 36074705 PMCID: PMC9465590 DOI: 10.1177/03946320221125591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: LPS-responsive beige-like anchor (LRBA) deficiency is one of the most common
monogenic disorders causing common variable immunodeficiency (CVID) and
CVID-like disorders. However, the clinical spectrum of compound heterozygous
(CHZ) LRBA variation should be extended. In this study, we presented five
cases of compound heterozygous LRBA with various refractory cytopenias. Materials and Methods: Retrospective analysis of the clinical manifestations, management, and
outcomes of five cases (from five pedigrees) with LRBA gene
CHZ variants which initially manifested as single/multilineage immune
cytopenias was performed. Results: 1. Gene variations: All five patients inherited the compound heterozygous
LRBA variations from their parents which were thought to be pathogenic.
BEACH, DUF4704, and LamG were the main affected domains of LRBA gene in this
case series. 2. Immune dysregulation of clinic: (1) Hypogammaglobulinemia
were recorded in four patients, and the proportion of Treg was decreased in
two patients. Only one patient had been with increased TCRαβ+CD4/CD8
double-negative T cells (DNT). (2) Lymphoproliferative manifestations were
seen in three patients. (3) All five patients were complained with
cytopenia, although they showed different clinical manifestations. None of
the parents was asymptomatic. (4) Other immune disorders: P5 also had
relapsed infections and autoimmune endocrinopathy. 3. Management and
outcomes: P1 and P5 responded well to immunomodulatory therapy and P3 was
effectively treated with hemophagocytic lymphohistiocytosis (HLH) first-line
regimen chemotherapy. P4 showed no responses to steroids and IVIG. However,
TPO-R agonist was effective. Conclusion: Unlike homozygous mutations, compound heterozygous LRBA variation should
always be kept in mind for the various phenotypes and different treatment
responses.
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Affiliation(s)
- Jiafeng Yao
- Hematology Center, National Center for Children`s Health, 117984Beijing Children`s Hospital, Capital Medical University, Beijing, China
| | - Hao Gu
- Hematologic Disease Laboratory, National Center for Children's Health, 117984Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wenjun Mou
- Laboratory of Tumor Immunology, National Center for Children's Health, 117984Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Laboratory of Tumor Immunology, National Center for Children's Health, 117984Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jie Ma
- Hematology Center, National Center for Children`s Health, 117984Beijing Children`s Hospital, Capital Medical University, Beijing, China
| | - Honghao Ma
- Hematology Center, National Center for Children`s Health, 117984Beijing Children`s Hospital, Capital Medical University, Beijing, China
| | - Nan Li
- Hematology Center, National Center for Children`s Health, 117984Beijing Children`s Hospital, Capital Medical University, Beijing, China
| | - Rui Zhang
- Hematology Center, National Center for Children`s Health, 117984Beijing Children`s Hospital, Capital Medical University, Beijing, China
| | - Tianyou Wang
- Hematologic Disease Laboratory, National Center for Children's Health, 117984Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jin Jiang
- Hematologic Disease Laboratory, National Center for Children's Health, 117984Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Center, National Center for Children`s Health, 117984Beijing Children`s Hospital, Capital Medical University, Beijing, China
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Tang WJ, Hu WH, Huang Y, Wu BB, Peng XM, Zhai XW, Qian XW, Ye ZQ, Xia HJ, Wu J, Shi JR. Potential protein–phenotype correlation in three lipopolysaccharide-responsive beige-like anchor protein-deficient patients. World J Clin Cases 2021; 9:5873-5888. [PMID: 34368306 PMCID: PMC8316938 DOI: 10.12998/wjcc.v9.i21.5873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/22/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with lipopolysaccharide (LPS)-responsive beige-like anchor protein (LRBA) deficiency have a variety of clinical symptoms, but there is no apparent genotype–phenotype correlation, and patients carrying the same mutations may have different phenotypes. Therefore, it is not easy for doctors to make a decision regarding hematopoietic stem cell transplantation (HSCT) for LRBA-deficient patients. We hypothesized that there may be a protein–phenotype correlation to indicate HSCT for LRBA-deficient patients.
AIM To report on three Chinese LRBA-deficient patients and determine the correlation between residual protein expression and disease phenotypes.
METHODS Clinical data of three Chinese LRBA-deficient patients were collected, and protein levels were detected by Western blot analysis. In addition, LRBA mutation information of another 83 previously reported patients was summarized.
RESULTS All the major clinical findings indicated enteropathy, but patients 1 and 3 presented with more severe symptoms than patient 2. Endoscopy and histology indicated nonspecific colitis for patients 1 and 3 but Crohn's disease-like colitis for patient 2. Compound heterozygous mutations in LRBA were found in patient 1, and homozygous mutations in LRBA were found in patient 2 and patient 3. Only patient 2 responded well to traditional immunosuppressive treatment. Residual expression of the LRBA protein in patients 1 and 3 was very low, but in patient 2, a more than 0.5-fold in expression of the LRBA protein was found compared to that in the control. After HSCT, patient 1 had increased LRBA protein expression. We summarized the genetic information of 86 patients, and the mutations in patients 1 and 3 were novel mutations.
CONCLUSION We described three Chinese LRBA-deficient patients, two of whom carried novel mutations. These patients had no genotype-phenotype correlations, but their residual LRBA protein expression might be associated with disease outcome and could be an indicator for HSCT.
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Affiliation(s)
- Wen-Juan Tang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Wen-Hui Hu
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Ying Huang
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Bing-Bing Wu
- The Molecular Genetic Diagnosis Center, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xiao-Min Peng
- The Molecular Genetic Diagnosis Center, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xiao-Wen Zhai
- Department of Hematology Oncology, Children's Hospital of Fudan university, National Children's Medical Center, Shanghai 201102, China
| | - Xiao-Wen Qian
- Department of Hematology Oncology, Children's Hospital of Fudan university, National Children's Medical Center, Shanghai 201102, China
| | - Zi-Qing Ye
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Hai-Jiao Xia
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Jie Wu
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
| | - Jie-Ru Shi
- Department of Gastroenterology, Pediatric Inflammatory Bowel Disease Research Center, Children’s Hospital of Fudan University, National Children's Medical Center, Shanghai 201102, China
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7
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Arnold DE, Chellapandian D, Leiding JW. The Use of Biologic Modifiers as a Bridge to Hematopoietic Cell Transplantation in Primary Immune Regulatory Disorders. Front Immunol 2021; 12:692219. [PMID: 34248986 PMCID: PMC8264452 DOI: 10.3389/fimmu.2021.692219] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/12/2021] [Indexed: 11/13/2022] Open
Abstract
Recently, primary immune regulatory disorders have been described as a subset of inborn errors of immunity that are dominated by immune mediated pathology. As the pathophysiology of disease is elucidated, use of biologic modifiers have been increasingly used successfully to treat disease mediated clinical manifestations. Hematopoietic cell transplant (HCT) has also provided definitive therapy in several PIRDs. Although biologic modifiers have been largely successful at treating disease related manifestations, data are lacking regarding long term efficacy, safety, and their use as a bridge to HCT. This review highlights biologic modifiers in the treatment of several PIRDs and there use as a therapeutic bridge to HCT.
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Affiliation(s)
- Danielle E Arnold
- National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Deepak Chellapandian
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Jennifer W Leiding
- Center for Cell and Gene Therapy for Non-Malignant Conditions, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States.,Division of Allergy and Immunology, Department of Pediatrics, University of South Florida, St. Petersburg, FL, United States
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8
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Chellapandian D, Chitty-Lopez M, Leiding JW. Precision Therapy for the Treatment of Primary Immunodysregulatory Diseases. Immunol Allergy Clin North Am 2020; 40:511-526. [DOI: 10.1016/j.iac.2020.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Delmonte OM, Notarangelo LD. Targeted Therapy with Biologicals and Small Molecules in Primary Immunodeficiencies. Med Princ Pract 2020; 29:101-112. [PMID: 31597133 PMCID: PMC7098309 DOI: 10.1159/000503997] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/09/2019] [Indexed: 01/14/2023] Open
Abstract
Primary immunodeficiencies are disorders resulting from mutations in genes involved in immune defense and immune regulation. These conditions are characterized by various combinations of recurrent infections, autoimmunity, lymphoproliferation, inflammatory manifestations, and malignancy. In the last 20 years, newborn screening programs and next generation sequencing techniques have increased the ability to diagnose primary immunodeficiencies. Furthermore, an advanced understanding of the molecular basis of these inherited disorders has led to the implementation of targeted therapies that utilize small molecules and biologics to modulate the activity of impaired intracellular pathways. This article will discuss selected primary immunodeficiencies, the genetic defects of which have been recently studied and are amenable to targeted therapy as a reflection of the potential of precision medicine in the future.
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Affiliation(s)
- Ottavia Maria Delmonte
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Luigi Daniele Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA,
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10
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Tesch VK, Abolhassani H, Shadur B, Zobel J, Mareika Y, Sharapova S, Karakoc-Aydiner E, Rivière JG, Garcia-Prat M, Moes N, Haerynck F, Gonzales-Granado LI, Santos Pérez JL, Mukhina A, Shcherbina A, Aghamohammadi A, Hammarström L, Dogu F, Haskologlu S, İkincioğulları AI, Köstel Bal S, Baris S, Kilic SS, Karaca NE, Kutukculer N, Girschick H, Kolios A, Keles S, Uygun V, Stepensky P, Worth A, van Montfrans JM, Peters AMJ, Meyts I, Adeli M, Marzollo A, Padem N, Khojah AM, Chavoshzadeh Z, Avbelj Stefanija M, Bakhtiar S, Florkin B, Meeths M, Gamez L, Grimbacher B, Seppänen MRJ, Lankester A, Gennery AR, Seidel MG. Long-term outcome of LRBA deficiency in 76 patients after various treatment modalities as evaluated by the immune deficiency and dysregulation activity (IDDA) score. J Allergy Clin Immunol 2019; 145:1452-1463. [PMID: 31887391 DOI: 10.1016/j.jaci.2019.12.896] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/07/2019] [Accepted: 12/13/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Recent findings strongly support hematopoietic stem cell transplantation (HSCT) in patients with severe presentation of LPS-responsive beige-like anchor protein (LRBA) deficiency, but long-term follow-up and survival data beyond previous patient reports or meta-reviews are scarce for those patients who do not receive a transplant. OBJECTIVE This international retrospective study was conducted to elucidate the longitudinal clinical course of patients with LRBA deficiency who do and do not receive a transplant. METHOD We assessed disease burden and treatment responses with a specially developed immune deficiency and dysregulation activity score, reflecting the sum and severity of organ involvement and infections, days of hospitalization, supportive care requirements, and performance indices. RESULTS Of 76 patients with LRBA deficiency from 29 centers (median follow-up, 10 years; range, 1-52), 24 underwent HSCT from 2005 to 2019. The overall survival rate after HSCT (median follow-up, 20 months) was 70.8% (17 of 24 patients); all deaths were due to nonspecific, early, transplant-related mortality. Currently, 82.7% of patients who did not receive a transplant (43 of 52; age range, 3-69 years) are alive. Of 17 HSCT survivors, 7 are in complete remission and 5 are in good partial remission without treatment (together, 12 of 17 [70.6%]). In contrast, only 5 of 43 patients who did not receive a transplant (11.6%) are without immunosuppression. Immune deficiency and dysregulation activity scores were significantly lower in patients who survived HSCT than in those receiving conventional treatment (P = .005) or in patients who received abatacept or sirolimus as compared with other therapies, and in patients with residual LRBA expression. Higher disease burden, longer duration before HSCT, and lung involvement were associated with poor outcome. CONCLUSION The lifelong disease activity, implying a need for immunosuppression and risk of malignancy, must be weighed against the risks of HSCT.
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Affiliation(s)
- Victoria Katharina Tesch
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Graz, Austria; Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Hassan Abolhassani
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden; Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Bella Shadur
- Department of Bone Marrow Transplantation, Hadassah, Hebrew University Medical Centre, Jerusalem, Israel; Garvan Institute of Medical Research, Department of Immunology, Darlinghurst, Australia
| | - Joachim Zobel
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Yuliya Mareika
- Bone Marrow Transplantation Unit, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Svetlana Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Elif Karakoc-Aydiner
- Faculty of Medicine, Pediatric Immunology and Allergy Division, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Jacques G Rivière
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Marina Garcia-Prat
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Nicolette Moes
- Department of Pediatric Gastroenterology, Antwerp University Hospital, Edegem, and Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Filomeen Haerynck
- Primary Immune Deficiency Research Lab and Department of Internal Medicine and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium
| | - Luis I Gonzales-Granado
- Immunodeficiencies Unit, Hospital 12 de Octubre, Research Institute Hospital 12 Octubre (i+12), Madrid, Spain
| | - Juan Luis Santos Pérez
- Infectious Diseases and Immunodeficiencies Unit, Service of Pediatrics, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Anna Mukhina
- Immunology, the Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Immunology, the Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Lennart Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Sule Haskologlu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Aydan I İkincioğulları
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Sevgi Köstel Bal
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria; CeMM Research Center for Molecular Medicine, Austrian Academy of Sciences, Vienna, Austria
| | - Safa Baris
- Faculty of Medicine, Pediatric Immunology and Allergy Division, Marmara University, Istanbul, Turkey; Istanbul Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Istanbul, Turkey
| | - Sara Sebnem Kilic
- Pediatric Immunology-Rheumatology, Medical Faculty Department of Pediatrics, Uludag University Bursa, Bursa, Turkey
| | - Neslihan Edeer Karaca
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
| | - Necil Kutukculer
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
| | - Hermann Girschick
- Children's Hospital, Vivantes Berlin Friedrichshain, Berlin, Germany
| | - Antonios Kolios
- Department of Immunology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Sevgi Keles
- Meram Medical Faculty, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Konya, Turkey
| | - Vedat Uygun
- Meram Medical Faculty, Division of Pediatric Allergy and Immunology, Necmettin Erbakan University, Konya, Turkey
| | - Polina Stepensky
- Department of Bone Marrow Transplantation, Hadassah, Hebrew University Medical Centre, Jerusalem, Israel
| | - Austen Worth
- Institute of Child Health, University College London, London, United Kingdom
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, UMC Utrecht, The Netherlands
| | - Anke M J Peters
- Department of Pediatric Hematology and Oncology, Center for Pediatrics, Medical Center-University of Freiburg, Freiburg, Germany
| | - Isabelle Meyts
- Department of Pediatrics, University Hospitals Leuven, and the Laboratory for Inborn Errors of Immunity, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Mehdi Adeli
- Sidra Medicine/Hamad Medical Corporation, Doha, Qatar
| | - Antonio Marzollo
- Pediatric Hematology-Oncology Unit, Department of Women's and Children's Health, Azienda Ospedaliera-University of Padova, Padova, Italy
| | - Nurcicek Padem
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Amer M Khojah
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Zahra Chavoshzadeh
- Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Magdalena Avbelj Stefanija
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Shahrzad Bakhtiar
- Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt, Germany
| | - Benoit Florkin
- Immuno-Hémato-Rhumatologie Pédiatrique, Service de Pédiatrie, CHR Citadelle, Liege, Belgium
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health and Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Laura Gamez
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany; DZIF-German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany; Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany; RESIST-Cluster of Excellence 2155 to Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
| | - Mikko R J Seppänen
- Rare Diseases Center and Pediatric Research Center, Children and Adolescents, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland; Adult Immunodeficiency Unit, Inflammation Center, University of Helsinki, and HUS Helsinki University Hospital, Helsinki, Finland; Translational Immunology, Research Programs Unit and Clinicum, University of Helsinki, Helsinki, Finland
| | - Arjan Lankester
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Medical University Graz, Graz, Austria; Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria.
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Using high-throughput sequencing to explore the anti-inflammatory effects of α-mangostin. Sci Rep 2019; 9:15626. [PMID: 31666566 PMCID: PMC6821923 DOI: 10.1038/s41598-019-52036-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022] Open
Abstract
Lipopolysaccharide (LPS) causes an inflammatory response, and α-mangostin (α-MG) is an ingredient of a Chinese herbal medicine with anti-inflammatory effects. We investigated the mechanism by which α-MG reduces LPS-stimulated IEC-6 cells inflammation. A genome-wide examination of control, LPS-stimulated, and α-MG-pretreated cells was performed with the Illumina Hiseq sequencing platform, and gene expression was verified with quantitative real-time PCR (qPCR). Among the 37,199 genes profiled, 2014 genes were regulated in the LPS group, and 475 genes were regulated in the α-MG group. GO enrichment and KEGG pathway analyses of the differentially expressed genes (DEGs) showed that they were mainly related to inflammation and oxidative stress. Based on the transcriptomic results, we constructed a rat model of inflammatory bowel disease (IBD) with LPS and investigated the effects of α-MG on NLRP3 inflammasomes. After LPS stimulation, the rat intestinal villi were significantly detached, with congestion and hemorrhage; the intestinal epithelial cell nuclei were deformed; and the mitochondria were swollen. However, after pretreatment with α-MG, the intestinal villus congestion and hemorrhage were reduced, the epithelial nuclei were rounded, and the mitochondrial morphology was intact. qPCR and western blotting were used to detect NLRP3, caspase 1, interleukin (IL)-18, and IL-1β expression at the gene and protein levels. Their expression increased at both the transcript and protein levels after LPS stimulation, whereas it decreased after pretreatment with α-MG. This study provides new methods and ideas for the treatment of inflammation. α-MG may have utility as a drug for intestinal inflammation.
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12
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Cagdas D, Halaçlı SO, Tan Ç, Lo B, Çetinkaya PG, Esenboğa S, Karaatmaca B, Matthews H, Balcı-Hayta B, Arıkoğlu T, Ezgü F, Aladağ E, Saltık-Temizel İN, Demir H, Kuşkonmaz B, Okur V, Gümrük F, Göker H, Çetinkaya D, Boztuğ K, Lenardo M, Sanal Ö, Tezcan İ. A Spectrum of Clinical Findings from ALPS to CVID: Several Novel LRBA Defects. J Clin Immunol 2019; 39:726-738. [PMID: 31432443 PMCID: PMC11090043 DOI: 10.1007/s10875-019-00677-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/25/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Autosomal recessively inherited lipopolysaccharide-responsive beige-like anchor (LRBA) protein deficiency was shown to be responsible for different types of inborn errors of immunity, such as common variable immunodeficiency (CVID) and autoimmune lymphoproliferative syndrome (ALPS). The aim of this study was to compare patients with LRBA-related ALPS and LRBA-related CVID, to describe their clinical and laboratory phenotypes, and to prepare an algorithm for their diagnosis and management. METHODS Fifteen LRBA-deficient patients were identified among 31 CVID and 14 possible ALPS patients with Western blotting (WB), primary immunodeficiency disease (PIDD) gene, next-generation panel screening (NGS), and whole exome sequencing (WES). RESULTS The median age on admission and age of diagnosis were 7 years (0.3-16.5) and 11 years (5-44), respectively. Splenomegaly was seen in 93.3% (14/15) of the patients on admission. Splenectomy was performed to 1/5. Recurrent upper respiratory tract infections (93.3% (14/15)), autoimmune cytopenia (80% (12/15)), chronic diarrhea (53.3% (8/15)), lower respiratory tract infections (53.3% (8/15)), lymphoma (26.6% (4/15)), Evans syndrome (26.6% (4/15)), and autoimmune thyroiditis (20% (3/15)) were common clinical findings and diseases. Lymphopenia (5/15), intermittant neutropenia (4/15), eosinophilia (4/15), and progressive hypogammaglobulinemia are recorded in given number of patients. Double negative T cells (TCRαβ+CD4-CD8-) were increased in 80% (8/10) of the patients. B cell percentage/numbers were low in 60% (9/15) of the patients on admission. Decreased switched memory B cells, decreased naive and recent thymic emigrant (RTE) Thelper (Th) cells, markedly increased effector memory/effector memory RA+ (TEMRA) Th were documented. Large PD1+ population, increased memory, and enlarged follicular helper T cell population in the CD4+ T cell compartment was seen in one of the patients. Most of the deleterious missense mutations were located in the DUF1088 and BEACH domains. Interestingly, one of the two siblings with the same homozygous LRBA defect did not have any clinical symptom. Hematopoietic stem cell transplantation (HSCT) was performed to 7/15 (46.6%) of the patients. Transplanted patients are alive and well after a median of 2 years (1-3). In total, one patient died from sepsis during adulthood before HSCT. CONCLUSION Patients with LRBA deficiency may initially be diagnosed as CVID or ALPS in the clinical practice. Progressive decrease in B cells as well as IgG in ALPS-like patients and addition of IBD symptoms in the follow-up should raise the suspicion for LRBA deficiency. Decreased switched memory B cells, decreased naive and recent thymic emigrant (RTE) Th cells, and markedly increased effector memory/effector memory RA+ Th cells (TEMRA Th) cells are important for the diagnosis of the patients in addition to clinical features. Analysis of protein by either WB or flow cytometry is required when the clinicians come across especially with missense LRBA variants of uncertain significance. High rate of malignancy shows the regulatory T cell's important role of immune surveillance. HSCT is curative and succesful in patients with HLA-matched family donor.
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Affiliation(s)
- Deniz Cagdas
- Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey.
| | | | - Çağman Tan
- Institute of Child Health, Immunology, Hacettepe University, Ankara, Turkey
| | - Bernice Lo
- Sidra Medical and Research Center, Al Rayyan, Qatar
| | - Pınar Gür Çetinkaya
- Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Saliha Esenboğa
- Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Betül Karaatmaca
- Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Helen Matthews
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Burcu Balcı-Hayta
- Department of Medical Biology, Hacettepe University Medical School, Ankara, Turkey
| | - Tuba Arıkoğlu
- Department of Pediatrics, Division of Allergy and Immunology, Mersin University Medical School, Mersin, Turkey
| | - Fatih Ezgü
- Department of Pediatrics, Division of Pediatric Inborn Metabolic Disorders, Metabolism and Genetics, Gazi University Medical School, Ankara, Turkey
| | - Elifcan Aladağ
- Department of Internal Medicine, Division of Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - İnci N Saltık-Temizel
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hacettepe University Medical School, Ankara, Turkey
| | - Hülya Demir
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hacettepe University Medical School, Ankara, Turkey
| | - Barış Kuşkonmaz
- Department of Pediatrics, Division of Pediatric Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Visal Okur
- Department of Pediatrics, Division of Pediatric Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Fatma Gümrük
- Department of Pediatrics, Division of Pediatric Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Hakan Göker
- Department of Internal Medicine, Division of Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Duygu Çetinkaya
- Department of Pediatrics, Division of Pediatric Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Kaan Boztuğ
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Michael Lenardo
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Özden Sanal
- Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - İlhan Tezcan
- Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
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13
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Okur FV, Kuskonmaz B, Cagdas D, Tezcan I, Uckan-Cetinkaya D. Bone marrow transplantation with Favorable outcome in three patients with LPS-responsive beige-like anchor (LRBA) deficiency. Clin Immunol 2019; 203:162-165. [PMID: 31026575 DOI: 10.1016/j.clim.2019.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/29/2019] [Accepted: 04/22/2019] [Indexed: 01/26/2023]
Affiliation(s)
- F V Okur
- Department of Pediatrics and Pediatric Hematology, BMT Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey; Center for Stem Cell Research and Development, Hacettepe University, Ankara, Turkey.
| | - B Kuskonmaz
- Department of Pediatrics and Pediatric Hematology, BMT Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - D Cagdas
- Department of Pediatrics and Pediatric Immunology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - I Tezcan
- Department of Pediatrics and Pediatric Immunology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - D Uckan-Cetinkaya
- Department of Pediatrics and Pediatric Hematology, BMT Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey; Center for Stem Cell Research and Development, Hacettepe University, Ankara, Turkey
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Habibi S, Zaki-Dizaji M, Rafiemanesh H, Lo B, Jamee M, Gámez-Díaz L, Salami F, Kamali AN, Mohammadi H, Abolhassani H, Yazdani R, Aghamohammadi A, Anaya JM, Azizi G. Clinical, Immunologic, and Molecular Spectrum of Patients with LPS-Responsive Beige-Like Anchor Protein Deficiency: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2379-2386.e5. [PMID: 30995531 DOI: 10.1016/j.jaip.2019.04.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND LPS-responsive beige-like anchor protein (LRBA) deficiency is a primary immunodeficiency and immune dysregulation syndrome caused by biallelic mutations in the LRBA gene. These mutations usually abrogate the protein expression of LRBA, leading to a broad spectrum of clinical phenotypes including autoimmunity, chronic diarrhea, hypogammaglobulinemia, and recurrent infections. OBJECTIVE Our aim was to systematically collect all studies reporting on the clinical manifestations, molecular and laboratory findings, and management of patients with LRBA deficiency. METHODS We searched in PubMed, Web of Science, and Scopus without any restrictions on study design and publication time. A total of 109 LRBA-deficient cases were identified from 45 eligible articles. For all patients, demographic information, clinical records, and immunologic and molecular data were collected. RESULTS Of the patients with LRBA deficiency, 93 had homozygous and 16 had compound heterozygous mutations in LRBA. The most common clinical manifestations were autoimmunity (82%), enteropathy (63%), splenomegaly (57%), and pneumonia (49%). Reduction in numbers of CD4+ T cells and regulatory T cells as well as IgG levels was recorded for 21.6%, 65.6%, and 54.2% of evaluated patients, respectively. B-cell subpopulation analysis revealed low numbers of switched-memory and increased numbers of CD21low B cells in 73.5% and 77.8% of patients, respectively. Eighteen (16%) patients underwent hematopoietic stem cell transplantation due to the severity of complications and the outcomes improved in 13 of them. CONCLUSIONS Autoimmune disorders are the main clinical manifestations of LRBA deficiency. Therefore, LRBA deficiency should be included in the list of monogenic autoimmune diseases, and screening for LRBA mutations should be routinely performed for patients with these conditions.
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Affiliation(s)
- Sima Habibi
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Zaki-Dizaji
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Hosein Rafiemanesh
- Student Research Committee, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bernice Lo
- Division of Translational Medicine, Research Branch, Sidra Medicine, Doha, Qatar
| | - Mahnaz Jamee
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | - Laura Gámez-Díaz
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg im Breisgau, Germany
| | - Fereshte Salami
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali N Kamali
- CinnaGen Medical Biotechnology Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Hamed Mohammadi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Abolhassani
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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15
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Neurological Involvement in Childhood Evans Syndrome. J Clin Immunol 2019; 39:171-181. [PMID: 30671780 DOI: 10.1007/s10875-019-0594-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia (AIHA) are associated in the definition of Evans syndrome (ES). The occurrence of neurological involvement in this population is poorly described and suggests an underlying primary immunodeficiency (PID). We aimed to describe the clinical manifestations, evolution, and PID profiles of these patients. METHODS OBS'CEREVANCE is a French, nationwide prospective cohort that includes children with chronic ITP, AIHA, and ES. Patients with a neurological involvement were described. Centralized radiological and pathological reviews and genetic analyses were performed. RESULTS On October 2016, eight patients (7/181 ES, 1/371 AIHA, and 0/615 ITP) were identified, all male, with a median age (range) at cytopenia onset of 11.5 years (1.6-15.8). Neurological symptoms appeared with a median delay of 6 years (2.5-18) after cytopenia and were polymorphic: seizures (n = 4), cranial nerve palsy (n = 2), Brown-Sequard syndrome (n = 2), intracranial pressure (n = 2), vertigo (n = 1), and/or sensory neuropathy (n = 1). Magnetic resonance imaging (MRI) showed inflammatory lesions, confirmed by pathology for five patients with macrophagic or lymphoplasmocytic infiltrates. All patients had other relevant immunopathological manifestations: pulmonary nodules (n = 6), lymphoproliferation (n = 4), abnormal immunophenotype (n = 8), and hypogammaglobulinemia (n = 7). Treatment consisted of steroids that improved symptomatology and MRI. Five patients relapsed and three had an asymptomatic radiological progression. A PID was identified in 3/8 patients: 22q11.2 microdeletion (n = 1) and CTLA deficiency (n = 2). CONCLUSION Neurological involvement is a rare and severe late event in the course of childhood ES, which can reveal an underlying PID. Imaging and pathology examination highlight a causative immune dysregulation that may guide targeted therapeutic strategies.
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Castagnoli R, Delmonte OM, Calzoni E, Notarangelo LD. Hematopoietic Stem Cell Transplantation in Primary Immunodeficiency Diseases: Current Status and Future Perspectives. Front Pediatr 2019; 7:295. [PMID: 31440487 PMCID: PMC6694735 DOI: 10.3389/fped.2019.00295] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/03/2019] [Indexed: 12/29/2022] Open
Abstract
Primary immunodeficiencies (PID) are disorders that for the most part result from mutations in genes involved in immune host defense and immunoregulation. These conditions are characterized by various combinations of recurrent infections, autoimmunity, lymphoproliferation, inflammatory manifestations, atopy, and malignancy. Most PID are due to genetic defects that are intrinsic to hematopoietic cells. Therefore, replacement of mutant cells by healthy donor hematopoietic stem cells (HSC) represents a rational therapeutic approach. Full or partial ablation of the recipient's marrow with chemotherapy is often used to allow stable engraftment of donor-derived HSCs, and serotherapy may be added to the conditioning regimen to reduce the risks of graft rejection and graft versus host disease (GVHD). Initially, hematopoietic stem cell transplantation (HSCT) was attempted in patients with severe combined immunodeficiency (SCID) as the only available curative treatment. It was a challenging procedure, associated with elevated rates of morbidity and mortality. Overtime, outcome of HSCT for PID has significantly improved due to availability of high-resolution HLA typing, increased use of alternative donors and new stem cell sources, development of less toxic, reduced-intensity conditioning (RIC) regimens, and cellular engineering techniques for graft manipulation. Early identification of infants affected by SCID, prior to infectious complication, through newborn screening (NBS) programs and prompt genetic diagnosis with Next Generation Sequencing (NGS) techniques, have also ameliorated the outcome of HSCT. In addition, HSCT has been applied to treat a broader range of PID, including disorders of immune dysregulation. Yet, the broad spectrum of clinical and immunological phenotypes associated with PID makes it difficult to define a universal transplant regimen. As such, integration of knowledge between immunologists and transplant specialists is necessary for the development of innovative transplant protocols and to monitor their results during follow-up. Despite the improved outcome observed after HSCT, patients with severe forms of PID still face significant challenges of short and long-term transplant-related complications. To address this issue, novel HSCT strategies are being implemented aiming to improve both survival and long-term quality of life. This article will discuss the current status and latest developments in HSCT for PID, and present data regarding approach and outcome of HSCT in recently described PID, including disorders associated with immune dysregulation.
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Affiliation(s)
- Riccardo Castagnoli
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Ottavia Maria Delmonte
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Enrica Calzoni
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Department of Molecular and Translational Medicine, A. Nocivelli Institute for Molecular Medicine, University of Brescia, Brescia, Italy
| | - Luigi Daniele Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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17
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Delmonte OM, Castagnoli R, Calzoni E, Notarangelo LD. Inborn Errors of Immunity With Immune Dysregulation: From Bench to Bedside. Front Pediatr 2019; 7:353. [PMID: 31508401 PMCID: PMC6718615 DOI: 10.3389/fped.2019.00353] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/08/2019] [Indexed: 12/20/2022] Open
Abstract
Inborn errors of immunity are genetic disorders with broad clinical manifestations, ranging from increased susceptibility to infections to significant immune dysregulation, often leading to multiple autoimmune phenomena, lymphoproliferation, and malignancy. The treatment is challenging as it requires careful balancing of immunosuppression in subjects at increased risk of infections. Recently, the improved ability to define inborn errors of immunity pathophysiology at the molecular level has set the basis for the development of targeted therapeutic interventions. Such a "precision medicine" approach is mainly bases on the use of available small molecules and biologics to target a specific cell function. In this article, we summarize the clinical and laboratory features of various recently described inborn errors of immunity associated with immune dysregulation and hyperinflammation in which mechanism-based therapeutic approaches have been implemented.
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Affiliation(s)
- Ottavia Maria Delmonte
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Riccardo Castagnoli
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Foundation IRCCS Policlinico San Matteo, Department of Pediatrics, University of Pavia, Pavia, Italy
| | - Enrica Calzoni
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States.,Department of Molecular and Translational Medicine, A. Nocivelli Institute for Molecular Medicine, University of Brescia, Brescia, Italy
| | - Luigi Daniele Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
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18
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Bakhtiar S, Fekadu J, Seidel MG, Gambineri E. Allogeneic Hematopoietic Stem Cell Transplantation for Congenital Immune Dysregulatory Disorders. Front Pediatr 2019; 7:461. [PMID: 31799221 PMCID: PMC6865355 DOI: 10.3389/fped.2019.00461] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/23/2019] [Indexed: 12/30/2022] Open
Abstract
Primary immunodeficiency disorders that predominantly affect immune regulation and mechanisms of self-tolerance have come into the limelight, because at least for a subgroup of monogenetic disorders, a targeted therapy has become available. Nevertheless, their management often involves the treatment of severely compromising, refractory, multi-organ autoimmunity, leading to further increased susceptibility to infections and complications of long-term immune suppressive treatment, including the risk of malignancy. While evidence for allogeneic hematopoietic stem cell transplantation (alloHSCT) as a curative treatment option for severely affected patients by this disease category accumulates, clear indications, and guidelines for alloHSCT are lacking. Predictive and stratification-relevant tools such as disease activity scores are largely missing and often there is not a consistent genotype-phenotype correlation within the same family to facilitate the decision whether to transplant or not. In this review, we provide a literature-based update on indications and outcomes of alloHSCT for congenital immune dysregulative inborn errors of immunity according to the IUIS classification 2017.
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Affiliation(s)
- Shahrzad Bakhtiar
- Division for Pediatric Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt, Germany
| | - Julia Fekadu
- Division for Pediatric Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt, Germany
| | - Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Eleonora Gambineri
- NEUROFARBA Department, University of Florence, University of Florence, Florence, Italy.,Haematology-Oncology Department, Anna Meyer Children's Hospital, Florence, Italy
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Schwab C, Gabrysch A, Olbrich P, Patiño V, Warnatz K, Wolff D, Hoshino A, Kobayashi M, Imai K, Takagi M, Dybedal I, Haddock JA, Sansom DM, Lucena JM, Seidl M, Schmitt-Graeff A, Reiser V, Emmerich F, Frede N, Bulashevska A, Salzer U, Schubert D, Hayakawa S, Okada S, Kanariou M, Kucuk ZY, Chapdelaine H, Petruzelkova L, Sumnik Z, Sediva A, Slatter M, Arkwright PD, Cant A, Lorenz HM, Giese T, Lougaris V, Plebani A, Price C, Sullivan KE, Moutschen M, Litzman J, Freiberger T, van de Veerdonk FL, Recher M, Albert MH, Hauck F, Seneviratne S, Pachlopnik Schmid J, Kolios A, Unglik G, Klemann C, Speckmann C, Ehl S, Leichtner A, Blumberg R, Franke A, Snapper S, Zeissig S, Cunningham-Rundles C, Giulino-Roth L, Elemento O, Dückers G, Niehues T, Fronkova E, Kanderová V, Platt CD, Chou J, Chatila TA, Geha R, McDermott E, Bunn S, Kurzai M, Schulz A, Alsina L, Casals F, Deyà-Martinez A, Hambleton S, Kanegane H, Taskén K, Neth O, Grimbacher B. Phenotype, penetrance, and treatment of 133 cytotoxic T-lymphocyte antigen 4-insufficient subjects. J Allergy Clin Immunol 2018; 142:1932-1946. [PMID: 29729943 PMCID: PMC6215742 DOI: 10.1016/j.jaci.2018.02.055] [Citation(s) in RCA: 287] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/16/2018] [Accepted: 02/25/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cytotoxic T-lymphocyte antigen 4 (CTLA-4) is a negative immune regulator. Heterozygous CTLA4 germline mutations can cause a complex immune dysregulation syndrome in human subjects. OBJECTIVE We sought to characterize the penetrance, clinical features, and best treatment options in 133 CTLA4 mutation carriers. METHODS Genetics, clinical features, laboratory values, and outcomes of treatment options were assessed in a worldwide cohort of CTLA4 mutation carriers. RESULTS We identified 133 subjects from 54 unrelated families carrying 45 different heterozygous CTLA4 mutations, including 28 previously undescribed mutations. Ninety mutation carriers were considered affected, suggesting a clinical penetrance of at least 67%; median age of onset was 11 years, and the mortality rate within affected mutation carriers was 16% (n = 15). Main clinical manifestations included hypogammaglobulinemia (84%), lymphoproliferation (73%), autoimmune cytopenia (62%), and respiratory (68%), gastrointestinal (59%), or neurological features (29%). Eight affected mutation carriers had lymphoma, and 3 had gastric cancer. An EBV association was found in 6 patients with malignancies. CTLA4 mutations were associated with lymphopenia and decreased T-, B-, and natural killer (NK) cell counts. Successful targeted therapies included application of CTLA-4 fusion proteins, mechanistic target of rapamycin inhibitors, and hematopoietic stem cell transplantation. EBV reactivation occurred in 2 affected mutation carriers after immunosuppression. CONCLUSIONS Affected mutation carriers with CTLA-4 insufficiency can present in any medical specialty. Family members should be counseled because disease manifestation can occur as late as 50 years of age. EBV- and cytomegalovirus-associated complications must be closely monitored. Treatment interventions should be coordinated in clinical trials.
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Affiliation(s)
- Charlotte Schwab
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Annemarie Gabrysch
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Olbrich
- Sección de Infectología e Inmunopatología, Unidad de Pediatría, Hospital Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | | | - Klaus Warnatz
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Akihiro Hoshino
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masao Kobayashi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan
| | - Kohsuke Imai
- Department of Community Pediatrics, Perinatal and Maternal Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masatoshi Takagi
- Department of Community Pediatrics, Perinatal and Maternal Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ingunn Dybedal
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Jamanda A Haddock
- Department of Radiology, Royal Free Hospital, University College London, London, United Kingdom
| | - David M Sansom
- UCL Institute of Immunity and Transplantation, Royal Free Hospital, London, United Kingdom
| | - Jose M Lucena
- Unidad de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Maximilian Seidl
- Center for Chronic Immunodeficiency and Molecular Pathology, Department of Pathology, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Annette Schmitt-Graeff
- Department of Pathology, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Veronika Reiser
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Florian Emmerich
- Institute for Transfusion Medicine and Gene Therapy, University Medical Center Freiburg, Freiburg, Germany
| | - Natalie Frede
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alla Bulashevska
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Salzer
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Desirée Schubert
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Spemann Graduate School of Biology and Medicine, Freiburg University, Freiburg, Germany
| | - Seiichi Hayakawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima, Japan
| | - Maria Kanariou
- Department of Immunology and Histocompatibility, Centre for Primary Immunodeficiencies, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Zeynep Yesim Kucuk
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati, Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hugo Chapdelaine
- Department of Medicine, Clinical Immunology and Allergy Division, Centre Hospitalier de l'Université de Montréal (CHUM), Université de Montréal, Montreal, Quebec, Canada
| | - Lenka Petruzelkova
- Department of Pediatrics, University Hospital Motol and 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, University Hospital Motol and 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, University Hospital Motol and 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Mary Slatter
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Institute of Cellular Medicine, Newcastle University, Newcastle, United Kingdom
| | - Peter D Arkwright
- University of Manchester, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Andrew Cant
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Institute of Cellular Medicine, Newcastle University, Newcastle, United Kingdom
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Thomas Giese
- Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Vassilios Lougaris
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Alessandro Plebani
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - Christina Price
- Section of Allergy and Clinical Immunology, Yale University School of Medicine, New Haven, Conn
| | - Kathleen E Sullivan
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Michel Moutschen
- Department of Infectious Diseases and General Internal Medicine, University Hospital of Liège, Liege, Belgium
| | - Jiri Litzman
- Department of Clinical Immunology and Allergology, Medical Faculty, Masaryk University, Brno, Czech Republic; Department of Clinical Immunology and Allergology, St Anne's University Hospital, Brno, Czech Republic
| | - Tomas Freiberger
- Molecular Genetics Laboratory, Centre for Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Medical Genomics RG, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Mike Recher
- Immunodeficiency Clinic, Medical Outpatient Unit and Immunodeficiency Lab, Department Biomedicine, University Hospital, Basel, Switzerland
| | - Michael H Albert
- Department of Pediatric Immunology and Stem Cell Transplantation, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Fabian Hauck
- Department of Pediatric Immunology and Stem Cell Transplantation, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Suranjith Seneviratne
- Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
| | - Jana Pachlopnik Schmid
- Division of Immunology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Antonios Kolios
- Department of Immunology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gary Unglik
- Department of Clinical Immunology and Allergy, Royal Melbourne Hospital, Melbourne, Australia
| | - Christian Klemann
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Pediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany; Center of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Carsten Speckmann
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Pediatrics, University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Ehl
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alan Leichtner
- Division of Gastroenterology and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Richard Blumberg
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Scott Snapper
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Children's Hospital Boston, Mass
| | - Sebastian Zeissig
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Medicine I, University Medical Center Dresden, Technical University Dresden, Dresden, Germany; Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Charlotte Cunningham-Rundles
- Mount Sinai Hospital, Mount Sinai St Luke's and Mount Sinai West, Department of Medicine-Allergy & Immunology, New York, NY
| | - Lisa Giulino-Roth
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY
| | - Olivier Elemento
- Institute for Computational Biomedicine, Department of Physiology and Biophysics, Weill Cornell Medical College, New York, NY
| | | | - Tim Niehues
- HELIOS Children's Hospital, Krefeld, Germany
| | - Eva Fronkova
- CLIP, Department of Paediatric Haematology/Oncology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Veronika Kanderová
- CLIP, Department of Paediatric Haematology/Oncology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Talal A Chatila
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Raif Geha
- Division of Immunology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Elizabeth McDermott
- Clinical Immunology and Allergy Unit, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Su Bunn
- Department of Paediatric Gastroenterology, Great North Children's Hospital, Newcastle, United Kingdom
| | - Monika Kurzai
- Department of Pediatrics, University Hospital Jena, Jena, Germany
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Laia Alsina
- Allergy and Clinical Immunology Department, Functional Unit of Immunology SJD-Clinic, Hospital Sant Joan de Déu, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Ferran Casals
- Servei de Genòmica, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain
| | - Angela Deyà-Martinez
- Allergy and Clinical Immunology Department, Functional Unit of Immunology SJD-Clinic, Hospital Sant Joan de Déu, Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Sophie Hambleton
- Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Institute of Cellular Medicine, Newcastle University, Newcastle, United Kingdom
| | - Hirokazu Kanegane
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kjetil Taskén
- Centre for Molecular Medicine Norway, Nordic EMBL Partnership, University of Oslo and Institute for Cancer Research, University Hospital Oslo, Oslo, Norway
| | - Olaf Neth
- Sección de Infectología e Inmunopatología, Unidad de Pediatría, Hospital Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency (CCI), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, United Kingdom.
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20
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Soler-Palacín P, Garcia-Prat M, Martín-Nalda A, Franco-Jarava C, Rivière JG, Plaja A, Bezdan D, Bosio M, Martínez-Gallo M, Ossowski S, Colobran R. LRBA Deficiency in a Patient With a Novel Homozygous Mutation Due to Chromosome 4 Segmental Uniparental Isodisomy. Front Immunol 2018; 9:2397. [PMID: 30386343 PMCID: PMC6198091 DOI: 10.3389/fimmu.2018.02397] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/27/2018] [Indexed: 12/20/2022] Open
Abstract
LRBA deficiency was first described in 2012 as an autosomal recessive disorder caused by biallelic mutations in the LRBA gene (OMIM #614700). It was initially characterized as producing early-onset hypogammaglobulinemia, autoimmune manifestations, susceptibility to inflammatory bowel disease, and recurrent infection. However, further reports expanded this phenotype (including patients without hypogammaglobulinemia) and described LRBA deficiency as a clinically variable syndrome with a wide spectrum of clinical manifestations. We present the case of a female patient who presented with type 1 diabetes, psoriasis, oral thrush, and enlarged liver and spleen at the age of 8 months. She later experienced recurrent bacterial and viral infections, including pneumococcal meningitis and Epstein Barr viremia. She underwent two consecutive stem cell transplants at the age of 8 and 9 years, and ultimately died. Samples from the patient and her parents were subjected to whole exome sequencing, which revealed a homozygous 1-bp insertion in exon 23 of the patient's LRBA gene, resulting in frameshift and premature stop codon. The patient's healthy mother was heterozygous for the mutation and her father tested wild-type. This finding suggested that either one copy of the paternal chromosome 4 bore a deletion including the LRBA locus, or the patient inherited two copies of the mutant maternal LRBA allele. The patient's sequencing data showed a 1-Mb loss of heterozygosity region in chromosome 4, including the LRBA gene. Comparative genomic hybridization array of the patient's and father's genomic DNA yielded normal findings, ruling out genomic copy number abnormalities. Here, we present the first case of LRBA deficiency due to a uniparental disomy (UPD). In contrast to classical Mendelian inheritance, UPD involves inheritance of 2 copies of a chromosomal region from only 1 parent. Specifically, our patient carried a small segmental isodisomy of maternal origin affecting 1 Mb of chromosome 4.
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Affiliation(s)
- Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Marina Garcia-Prat
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Andrea Martín-Nalda
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Clara Franco-Jarava
- Jeffrey Modell Foundation Excellence Center, Barcelona, Spain.,Immunology Division, Department of Cell Biology, Physiology and Immunology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Jacques G Rivière
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.,Jeffrey Modell Foundation Excellence Center, Barcelona, Spain
| | - Alberto Plaja
- Department of Clinical and Molecular Genetics, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Daniela Bezdan
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
| | - Mattia Bosio
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain
| | - Mónica Martínez-Gallo
- Jeffrey Modell Foundation Excellence Center, Barcelona, Spain.,Immunology Division, Department of Cell Biology, Physiology and Immunology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Stephan Ossowski
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain.,Universitat Pompeu Fabra, Barcelona, Spain.,Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Roger Colobran
- Jeffrey Modell Foundation Excellence Center, Barcelona, Spain.,Immunology Division, Department of Cell Biology, Physiology and Immunology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain.,Department of Clinical and Molecular Genetics, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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21
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Rotz SJ, Ware RE, Kumar A. Diagnosis and management of chronic and refractory immune cytopenias in children, adolescents, and young adults. Pediatr Blood Cancer 2018; 65:e27260. [PMID: 29856527 DOI: 10.1002/pbc.27260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/26/2018] [Accepted: 05/06/2018] [Indexed: 12/13/2022]
Abstract
Children, adolescents, and young adults with chronic refractory autoimmune cytopenias represent a rare but challenging group of patients, who are managed frequently by pediatric hematologists. Novel diagnostic tests and genomic discoveries are refining historical diagnoses of Evans syndrome and common variable immunodeficiency, while also elucidating the cellular and molecular basis for these disorders. Genetic characterization of chronic and refractory autoimmune cytopenias has led to targeted therapies with improved clinical outcomes and fewer off-target toxicities. In this review, we focus on the appropriate diagnostic workup, expanded genetic testing, and novel treatment opportunities that are available for these challenging patients.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Russell E Ware
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashish Kumar
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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22
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The Treatment of Inflammatory Bowel Disease in Patients with Selected Primary Immunodeficiencies. J Clin Immunol 2018; 38:579-588. [DOI: 10.1007/s10875-018-0524-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 06/06/2018] [Indexed: 12/25/2022]
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23
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Nunes-Santos CDJ, Rosenzweig SD. Bacille Calmette-Guerin Complications in Newly Described Primary Immunodeficiency Diseases: 2010-2017. Front Immunol 2018; 9:1423. [PMID: 29988375 PMCID: PMC6023996 DOI: 10.3389/fimmu.2018.01423] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/07/2018] [Indexed: 12/25/2022] Open
Abstract
Bacille Calmette–Guerin (BCG) vaccine is widely used as a prevention strategy against tuberculosis. BCG is a live vaccine, usually given early in life in most countries. While safe to most recipients, it poses a risk to immunocompromised patients. Several primary immunodeficiency diseases (PIDD) have been classically associated with complications related to BCG vaccine. However, a number of new inborn errors of immunity have been described lately in which little is known about adverse reactions following BCG vaccination. The aim of this review is to summarize the existing data on BCG-related complications in patients diagnosed with PIDD described since 2010. When BCG vaccination status or complications were not specifically addressed in those manuscripts, we directly contacted the corresponding authors for further clarification. We also analyzed data on other mycobacterial infections in these patients. Based on our analysis, around 8% of patients with gain-of-function mutations in STAT1 had mycobacterial infections, including localized complications in 3 and disseminated disease in 4 out of 19 BCG-vaccinated patients. Localized BCG reactions were also frequent in activated PI3Kδ syndrome type 1 (3/10) and type 2 (2/18) vaccinated children. Also, of note, no BCG-related complications have been described in either CTLA4 or LRBA protein-deficient patients; and not enough information on BCG-vaccinated NFKB1 or NFKB2-deficient patients was available to drive any conclusions about these diseases. Despite the high prevalence of environmental mycobacterial infections in GATA2-deficient patients, only one case of BCG reaction has been reported in a patient who developed disseminated disease. In conclusion, BCG complications could be expected in some particular, recently described PIDD and it remains a preventable risk factor for pediatric PIDD patients.
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Affiliation(s)
- Cristiane de Jesus Nunes-Santos
- Faculdade de Medicina, Instituto da Crianca, Universidade de São Paulo, São Paulo, Brazil.,Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, NIH Clinical Center, National Institutes of Health (NIH), Bethesda, MD, United States
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24
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Sharapova SO, Haapaniemi E, Sakovich IS, Rojas J, Gámez-Díaz L, Mareika YE, Guryanova IE, Migas AA, Mikhaleuskaya TM, Grimbacher B, Aleinikova OV. Novel LRBA Mutation and Possible Germinal Mosaicism in a Slavic Family. J Clin Immunol 2018; 38:471-474. [PMID: 29804237 DOI: 10.1007/s10875-018-0515-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 05/17/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Svetlana O Sharapova
- Research Department, Immunology Laboratory, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Minsk Region, Belarus.
| | - Emma Haapaniemi
- Department of Hematology and Regenerative Medicine, Karolinska Institutet, Huddinge, Sweden
- Genome-Scale Biology Program, University of Helsinki, Helsinki, Finland
| | - Inga S Sakovich
- Research Department, Immunology Laboratory, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Minsk Region, Belarus
| | - Jessica Rojas
- Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Laura Gámez-Díaz
- Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Yuliya E Mareika
- Research Department, Immunology Laboratory, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Minsk Region, Belarus
| | - Irina E Guryanova
- Research Department, Immunology Laboratory, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Minsk Region, Belarus
| | - Alexandr A Migas
- Research Department, Immunology Laboratory, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Minsk Region, Belarus
| | - Taisiya M Mikhaleuskaya
- Research Department, Immunology Laboratory, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Minsk Region, Belarus
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Olga V Aleinikova
- Research Department, Immunology Laboratory, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, 223053, Borovliani, Minsk Region, Belarus
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25
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Gámez-Díaz L, Sigmund EC, Reiser V, Vach W, Jung S, Grimbacher B. Rapid Flow Cytometry-Based Test for the Diagnosis of Lipopolysaccharide Responsive Beige-Like Anchor (LRBA) Deficiency. Front Immunol 2018; 9:720. [PMID: 29740429 PMCID: PMC5925005 DOI: 10.3389/fimmu.2018.00720] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/22/2018] [Indexed: 12/18/2022] Open
Abstract
The diagnosis of lipopolysaccharide-responsive beige-like-anchor-protein (LRBA) deficiency currently relies on gene sequencing approaches that do not support a timely diagnosis and clinical management. We developed a rapid and sensitive test for clinical implementation based on the detection of LRBA protein by flow cytometry in peripheral blood cells after stimulation. LRBA protein was assessed in a prospective cohort of 54 healthy donors and 57 patients suspected of LRBA deficiency. Receiver operating characteristics analysis suggested an LRBA:MFI ratio cutoff point of 2.6 to identify LRBA-deficient patients by FACS with 94% sensitivity and 80% specificity and to discriminate them from patients with a similar clinical picture but other disease-causing mutations. This easy flow cytometry-based assay allows a fast screening of patients with suspicion of LRBA deficiency reducing therefore the number of patients requiring LRBA sequencing and accelerating the treatment implementation. Detection of biallelic mutations in LRBA is however required for a definitive diagnosis.
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Affiliation(s)
- Laura Gámez-Díaz
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Elena C Sigmund
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
| | - Veronika Reiser
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany.,Institute of Medical Biometry and Statistics, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Werner Vach
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Sophie Jung
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany.,Pôle de Médecine et de Chirurgie Bucco-Dentaires, University Hospital, Faculty of Dentistry, University of Strasbourg, Strasbourg, France
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany.,Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, United Kingdom
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26
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Hauck F, Voss R, Urban C, Seidel MG. Intrinsic and extrinsic causes of malignancies in patients with primary immunodeficiency disorders. J Allergy Clin Immunol 2018; 141:59-68.e4. [DOI: 10.1016/j.jaci.2017.06.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/19/2017] [Accepted: 06/06/2017] [Indexed: 12/11/2022]
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27
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Kostel Bal S, Haskologlu S, Serwas NK, Islamoglu C, Aytekin C, Kendirli T, Kuloglu Z, Yavuz G, Dalgic B, Siklar Z, Kansu A, Ensari A, Boztug K, Dogu F, Ikinciogullari A. Multiple Presentations of LRBA Deficiency: a Single-Center Experience. J Clin Immunol 2017; 37:790-800. [PMID: 28956255 PMCID: PMC7086713 DOI: 10.1007/s10875-017-0446-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 09/18/2017] [Indexed: 11/25/2022]
Abstract
Introduction LPS-responsive beige-like anchor protein (LRBA) deficiency is a primary immunodeficiency categorized as common variable immunodeficiency associated with autoimmune manifestations and inflammatory bowel diseases; however, the clinical spectrum has been extended. Here, we present our cohort of Turkish LRBA-deficient patients from a single center, demonstrating a diversity of clinical manifestations. Method Seven affected individuals from five families were assessed retrospectively in this study. Results Of the seven patients with LRBA deficiency, four had homozygous, and two had compound heterozygous mutations. One patient remained disease free until the last follow-up (age 17 years). The most common clinical manifestations of the six symptomatic patients were organomegaly (6/6), autoimmunity (6/6), and chronic diarrhea (5/6). Recurrent infectious episodes were observed in three patients. None of the patients had hypogammaglobulinemia at presentation. B cell subpopulation analysis revealed low numbers of switched-memory B cell numbers in two of the four tested patients. During the disease course, three of the patients died, two of them underwent successful hematopoietic stem cell transplantation (HSCT) from matched sibling donors, and one is under abatacept therapy. Conclusion LRBA defects should always be kept in mind as a differential diagnosis for patients with autoimmune disease affecting multiple organs, chronic diarrhea, and organomegalies. In our experience, early HSCT is a life-saving therapeutic strategy.
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Affiliation(s)
- Sevgi Kostel Bal
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Cebeci, 06590, Ankara, Turkey
| | - Sule Haskologlu
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Cebeci, 06590, Ankara, Turkey
| | - Nina K Serwas
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Candan Islamoglu
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Cebeci, 06590, Ankara, Turkey
| | - Caner Aytekin
- Department of Pediatric Immunology, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Tanil Kendirli
- Department of Pediatric Intensive Care, Ankara University School of Medicine, Ankara, Turkey
| | - Zarife Kuloglu
- Department of Pediatric Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Gulsan Yavuz
- Department of Pediatric Oncology, Ankara University School of Medicine, Ankara, Turkey
| | - Buket Dalgic
- Department of Pediatric Gastroenterology, Gazi University School of Medicine, Ankara, Turkey
| | - Zeynep Siklar
- Department of Pediatric Endocrinology, Ankara University School of Medicine, Ankara, Turkey
| | - Aydan Kansu
- Department of Pediatric Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Arzu Ensari
- Department of Pathology, Ankara University School of Medicine, Ankara, Turkey
| | - Kaan Boztug
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- St. Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Figen Dogu
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Cebeci, 06590, Ankara, Turkey
| | - Aydan Ikinciogullari
- Department of Pediatric Allergy and Immunology, Ankara University School of Medicine, Cebeci, 06590, Ankara, Turkey.
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28
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Johnson MB, De Franco E, Lango Allen H, Al Senani A, Elbarbary N, Siklar Z, Berberoglu M, Imane Z, Haghighi A, Razavi Z, Ullah I, Alyaarubi S, Gardner D, Ellard S, Hattersley AT, Flanagan SE. Recessively Inherited LRBA Mutations Cause Autoimmunity Presenting as Neonatal Diabetes. Diabetes 2017; 66:2316-2322. [PMID: 28473463 PMCID: PMC5524180 DOI: 10.2337/db17-0040] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/26/2017] [Indexed: 12/30/2022]
Abstract
Young-onset autoimmune diabetes associated with additional autoimmunity usually reflects a polygenic predisposition, but rare cases result from monogenic autoimmunity. Diagnosing monogenic autoimmunity is crucial for patients' prognosis and clinical management. We sought to identify novel genetic causes of autoimmunity presenting with neonatal diabetes (NDM) (diagnosis <6 months). We performed exome sequencing in a patient with NDM and autoimmune lymphoproliferative syndrome and his unrelated, unaffected parents and identified compound heterozygous null mutations in LRBA Biallelic LRBA mutations cause common variable immunodeficiency-8; however, NDM has not been confirmed in this disorder. We sequenced LRBA in 169 additional patients with diabetes diagnosed <1 year without mutations in the 24 known NDM genes. We identified recessive null mutations in 8 additional probands, of which, 3 had NDM (<6 months). Diabetes was the presenting feature in 6 of 9 probands. Six of 17 (35%) patients born to consanguineous parents and with additional early-onset autoimmunity had recessive LRBA mutations. LRBA testing should be considered in patients with diabetes diagnosed <12 months, particularly if they have additional autoimmunity or are born to consanguineous parents. A genetic diagnosis is important as it can enable personalized therapy with abatacept, a CTLA-4 mimetic, and inform genetic counseling.
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Affiliation(s)
- Matthew B Johnson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Elisa De Franco
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Hana Lango Allen
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | | | - Nancy Elbarbary
- Department of Pediatrics, Ain Shams University, Cairo, Egypt
| | - Zeynep Siklar
- Ankara University School of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Merih Berberoglu
- Ankara University School of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zineb Imane
- Rabat Children's Hospital, Université Mohammed V Souissi, Rabat, Morocco
| | - Alireza Haghighi
- Division of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Howard Hughes Medical Institute, Chevy Chase, MD
- Broad Institute of Harvard and MIT, Cambridge, MA
| | - Zahra Razavi
- Department of Pediatrics, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Irfan Ullah
- Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Daphne Gardner
- Academia Endocrinology Department, Singapore General Hospital, Singapore
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K.
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
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29
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Azizi G, Abolhassani H, Mahdaviani SA, Chavoshzadeh Z, Eshghi P, Yazdani R, Kiaee F, Shaghaghi M, Mohammadi J, Rezaei N, Hammarström L, Aghamohammadi A. Clinical, immunologic, molecular analyses and outcomes of iranian patients with LRBA deficiency: A longitudinal study. Pediatr Allergy Immunol 2017; 28:478-484. [PMID: 28512785 DOI: 10.1111/pai.12735] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND LPS-responsive beige-like anchor protein (LRBA) deficiency is a combined immunodeficiency caused by mutation in LRBA gene. The patients have a variety of clinical symptoms including hypogammaglobulinemia, recurrent infections, autoimmunity, and enteropathy. METHODS A total of 17 LRBA-deficient patients were enrolled in this longitudinal study. For all patients, demographic information, clinical records, laboratory, and molecular data were collected. RESULT Hypogammaglobulinemia was reported in 14 (82.4%), CD4+ T-cell deficiency in five (29.4%), NK cell deficiency in three (21.4%), and CD19+ B-cell deficiency in 11 (64.7%) patients. All patients had history of infectious complications; pneumonia was the most common (76.5%) occurring infection. A history of lymphoproliferative disorders was observed in 14 (82.3%), enteropathy in 13 (76.5%), allergic symptoms in six (35.5%), neurologic problems in four (23.5), and autoimmunity (mostly autoimmune cytopenia) in 13 (76.5%) patients. Sirolimus treatment improved enteropathy of patients with remarkable success. The 20-year overall survival rate declined to 70.6%. CONCLUSION LRBA deficiency has a very broad and variable phenotype and should be considered, especially in children with early-onset hypogammaglobulinemia, severe autoimmune manifestations, enteropathy, lymphoproliferation, and recurrent respiratory tract infections.
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Affiliation(s)
- Gholamreza Azizi
- Department of Laboratory Medicine, Imam Hassan Mojtaba Hospital, Alborz University of Medical Sciences, Karaj, Iran.,Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Primary Immunodeficiency Diseases Network (PIDNet), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Primary Immunodeficiency Diseases Network (PIDNet), Universal Scientific Education and Research Network (USERN), Tehran, Iran.,Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Seyed Alireza Mahdaviani
- Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Chavoshzadeh
- Pediatric Infections Research Center, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Kiaee
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Primary Immunodeficiency Diseases Network (PIDNet), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mohammadreza Shaghaghi
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Javad Mohammadi
- Department of Biomedical Engineering, Faculty of New Sciences and Technologies, University of Tehran, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Lennart Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Primary Immunodeficiency Diseases Network (PIDNet), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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30
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Gámez-Díaz L, Neumann J, Jäger F, Proietti M, Felber F, Soulas-Sprauel P, Perruzza L, Grassi F, Kögl T, Aichele P, Kilimann M, Grimbacher B, Jung S. Immunological phenotype of the murine Lrba knockout. Immunol Cell Biol 2017; 95:789-802. [PMID: 28652580 DOI: 10.1038/icb.2017.52] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 06/06/2017] [Accepted: 06/06/2017] [Indexed: 01/01/2023]
Abstract
Biallelic mutations in the human lipopolysaccharide responsive beige-like anchor (LRBA) gene lead to a primary immunodeficiency known as LRBA deficiency, characterized by a broad range of clinical manifestations including autoimmunity, organomegaly, hypogammaglobulinemia and recurrent infections. Considering the phenotypic heterogeneity in patients and the severity of the disease, our aim was to assess the role of LRBA in immune cells and to understand the underlying pathomechanisms through the study of a Lrba knockout (Lrba-/-) mouse model. LRBA-deficient mice did not show severe clinical or immunological signs of disease, either at steady state under specific-pathogen-free conditions, after vaccination with T-dependent and T-independent antigens, or in the context of acute infections with lymphocytic choriomeningitis virus (LCMV) or Salmonella Typhimurium. Although Lrba-/- mice were able to produce normal serum immunoglobulin M (IgM) and IgG and to mount a specific immune response after immunization, they showed elevated serum and secretory basal IgA levels. LRBA was dispensable for B- and T-cell development, as well as for in vitro B-cell proliferation, survival, isotype switching and plasmablast differentiation. Interestingly, Lrba-/- mice displayed decreased cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) expression by regulatory T cells and activated conventional CD4+ and CD8+ T lymphocytes, reduced frequency of peritoneal B-1a cells along with diminished interleukin-10 production and increased percentages of T follicular helper cells in Peyer's patches, but without developing overt signs of autoimmunity. Our findings expand the role of LRBA in immune regulatory mechanisms previously reported in patients, and suggest a novel role in IgA production that is crucial for the protection of mucosal surfaces and gut-associated immune tolerance.
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Affiliation(s)
- Laura Gámez-Díaz
- Center for Chronic Immunodeficiency (CCI), Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Julika Neumann
- Center for Chronic Immunodeficiency (CCI), Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Fiona Jäger
- Center for Chronic Immunodeficiency (CCI), Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michele Proietti
- Center for Chronic Immunodeficiency (CCI), Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Felicitas Felber
- Center for Chronic Immunodeficiency (CCI), Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pauline Soulas-Sprauel
- CNRS UPR 3572 'Immunopathology and Therapeutic Chemistry', Laboratory of Excellence Medalis, Institute of Molecular and Cellular Biology (IBMC), Strasbourg, France.,Department of Clinical Immunology and Internal Medicine, University Hospital, Strasbourg, France.,Faculty of Pharmacy, University of Strasbourg, Illkirch-Graffenstaden, France
| | - Lisa Perruzza
- Institute for Research in Biomedicine, Università della Svizzera Italiana, Bellinzona, Switzerland
| | - Fabio Grassi
- Institute for Research in Biomedicine, Università della Svizzera Italiana, Bellinzona, Switzerland.,Department of Medical Biotechnology and Translational Medicine (BIOMETRA), University of Milan, Milan, Italy.,Istituto Nazionale Genetica Molecolare 'Romeo ed Enrica Invernizzi', Milan, Italy
| | - Tamara Kögl
- Department of Immunology, Institute for Medical Microbiology and Hygiene, University of Freiburg, Freiburg, Germany
| | - Peter Aichele
- Department of Immunology, Institute for Medical Microbiology and Hygiene, University of Freiburg, Freiburg, Germany
| | - Manfred Kilimann
- Department of Molecular Neurobiology, Max-Planck-Institute for Experimental Medicine, Göttingen, Germany
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency (CCI), Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Sophie Jung
- Center for Chronic Immunodeficiency (CCI), Medical Center-Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Hôpitaux universitaires de Strasbourg, Pôle de Médecine et de Chirurgie Bucco-dentaires, Strasbourg, France.,Université de Strasbourg, Faculté de Chirurgie Dentaire, Strasbourg, France
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31
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Notarangelo LD, Fleisher TA. Targeted strategies directed at the molecular defect: Toward precision medicine for select primary immunodeficiency disorders. J Allergy Clin Immunol 2017; 139:715-723. [PMID: 28270363 DOI: 10.1016/j.jaci.2017.01.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 12/18/2022]
Abstract
Primary immunodeficiency disorders (PIDs) represent a range of genetically determined diseases that typically have increased susceptibility to infections and in many cases also have evidence of immune dysregulation that often presents as autoimmunity. Most recently, the concept of gain-of-function mutations associated with PIDs has become well recognized and adds a new dimension to the understanding of this group of disorders, moving beyond the more commonly seen loss-of-function mutations. The rapidly expanding genetic defects that have been identified in patients with previously uncharacterized PIDs has opened up the potential for targeted therapy directed at the specific disease-causing abnormality. This has been driven by linking PID-specific genetic defects to the associated unique abnormalities in cellular signaling pathways amenable to directed therapies. These include agents that either block overactive or enhance underresponsive cellular pathways. Selected primary immunodeficiencies were chosen, the genetic defects of which have been recently characterized and are amenable to targeted therapy, as a reflection of the power of precision medicine.
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Affiliation(s)
- Luigi D Notarangelo
- Laboratory of Clinical Immunology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Thomas A Fleisher
- Immunology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md.
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32
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Bratanič N, Kovač J, Pohar K, Trebušak Podkrajšek K, Ihan A, Battelino T, Avbelj Stefanija M. Multifocal gastric adenocarcinoma in a patient with LRBA deficiency. Orphanet J Rare Dis 2017; 12:131. [PMID: 28720148 PMCID: PMC5516372 DOI: 10.1186/s13023-017-0682-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background Lipopolysaccharide-responsive, beige-like anchor protein (LRBA) deficiency is characterized by primary immunodeficiency and autoimmunity. Cancer may present another feature of LRBA deficiency. We describe a case history of a young adult with LRBA deficiency and two independent malignancies. Methods Family-trio whole exome sequencing with unbiased phenotype ontology approach was used for identification of causative mutations of a primary immune deficiency disorder. Additionally, we sought to identify germline mutations in genes known to be associated with two independent malignancies using a targeted approach. A cytotoxic T-lymphocyte associated protein 4 (CTLA4) expression in T lymphocytes was determined by flow cytometry. Results In the patient with clinical signs of LRBA deficiency multifocal gastric carcinoma and malignant melanoma were diagnosed and surgically treated at 19 and 27 years of age, respectively. Despite refusal of any adjuvant chemotherapy or radiotherapy, the patient demonstrated disease free survival for at least 13 years after the first cancer diagnosis. A homozygous frameshift deletion in LRBA gene (p.Glu946Ter) and two common variants in TYR gene were identified. Reduced CTLA4 expression in a subset of regulatory T lymphocytes was identified in the patient and his unaffected mother carrying a heterozygous LRBA mutation as compared to control in a dose-dependent manner. Conclusion This is the first description of gastric cancer and malignant melanoma in a young adult with LRBA deficiency. The role of LRBA gene knockout in cancer development and its prognosis remains to be elucidated. Electronic supplementary material The online version of this article (doi:10.1186/s13023-017-0682-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina Bratanič
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre, University Children's Hospital, Bohoriceva 20, 1000, Ljubljana, Slovenia
| | - Jernej Kovač
- University Medical Centre, University Children's Hospital, Unit for Special Laboratory Diagnostics, Vrazov trg 1, 1000, Ljubljana, Slovenia
| | - Katka Pohar
- University of Ljubljana, Faculty of Medicine, Institute for Microbiology and Immunology, Zaloška 4, 1000, Ljubljana, Slovenia
| | - Katarina Trebušak Podkrajšek
- University Medical Centre, University Children's Hospital, Unit for Special Laboratory Diagnostics, Vrazov trg 1, 1000, Ljubljana, Slovenia.,University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Alojz Ihan
- University of Ljubljana, Faculty of Medicine, Institute for Microbiology and Immunology, Zaloška 4, 1000, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre, University Children's Hospital, Bohoriceva 20, 1000, Ljubljana, Slovenia.,University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Magdalena Avbelj Stefanija
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre, University Children's Hospital, Bohoriceva 20, 1000, Ljubljana, Slovenia.
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33
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Burnett DL, Parish IA, Masle-Farquhar E, Brink R, Goodnow CC. Murine LRBA deficiency causes CTLA-4 deficiency in Tregs without progression to immune dysregulation. Immunol Cell Biol 2017; 95:775-788. [PMID: 28611475 PMCID: PMC5636941 DOI: 10.1038/icb.2017.50] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/06/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
Inherited mutations in lipopolysaccharide-responsive beige-like anchor (LRBA) cause a recessive human immune dysregulation syndrome with memory B-cell and antibody deficiency (common variable immunodeficiency), inflammatory bowel disease, enlarged spleen and lymph nodes, accumulation of activated T cells and multiple autoimmune diseases. To understand the pathogenesis of the syndrome, C57BL/6 mice carrying a homozygous truncating mutation in Lrba were produced using CRISPR/Cas9-mediated gene targeting. These mice revealed that LRBA has a critical, cell-autonomous role in promoting cytotoxic T-lymphocyte antigen-4 (CTLA-4) accumulation within CD4 effector T cells and FOXP3+ T-regulatory cells (Tregs). In young mice, or in chimeric mice where only half of the T cells are LRBA deficient, low CTLA-4 was the only detectable abnormality in Tregs, whereas in old mice FOXP3 was also decreased. Low CTLA-4 did not translate into increased CD86 on B cells unless the LRBA-deficient mice were immunised, and neither immunisation nor chronic lymphocytic choriomeningitis virus infection precipitated immune dysregulation. LRBA deficiency did not alter antigen-specific B-cell activation, germinal centre (GC) formation, isotype switching or affinity maturation. Paradoxically, CD86 was decreased on GC B cells in LRBA-deficient mice, pointing to compensatory mechanisms for controlling CD86 in the face of low CTLA-4. These results add to the experimental rationale for treating LRBA deficiency with the CTLA4-Ig fusion protein, Abatacept, and pose questions about the limitations of laboratory experiments in mice to reproduce human disease in natura.
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Affiliation(s)
- Deborah L Burnett
- Immunology Division, Garvan Institute for Medical Research, Sydney, NSW, Australia
| | - Ian A Parish
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
| | | | - Robert Brink
- Immunology Division, Garvan Institute for Medical Research, Sydney, NSW, Australia
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Agammaglobulinaemia despite terminal B-cell differentiation in a patient with a novel LRBA mutation. Clin Transl Immunology 2017; 6:e144. [PMID: 28690850 PMCID: PMC5493589 DOI: 10.1038/cti.2017.20] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 04/10/2017] [Accepted: 04/10/2017] [Indexed: 01/01/2023] Open
Abstract
Mutations in lipopolysaccharide-responsive vesicle trafficking, beach and anchor-containing protein (LRBA) cause immune deficiency and inflammation. Here, we are reporting a novel homozygous mutation in LRBA allele in 7-year-old Omani boy, born to consanguineous parents. He presented with type 1 diabetes, autoimmune haematological cytopenia, recurrent chest infections and lymphocytic interstitial lung disease. The patient was treated with CTLA4-Ig (abatacept) with good outcome every 2 weeks for a period of 3 months. He developed complete IgG deficiency, but remarkably, histological examination revealed germinal centres and plasma cells in lymphoid and inflamed lung tissue. Further charatecterisation showed these cells to express IgM but not IgG. This ex vivo analysis suggests that LRBA mutation confers a defect in class switching despite plasma cell formation.
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35
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Seidel MG, Böhm K, Dogu F, Worth A, Thrasher A, Florkin B, İkincioğulları A, Peters A, Bakhtiar S, Meeths M, Stepensky P, Meyts I, Sharapova SO, Gámez-Díaz L, Hammarström L, Ehl S, Grimbacher B, Gennery AR. Treatment of severe forms of LPS-responsive beige-like anchor protein deficiency with allogeneic hematopoietic stem cell transplantation. J Allergy Clin Immunol 2017; 141:770-775.e1. [PMID: 28502825 DOI: 10.1016/j.jaci.2017.04.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Markus G Seidel
- Research Unit of Pediatric Hematology and Immunology, Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Gwraz, Graz, Austria.
| | - Katrin Böhm
- Research Unit of Pediatric Hematology and Immunology, Division of Pediatric Hematology-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Gwraz, Graz, Austria
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Austen Worth
- Institute of Child Health, University College London, London, United Kingdom
| | - Adrian Thrasher
- Institute of Child Health, University College London, London, United Kingdom
| | - Benoit Florkin
- Immuno-Hémato-Rhumatologie Pédiatrique, Service de Pédiatrie, CHR Citadelle, Liege, Belgium
| | - Aydan İkincioğulları
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Anke Peters
- Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Shahrzad Bakhtiar
- Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health and Clinical Genetics Unit, Department of Molecular Medicine and Surgery, and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Polina Stepensky
- Department of Bone Marrow Transplantation, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Isabelle Meyts
- Department of Pediatric Immunology, Microbiology and Immunology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Svetlana O Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk Region, Belarus
| | - Laura Gámez-Díaz
- Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Freiburg, Germany
| | - Lennart Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Stephan Ehl
- Department of Pediatrics and Adolescent Medicine, Medical Center, University of Freiburg, Freiburg, Germany; Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Freiburg, Germany
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency (CCI), Medical Center, University of Freiburg, Freiburg, Germany
| | - Andrew R Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Chandrakasan S, Venkateswaran S, Kugathasan S. Nonclassic Inflammatory Bowel Disease in Young Infants: Immune Dysregulation, Polyendocrinopathy, Enteropathy, X-Linked Syndrome, and Other Disorders. Pediatr Clin North Am 2017; 64:139-160. [PMID: 27894441 DOI: 10.1016/j.pcl.2016.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article discusses non-classical forms of inflammatory bowel disease (IBD) mainly occurs in infants and very young children. Defects in every aspect of the immune system, such as neutrophils, T-cell and B-cell lymphocytes, and macrophages are associated with IBD in infants. Also, non lympho-hematopoietic defects with primary defects in enterocytes can also lead to IBD-like manifestations. Clinical vignettes are presented and the genetic origins and possible management strategies are outlined. Early evaluation of these patients is important because identification of underlying immune defects would facilitate the use of better-targeted therapy for the specific genetic defect.
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Affiliation(s)
- Shanmuganathan Chandrakasan
- Department of Pediatrics, Children's Health Care of Atlanta, Emory University School of Medicine, Atlanta, GA, USA; Division of Hematology, Oncology and BMT, Emory University School of Medicine, Atlanta, GA, USA
| | - Suresh Venkateswaran
- Department of Pediatrics, Children's Health Care of Atlanta, Emory University School of Medicine, Atlanta, GA, USA; Division of Pediatric Gastroenterology, Emory University School of Medicine, Atlanta, GA, USA
| | - Subra Kugathasan
- Department of Pediatrics, Children's Health Care of Atlanta, Emory University School of Medicine, Atlanta, GA, USA; Division of Gastroenterology, Emory University School of Medicine, Atlanta, GA, USA.
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Bakhtiar S, Gámez-Díaz L, Jarisch A, Soerensen J, Grimbacher B, Belohradsky B, Keller KM, Rietschel C, Klingebiel T, Koletzko S, Albert MH, Bader P. Treatment of Infantile Inflammatory Bowel Disease and Autoimmunity by Allogeneic Stem Cell Transplantation in LPS-Responsive Beige-Like Anchor Deficiency. Front Immunol 2017; 8:52. [PMID: 28197149 PMCID: PMC5281554 DOI: 10.3389/fimmu.2017.00052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/12/2017] [Indexed: 01/21/2023] Open
Abstract
Inflammatory bowel disease (IBD) in young children can be a clinical manifestation of various primary immunodeficiency syndromes. Poor clinical outcome is associated with poor quality of life and high morbidity from the complications of prolonged immunosuppressive treatment and malabsorption. In 2012, mutations in the lipopolysaccharide-responsive beige-like anchor (LRBA) gene were identified as the cause of an autoimmunity and immunodeficiency syndrome. Since then, several LRBA-deficient patients have been reported with a broad spectrum of clinical manifestations without reliable predictive prognostic markers. Allogeneic hematopoietic stem cell transplantation (alloHSCT) has been performed in a few severely affected patients with complete or partial response. Herein, we present a detailed course of the disease and the transplantation procedure used in a LRBA-deficient patient suffering primarily from infantile IBD with immune enteropathy since the age of 6 weeks, and progressive autoimmunity with major complications following long-term immunosuppressive treatment. At 12 years of age, alloHSCT using bone marrow of a fully matched sibling donor—a healthy heterozygous LRBA mutant carrier—was performed after conditioning with a reduced-intensity regimen. During the 6-year follow-up, we observed a complete remission of enteropathy, autoimmunity, and skin vitiligo, with complete donor chimerism. The genetic diagnosis of LRBA deficiency was made post-alloHSCT by detection of two compound heterozygous mutations, using targeted sequencing of DNA samples extracted from peripheral blood before the transplantation.
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Affiliation(s)
- Shahrzad Bakhtiar
- Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital Frankfurt , Frankfurt/Main , Germany
| | - Laura Gámez-Díaz
- Center for Chronic Immunodeficiency, University Hospital , Freiburg , Germany
| | - Andrea Jarisch
- Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital Frankfurt , Frankfurt/Main , Germany
| | - Jan Soerensen
- Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital Frankfurt , Frankfurt/Main , Germany
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency, University Hospital , Freiburg , Germany
| | - Bernd Belohradsky
- Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University , Munich , Germany
| | | | | | - Thomas Klingebiel
- Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital Frankfurt , Frankfurt/Main , Germany
| | - Sibylle Koletzko
- Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University , Munich , Germany
| | - Michael H Albert
- Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University , Munich , Germany
| | - Peter Bader
- Division for Pediatric Stem-Cell Transplantation and Immunology, University Hospital Frankfurt , Frankfurt/Main , Germany
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38
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Kammermeier J, Dziubak R, Pescarin M, Drury S, Godwin H, Reeve K, Chadokufa S, Huggett B, Sider S, James C, Acton N, Cernat E, Gasparetto M, Noble-Jamieson G, Kiparissi F, Elawad M, Beales PL, Sebire NJ, Gilmour K, Uhlig HH, Bacchelli C, Shah N. Phenotypic and Genotypic Characterisation of Inflammatory Bowel Disease Presenting Before the Age of 2 years. J Crohns Colitis 2017; 11:60-69. [PMID: 27302973 PMCID: PMC5885808 DOI: 10.1093/ecco-jcc/jjw118] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Inflammatory bowel disease [IBD] presenting in early childhood is extremely rare. More recently, progress has been made to identify children with monogenic forms of IBD predominantly presenting very early in life. In this study, we describe the heterogeneous phenotypes and genotypes of patients with IBD presenting before the age of 2 years and establish phenotypic features associated with underlying monogenicity. METHODS Phenotype data of 62 children with disease onset before the age of 2 years presenting over the past 20 years were reviewed. Children without previously established genetic diagnosis were prospectively recruited for next-generation sequencing. RESULTS In all, 62 patients [55% male] were identified. The median disease onset was 3 months of age (interquartile range [IQR]: 1 to 11). Conventional IBD classification only applied to 15 patients with Crohn's disease [CD]-like [24%] and three with ulcerative colitis [UC]-like [5%] phenotype; 44 patients [71%] were diagnosed with otherwise unclassifiable IBD. Patients frequently required parenteral nutrition [40%], extensive immunosuppression [31%], haematopoietic stem-cell transplantation [29%], and abdominal surgery [19%]. In 31% of patients, underlying monogenic diseases were established [EPCAM, IL10, IL10RA, IL10RB, FOXP3, LRBA, SKIV2L, TTC37, TTC7A]. Phenotypic features significantly more prevalent in monogenic IBD were: consanguinity, disease onset before the 6th month of life, stunting, extensive intestinal disease and histological evidence of epithelial abnormalities. CONCLUSIONS IBD in children with disease onset before the age of 2 years is frequently unclassifiable into Crohn's disease and ulcerative colitis, particularly treatment resistant, and can be indistinguishable from monogenic diseases with IBD-like phenotype.
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Affiliation(s)
- Jochen Kammermeier
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK,Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Matilde Pescarin
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Suzanne Drury
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK,NE Thames Regional Genetics Laboratory, Great Ormond Street Hospital, London, UK
| | - Heather Godwin
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Kate Reeve
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | | | - Bonita Huggett
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Sara Sider
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Chela James
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Nikki Acton
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Elena Cernat
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Gabi Noble-Jamieson
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Fevronia Kiparissi
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Mamoun Elawad
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Phil L. Beales
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Neil J. Sebire
- Department of Histopathology, Great Ormond Street Hospital, London, UK
| | - Kimberly Gilmour
- Department of Immunology, Great Ormond Street Hospital, London, UK
| | - Holm H. Uhlig
- Transitional Gastroenterology Unit, Nuffield Department of Medicine and Department of Paediatrics, University of Oxford, UK
| | - Chiara Bacchelli
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Neil Shah
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
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39
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Chinen J, Notarangelo LD, Shearer WT. Advances in clinical immunology in 2015. J Allergy Clin Immunol 2016; 138:1531-1540. [PMID: 27931534 PMCID: PMC5157931 DOI: 10.1016/j.jaci.2016.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/02/2016] [Accepted: 10/07/2016] [Indexed: 12/17/2022]
Abstract
Advances in clinical immunology in the past year included the report of practice parameters for the diagnosis and management of primary immunodeficiencies to guide the clinician in the approach to these relatively uncommon disorders. We have learned of new gene defects causing immunodeficiency and of new phenotypes expanding the spectrum of conditions caused by genetic mutations such as a specific regulator of telomere elongation (RTEL1) mutation causing isolated natural killer cell deficiency and mutations in ras-associated RAB (RAB27) resulting in immunodeficiency without albinism. Advances in diagnosis included the increasing use of whole-exome sequencing to identify gene defects and the measurement of serum free light chains to identify secondary hypogammaglobulinemias. For several primary immunodeficiencies, improved outcomes have been reported after definitive therapy with hematopoietic stem cell transplantation and gene therapy.
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Affiliation(s)
- Javier Chinen
- Immunology, Allergy and Rheumatology Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex.
| | - Luigi D Notarangelo
- Division of Immunology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - William T Shearer
- Immunology, Allergy and Rheumatology Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
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40
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LRBA is Essential for Allogeneic Responses in Bone Marrow Transplantation. Sci Rep 2016; 6:36568. [PMID: 27824136 PMCID: PMC5099895 DOI: 10.1038/srep36568] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/18/2016] [Indexed: 12/25/2022] Open
Abstract
The PH-BEACH-WD40 (PBW) protein family members play a role in coordinating receptor signaling and intracellular vesicle trafficking. LPS-Responsive-Beige-like Anchor (LRBA) is a PBW protein whose immune function remains elusive. Here we show that LRBA-null mice are viable, but exhibit compromised rejection of allogeneic, xenogeneic and missing self bone-marrow grafts. Further, we demonstrate that LRBA-null Natural Killer (NK) cells exhibit impaired signaling by the key NK activating receptors, NKp46 and NKG2D. However, induction of IFN-γ by cytokines remains intact, indicating LRBA selectively facilitates signals by receptors for ligands expressed on the surface of NK targets. Surprisingly, LRBA limits immunoregulatory cell numbers in tissues where GvHD is primed or initiated, and consistent with this LRBA-null mice also demonstrate resistance to lethal GvHD. These findings demonstrate that LRBA is redundant for host longevity while being essential for both host and donor-mediated immune responses and thus represents a unique and novel molecular target in transplant immunology.
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41
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Massaad MJ, Zhou J, Tsuchimoto D, Chou J, Jabara H, Janssen E, Glauzy S, Olson BG, Morbach H, Ohsumi TK, Schmitz K, Kyriacos M, Kane J, Torisu K, Nakabeppu Y, Notarangelo LD, Chouery E, Megarbane A, Kang PB, Al-Idrissi E, Aldhekri H, Meffre E, Mizui M, Tsokos GC, Manis JP, Al-Herz W, Wallace SS, Geha RS. Deficiency of base excision repair enzyme NEIL3 drives increased predisposition to autoimmunity. J Clin Invest 2016; 126:4219-4236. [PMID: 27760045 DOI: 10.1172/jci85647] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 09/06/2016] [Indexed: 12/17/2022] Open
Abstract
Alterations in the apoptosis of immune cells have been associated with autoimmunity. Here, we have identified a homozygous missense mutation in the gene encoding the base excision repair enzyme Nei endonuclease VIII-like 3 (NEIL3) that abolished enzymatic activity in 3 siblings from a consanguineous family. The NEIL3 mutation was associated with fatal recurrent infections, severe autoimmunity, hypogammaglobulinemia, and impaired B cell function in these individuals. The same homozygous NEIL3 mutation was also identified in an asymptomatic individual who exhibited elevated levels of serum autoantibodies and defective peripheral B cell tolerance, but normal B cell function. Further analysis of the patients revealed an absence of LPS-responsive beige-like anchor (LRBA) protein expression, a known cause of immunodeficiency. We next examined the contribution of NEIL3 to the maintenance of self-tolerance in Neil3-/- mice. Although Neil3-/- mice displayed normal B cell function, they exhibited elevated serum levels of autoantibodies and developed nephritis following treatment with poly(I:C) to mimic microbial stimulation. In Neil3-/- mice, splenic T and B cells as well as germinal center B cells from Peyer's patches showed marked increases in apoptosis and cell death, indicating the potential release of self-antigens that favor autoimmunity. These findings demonstrate that deficiency in NEIL3 is associated with increased lymphocyte apoptosis, autoantibodies, and predisposition to autoimmunity.
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42
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Johnson MB, Hattersley AT, Flanagan SE. Monogenic autoimmune diseases of the endocrine system. Lancet Diabetes Endocrinol 2016; 4:862-72. [PMID: 27474216 DOI: 10.1016/s2213-8587(16)30095-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 12/29/2022]
Abstract
The most common endocrine diseases, type 1 diabetes, hyperthyroidism, and hypothyroidism, are the result of autoimmunity. Clustering of autoimmune endocrinopathies can result from polygenic predisposition, or more rarely, may present as part of a wider syndrome due to a mutation within one of seven genes. These monogenic autoimmune diseases show highly variable phenotypes both within and between families with the same mutations. The average age of onset of the monogenic forms of autoimmune endocrine disease is younger than that of the common polygenic forms, and this feature combined with the manifestation of other autoimmune diseases, specific hallmark features, or both, can inform clinicians as to the relevance of genetic testing. A genetic diagnosis can guide medical management, give an insight into prognosis, inform families of recurrence risk, and facilitate prenatal diagnoses.
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Affiliation(s)
- Matthew B Johnson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
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43
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Abstract
Regulatory T (Treg) cells that express the transcription factor forkhead box protein P3 (FOXP3) play an essential role in enforcing immune tolerance to self tissues, regulating host-commensal flora interaction, and facilitating tissue repair. Their deficiency and/or dysfunction trigger unbridled autoimmunity and inflammation. A growing number of monogenic defects have been recognized that adversely impact Treg cell development, differentiation, and/or function, leading to heritable diseases of immune dysregulation and autoimmunity. In this article, we review recent insights into Treg cell biology and function, with particular attention to lessons learned from newly recognized clinical disorders of Treg cell deficiency.
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Affiliation(s)
- Fayhan J Alroqi
- Division of Immunology, Boston Children's Hospital, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA
| | - Talal A Chatila
- Division of Immunology, Boston Children's Hospital, Karp Family Building, Room 10-214. 1 Blackfan Street, Boston, MA, 02115, USA. .,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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44
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CHAI and LATAIE: new genetic diseases of CTLA-4 checkpoint insufficiency. Blood 2016; 128:1037-42. [PMID: 27418640 DOI: 10.1182/blood-2016-04-712612] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 07/07/2016] [Indexed: 01/20/2023] Open
Abstract
CTLA-4 is a critical inhibitory "checkpoint" molecule of immune activation. Several recent reports have described patients with immune dysregulation and lymphoproliferative disease resulting from 2 different genetic diseases that directly or indirectly cause CTLA-4 deficiency. Numerous articles have also been published describing CTLA-4 blockade in cancer immunotherapy and its side effects, which are ultimately the consequence of treatment-induced CTLA-4 deficiency. Here, we review these 2 diseases and CTLA-4 blockade therapy, emphasizing the crucial role of CTLA-4 in immune checkpoint regulation.
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45
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Bogaert DJA, Dullaers M, Lambrecht BN, Vermaelen KY, De Baere E, Haerynck F. Genes associated with common variable immunodeficiency: one diagnosis to rule them all? J Med Genet 2016; 53:575-90. [PMID: 27250108 DOI: 10.1136/jmedgenet-2015-103690] [Citation(s) in RCA: 190] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/10/2016] [Indexed: 12/15/2022]
Abstract
Common variable immunodeficiency (CVID) is a primary antibody deficiency characterised by hypogammaglobulinaemia, impaired production of specific antibodies after immunisation and increased susceptibility to infections. CVID shows a considerable phenotypical and genetic heterogeneity. In contrast to many other primary immunodeficiencies, monogenic forms count for only 2-10% of patients with CVID. Genes that have been implicated in monogenic CVID include ICOS, TNFRSF13B (TACI), TNFRSF13C (BAFF-R), TNFSF12 (TWEAK), CD19, CD81, CR2 (CD21), MS4A1 (CD20), TNFRSF7 (CD27), IL21, IL21R, LRBA, CTLA4, PRKCD, PLCG2, NFKB1, NFKB2, PIK3CD, PIK3R1, VAV1, RAC2, BLK, IKZF1 (IKAROS) and IRF2BP2 With the increasing number of disease genes identified in CVID, it has become clear that CVID is an umbrella diagnosis and that many of these genetic defects cause distinct disease entities. Moreover, there is accumulating evidence that at least a subgroup of patients with CVID has a complex rather than a monogenic inheritance. This review aims to discuss current knowledge regarding the molecular genetic basis of CVID with an emphasis on the relationship with the clinical and immunological phenotype.
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Affiliation(s)
- Delfien J A Bogaert
- Clinical Immunology Research Lab, Department of Pulmonary Medicine, Ghent University Hospital, Ghent, Belgium Department of Pediatric Immunology and Pulmonology, Centre for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium Laboratory of Immunoregulation, VIB Inflammation Research Center, Ghent, Belgium
| | - Melissa Dullaers
- Clinical Immunology Research Lab, Department of Pulmonary Medicine, Ghent University Hospital, Ghent, Belgium Laboratory of Immunoregulation, VIB Inflammation Research Center, Ghent, Belgium Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Bart N Lambrecht
- Laboratory of Immunoregulation, VIB Inflammation Research Center, Ghent, Belgium Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Karim Y Vermaelen
- Clinical Immunology Research Lab, Department of Pulmonary Medicine, Ghent University Hospital, Ghent, Belgium Department of Internal Medicine, Ghent University, Ghent, Belgium Tumor Immunology Laboratory, Department of Pulmonary Medicine, Ghent University Hospital, Ghent, Belgium
| | - Elfride De Baere
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Filomeen Haerynck
- Clinical Immunology Research Lab, Department of Pulmonary Medicine, Ghent University Hospital, Ghent, Belgium Department of Pediatric Immunology and Pulmonology, Centre for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium
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46
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Gámez-Díaz L, August D, Stepensky P, Revel-Vilk S, Seidel MG, Noriko M, Morio T, Worth AJJ, Blessing J, Van de Veerdonk F, Feuchtinger T, Kanariou M, Schmitt-Graeff A, Jung S, Seneviratne S, Burns S, Belohradsky BH, Rezaei N, Bakhtiar S, Speckmann C, Jordan M, Grimbacher B. The extended phenotype of LPS-responsive beige-like anchor protein (LRBA) deficiency. J Allergy Clin Immunol 2016; 137:223-230. [PMID: 26768763 DOI: 10.1016/j.jaci.2015.09.025] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 09/13/2015] [Accepted: 09/15/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND LPS-responsive beige-like anchor protein (LRBA) deficiency is a primary immunodeficiency caused by biallelic mutations in LRBA that abolish LRBA protein expression. OBJECTIVE We sought to report the extended phenotype of LRBA deficiency in a cohort of 22 LRBA-deficient patients. METHODS Clinical criteria, protein detection, and genetic sequencing were applied to diagnose LRBA deficiency. RESULTS Ninety-three patients met the inclusion criteria and were considered to have possible LRBA deficiency. Twenty-four patients did not express LRBA protein and were labeled as having probable LRBA deficiency, whereas 22 were genetically confirmed as having definitive LRBA deficiency, with biallelic mutations in LRBA. Seventeen of these were novel and included homozygous or compound heterozygous mutations. Immune dysregulation (95%), organomegaly (86%), recurrent infections (71%), and hypogammaglobulinemia (57%) were the main clinical complications observed in LRBA-deficient patients. Although 81% of LRBA-deficient patients had normal T-cell counts, 73% had reduced regulatory T (Treg) cell numbers. Most LRBA-deficient patients had low B-cell subset counts, mainly in switched memory B cells (80%) and plasmablasts (92%), with a defective specific antibody response in 67%. Of the 22 patients, 3 are deceased, 2 were treated successfully with hematopoietic stem cell transplantation, 7 are receiving immunoglobulin replacement, and 15 are receiving immunosuppressive treatment with systemic corticosteroids alone or in combination with steroid-sparing agents. CONCLUSION This report describes the largest cohort of patients with LRBA deficiency and offers guidelines for physicians to identify LRBA deficiency, supporting appropriate clinical management.
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Affiliation(s)
- Laura Gámez-Díaz
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
| | - Dietrich August
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
| | - Polina Stepensky
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Shoshana Revel-Vilk
- Pediatric Hematology-Oncology and Bone Marrow Transplantation, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Markus G Seidel
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology-Oncology, Medical University Graz, Graz, Austria
| | - Mitsuiki Noriko
- Department of Pediatrics and Developmental Biology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University, Tokyo, Japan
| | - Austen J J Worth
- Department of Immunology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Jacob Blessing
- Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Cincinnati, Ohio
| | - Frank Van de Veerdonk
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Tobias Feuchtinger
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Dr. von Hauner University Children's Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Maria Kanariou
- Department of Immunology, "Aghia Sophia" Children's Hospital, Athens, Greece
| | | | - Sophie Jung
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany
| | - Suranjith Seneviratne
- UCL Centre for Immunodeficiency, Royal Free Hospital Foundation Trust, London, United Kingdom
| | - Siobhan Burns
- UCL Centre for Immunodeficiency, Royal Free Hospital Foundation Trust, London, United Kingdom
| | - Bernd H Belohradsky
- Division of Immunology and Infectious Disease, University Childrens Hospital Munich, Munich, Germany
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, and the Department of Immunology, School of Medicine Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Bakhtiar
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents Medicine, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Carsten Speckmann
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany; Center for Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Michael Jordan
- Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Cincinnati, Ohio
| | - Bodo Grimbacher
- Center for Chronic Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany; UCL Centre for Immunodeficiency, Royal Free Hospital Foundation Trust, London, United Kingdom.
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Tesi B, Priftakis P, Lindgren F, Chiang SCC, Kartalis N, Löfstedt A, Lörinc E, Henter JI, Winiarski J, Bryceson YT, Meeths M. Successful Hematopoietic Stem Cell Transplantation in a Patient with LPS-Responsive Beige-Like Anchor (LRBA) Gene Mutation. J Clin Immunol 2016; 36:480-9. [PMID: 27146671 DOI: 10.1007/s10875-016-0289-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 04/21/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Autosomal recessive mutations in LRBA, encoding for LPS-responsive beige-like anchor protein, were described in patients with a common variable immunodeficiency (CVID)-like disease characterized by hypogammaglobulinemia, autoimmune cytopenias, and enteropathy. Here, we detail the clinical, immunological, and genetic features of a patient with severe autoimmune manifestations. METHODS Whole exome sequencing was performed to establish a molecular diagnosis. Evaluation of lymphocyte subsets was performed for immunological characterization. Medical files were reviewed to collect clinical and immunological data. RESULTS A 7-year-old boy, born to consanguineous parents, presented with autoimmune hemolytic anemia, hepatosplenomegaly, autoimmune thyroiditis, and severe autoimmune gastrointestinal manifestations. Immunological investigations revealed low immunoglobulin levels and low numbers of B and NK cells. Treatment included immunoglobulin replacement and immunosuppressive therapy. Seven years after disease onset, the patient developed severe neurological symptoms resembling acute disseminated encephalomyelitis, prompting allogeneic hematopoietic stem cell transplantation (HSCT) with the HLA-identical mother as donor. Whole exome sequencing of the patient uncovered a homozygous 1 bp deletion in LRBA (c.7162delA:p.T2388Pfs*7). Importantly, during 2 years of follow-up post-HSCT, marked clinical improvement and recovery of immune function was observed. CONCLUSIONS Our data suggest a beneficial effect of HSCT in patients with LRBA deficiency.
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Affiliation(s)
- Bianca Tesi
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden. .,Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.
| | - Peter Priftakis
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Fredrik Lindgren
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Samuel C C Chiang
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Nikolaos Kartalis
- Department of Clinical Science Intervention and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Department of Radiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Alexandra Löfstedt
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.,Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Esther Lörinc
- Department of Pathology, University Hospital Karolinska Huddinge, Solna, Sweden.,Department of Pathology, Skåne University Hospital, Lund, Sweden
| | - Jan-Inge Henter
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Marie Meeths
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden. .,Clinical Genetics Unit, Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, Stockholm, Sweden.
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48
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Sipurzynski J, Fahrner B, Kerbl R, Crazzolara R, Jones N, Ebetsberger G, Jauk B, Strenger V, Wohlmuther B, Schwinger W, Lackner H, Urban C, Holter W, Minkov M, Kager L, Benesch M, Seidel M. Management of chronic immune thrombocytopenia in children and adolescents: lessons from an Austrian national cross-sectional study of 81 patients. Semin Hematol 2016; 53 Suppl 1:S43-7. [DOI: 10.1053/j.seminhematol.2016.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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49
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Schreiner F, Plamper M, Dueker G, Schoenberger S, Gámez-Díaz L, Grimbacher B, Hilger AC, Gohlke B, Reutter H, Woelfle J. Infancy-Onset T1DM, Short Stature, and Severe Immunodysregulation in Two Siblings With a Homozygous LRBA Mutation. J Clin Endocrinol Metab 2016; 101:898-904. [PMID: 26745254 DOI: 10.1210/jc.2015-3382] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CONTEXT Type 1 diabetes mellitus (T1DM) is caused by autoimmunity against pancreatic β-cells. Although a significant number of T1DM patients have or will develop further autoimmune disorders during their lifetime, coexisting severe immunodysregulation is rare. OBJECTIVE Presuming autosomal-recessive inheritance in a complex immunodysregulation disorder including T1DM and short stature in two siblings, we performed whole-exome sequencing. CASE PRESENTATION Two Libyan siblings born to consanguineous parents were presented to our diabetology department at ages 12 and 5 years, respectively. Apart from T1DM diagnosed at age 2 years, patient 1 suffered from chronic restrictive lung disease, mild enteropathy, hypogammaglobulinemia, and GH deficiency. Fluorescence-activated cell sorting analysis revealed B-cell deficiency. In addition, CD4(+)/CD25(+) and CD25(high)/FoxP3(+) cells were diminished, whereas an unusual CD25(-)/FoxP3(+) population was detectable. The younger brother, patient 2, also developed T1DM during infancy. Although his enteropathy was more severe and electrolyte derangements repeatedly led to hospitalization, he did not have significant pulmonary problems. IgG levels and B-lymphocytes were within normal ranges. RESULTS By whole-exome sequencing we identified a homozygous truncating mutation (c.2445_2447del(C)3ins(C)2, p.P816Lfs*4) in the lipopolysaccharide-responsive beige-like anchor (LRBA) gene in both siblings. The diagnosis of LRBA deficiency was confirmed by a fluorescence-activated cell sorting-based immunoassay showing the absence of LRBA protein in phytohemagglutinin-stimulated peripheral blood mononuclear cells. CONCLUSION We identified a novel truncating LRBA mutation in two siblings with T1DM, short stature, and severe immunodysregulation. LRBA mutations have previously been reported to cause multiorgan autoimmunity and immunodysfunction. In light of the variable phenotypes reported so far in LRBA-mutant individuals, LRBA deficiency should be considered in all patients presenting with T1DM and signs of severe immunodysregulation.
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Affiliation(s)
- Felix Schreiner
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Michaela Plamper
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Gesche Dueker
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Stefan Schoenberger
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Laura Gámez-Díaz
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Bodo Grimbacher
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Alina C Hilger
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Bettina Gohlke
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Heiko Reutter
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Joachim Woelfle
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
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50
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Spectrum of Phenotypes Associated with Mutations in LRBA. J Clin Immunol 2015; 36:33-45. [DOI: 10.1007/s10875-015-0224-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 12/10/2015] [Indexed: 01/08/2023]
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