1
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Fawzy MM, Nazmy MH, El-Sheikh AAK, Fathy M. Evolutionary preservation of CpG dinucleotides in RAG1 may elucidate the relatively high rate of methylation-mediated mutagenesis of RAG1 transposase. Immunol Res 2024; 72:438-449. [PMID: 38240953 PMCID: PMC11217092 DOI: 10.1007/s12026-023-09451-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/24/2023] [Indexed: 07/03/2024]
Abstract
Recombination-activating gene 1 (RAG1) is a vital player in V(D)J recombination, a fundamental process in primary B cell and T cell receptor diversification of the adaptive immune system. Current vertebrate RAG evolved from RAG transposon; however, it has been modified to play a crucial role in the adaptive system instead of being irreversibly silenced by CpG methylation. By interrogating a range of publicly available datasets, the current study investigated whether RAG1 has retained a disproportionate level of its original CpG dinucleotides compared to other genes, thereby rendering it more exposed to methylation-mediated mutation. Here, we show that 57.57% of RAG1 pathogenic mutations and 51.6% of RAG1 disease-causing mutations were associated with CpG methylation, a percentage that was significantly higher than that of its RAG2 cofactor alongside the whole genome. The CpG scores and densities for all RAG ancestors suggested that RAG transposon was CpG denser. The percentage of the ancestral CpG of RAG1 and RAG2 were 6% and 4.2%, respectively, with no preference towards CG containing codons. Furthermore, CpG loci of RAG1 in sperms were significantly higher methylated than that of RAG2. In conclusion, RAG1 has been exposed to CpG mediated methylation mutagenesis more than RAG2 and the whole genome, presumably due to its late entry to the genome later with an initially higher CpG content.
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Affiliation(s)
- Mariam M Fawzy
- Department of Biochemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Maiiada H Nazmy
- Department of Biochemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Azza A K El-Sheikh
- Basic Health Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, 11671, Riyadh, Saudi Arabia
| | - Moustafa Fathy
- Department of Biochemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt.
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2
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Pavel-Dinu M, Gardner CL, Nakauchi Y, Kawai T, Delmonte OM, Palterer B, Bosticardo M, Pala F, Viel S, Malech HL, Ghanim HY, Bode NM, Kurgan GL, Detweiler AM, Vakulskas CA, Neff NF, Sheikali A, Menezes ST, Chrobok J, Hernández González EM, Majeti R, Notarangelo LD, Porteus MH. Genetically corrected RAG2-SCID human hematopoietic stem cells restore V(D)J-recombinase and rescue lymphoid deficiency. Blood Adv 2024; 8:1820-1833. [PMID: 38096800 PMCID: PMC11006817 DOI: 10.1182/bloodadvances.2023011766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 10/23/2023] [Indexed: 04/10/2024] Open
Abstract
ABSTRACT Recombination-activating genes (RAG1 and RAG2) are critical for lymphoid cell development and function by initiating the variable (V), diversity (D), and joining (J) (V(D)J)-recombination process to generate polyclonal lymphocytes with broad antigen specificity. The clinical manifestations of defective RAG1/2 genes range from immune dysregulation to severe combined immunodeficiencies (SCIDs), causing life-threatening infections and death early in life without hematopoietic cell transplantation (HCT). Despite improvements, haploidentical HCT without myeloablative conditioning carries a high risk of graft failure and incomplete immune reconstitution. The RAG complex is only expressed during the G0-G1 phase of the cell cycle in the early stages of T- and B-cell development, underscoring that a direct gene correction might capture the precise temporal expression of the endogenous gene. Here, we report a feasibility study using the CRISPR/Cas9-based "universal gene-correction" approach for the RAG2 locus in human hematopoietic stem/progenitor cells (HSPCs) from healthy donors and RAG2-SCID patient. V(D)J-recombinase activity was restored after gene correction of RAG2-SCID-derived HSPCs, resulting in the development of T-cell receptor (TCR) αβ and γδ CD3+ cells and single-positive CD4+ and CD8+ lymphocytes. TCR repertoire analysis indicated a normal distribution of CDR3 length and preserved usage of the distal TRAV genes. We confirmed the in vivo rescue of B-cell development with normal immunoglobulin M surface expression and a significant decrease in CD56bright natural killer cells. Together, we provide specificity, toxicity, and efficacy data supporting the development of a gene-correction therapy to benefit RAG2-deficient patients.
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Affiliation(s)
- Mara Pavel-Dinu
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
| | - Cameron L. Gardner
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
- Sir William Dunn School of Pathology, University of Oxford, Oxford, United Kingdom
| | - Yusuke Nakauchi
- Division of Hematology, Department of Medicine, Cancer Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA
| | - Tomoki Kawai
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Ottavia M. Delmonte
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Boaz Palterer
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Marita Bosticardo
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Francesca Pala
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Sebastien Viel
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
- Service d’immunologie biologique, Hospices Civils de Lyon, Centre International de Recherche en Infectivologie, Centre International de Recheerche in Infectivalogie, INSERM U1111, Université Claude Bernard Lyon 1, Centre National de la Recherge Scientifique, UMR5308, École Normale Supérieure de Lyon, University of Lyon, Lyon, France
| | - Harry L. Malech
- Genetic Immunotherapy Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Hana Y. Ghanim
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
| | | | | | | | | | | | - Adam Sheikali
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
| | - Sherah T. Menezes
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
| | - Jade Chrobok
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
| | - Elaine M. Hernández González
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
| | - Ravindra Majeti
- Division of Hematology, Department of Medicine, Cancer Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA
| | - Luigi D. Notarangelo
- Immune Deficiency Genetics Section, Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Matthew H. Porteus
- Division of Oncology, Hematology, Stem Cell Transplantation, Department of Pediatrics, Stanford University, Stanford, CA
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3
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Mathias B, O'Leary D, Saucier N, Ahmad F, White LS, Russell L, Shinawi M, Smith MJ, Abraham RS, Cooper MA, Kitcharoensakkul M, Green AM, Bednarski JJ. MYSM1 attenuates DNA damage signals triggered by physiologic and genotoxic DNA breaks. J Allergy Clin Immunol 2024; 153:1113-1124.e7. [PMID: 38065233 DOI: 10.1016/j.jaci.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 12/31/2023]
Abstract
BACKGROUND Patients with deleterious variants in MYSM1 have an immune deficiency characterized by B-cell lymphopenia, hypogammaglobulinemia, and increased radiosensitivity. MYSM1 is a histone deubiquitinase with established activity in regulating gene expression. MYSM1 also localizes to sites of DNA injury but its function in cellular responses to DNA breaks has not been elucidated. OBJECTIVES This study sought to determine the activity of MYSM1 in regulating DNA damage responses (DDRs) to DNA double-stranded breaks (DSBs) generated during immunoglobulin receptor gene (Ig) recombination and by ionizing radiation. METHODS MYSM1-deficient pre- and non-B cells were used to determine the role of MYSM1 in DSB generation, DSB repair, and termination of DDRs. RESULTS Genetic testing in a newborn with abnormal screen for severe combined immune deficiency, T-cell lymphopenia, and near absence of B cells identified a novel splice variant in MYSM1 that results in nearly absent protein expression. Radiosensitivity testing in patient's peripheral blood lymphocytes showed constitutive γH2AX, a marker of DNA damage, in B cells in the absence of irradiation, suggesting a role for MYSM1 in response to DSBs generated during Ig recombination. Suppression of MYSM1 in pre-B cells did not alter generation or repair of Ig DSBs. Rather, loss of MYSM1 resulted in persistent DNA damage foci and prolonged DDR signaling. Loss of MYSM1 also led to protracted DDRs in U2OS cells with irradiation induced DSBs. CONCLUSIONS MYSM1 regulates termination of DNA damage responses but does not function in DNA break generation and repair.
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Affiliation(s)
- Brendan Mathias
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - David O'Leary
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Nermina Saucier
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Faiz Ahmad
- Department of Medicine, Washington University School of Medicine, St Louis, Mo
| | - Lynn S White
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Le'Mark Russell
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Marwan Shinawi
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Matthew J Smith
- Division of Hematology Research, Mayo Clinic, Rochester, Minn
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan A Cooper
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | | | - Abby M Green
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo
| | - Jeffrey J Bednarski
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo.
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4
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Wang C, Sun B, Wu K, Farmer JR, Ujhazi B, Geier CB, Gordon S, Westermann-Clark E, Savic S, Secord E, Sargur R, Chen K, Jin JJ, Dutmer CM, Kanariou MG, Adeli M, Palma P, Bonfim C, Lycopoulou E, Wolska-Kusnierz B, Dbaibo G, Bleesing J, Moshous D, Neven B, Schuetz C, Geha RS, Notarangelo LD, Miano M, Buchbinder DK, Csomos K, Wang W, Wang JY, Wang X, Walter JE. Clinical, immunological features, treatments, and outcomes of autoimmune hemolytic anemia in patients with RAG deficiency. Blood Adv 2024; 8:603-607. [PMID: 37883797 PMCID: PMC10837476 DOI: 10.1182/bloodadvances.2023011264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/05/2023] [Accepted: 09/28/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- Chen Wang
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL
| | - Bijun Sun
- Department of Clinical Immunology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Kevin Wu
- Department of Pediatrics & Medicine, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Jocelyn R. Farmer
- Division of Allergy and Inflammation, Beth Israel Lahey Health, Harvard Medical School, Boston, MA
| | - Boglarka Ujhazi
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Christoph B. Geier
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, University of Freiburg; Center for Chronic Immunodeficiency, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sumai Gordon
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Emma Westermann-Clark
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Sinisa Savic
- St James’s University Hospital, University of Leeds, Leeds, United Kingdom
| | - Elizabeth Secord
- Division of Allergy and Immunology, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - Ravishankar Sargur
- Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
| | - Karin Chen
- Division of Immunology, Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Jay J. Jin
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Cullen M. Dutmer
- Section of Allergy & Immunology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Maria G. Kanariou
- Department of Immunology and Histocompatibility, Aghia Sophia Children’s Hospital, Athens, Greece
| | - Mehdi Adeli
- Pediatric Allergy and Immunology, Sidra Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Paolo Palma
- Unit of Clinical Immunology and Vaccinology, Bambino Gesu` Children’s Hospital, Department of Systems Medicine, University of Rome ‘‘Tor Vergata,’’ Rome, Italy
| | - Carmem Bonfim
- Hospital Pequeno Príncipe/Instituto de Pesquisa Pelé Pequeno Príncipe/Faculdades Pequeno Príncipe, Curitiba, Paraná, Brazil
| | - Evangelia Lycopoulou
- 1st Department of Pediatrics, University of Athens, Aghia Sofia Children’s Hospital, Athens, Greece
| | | | - Ghassan Dbaibo
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Jack Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cancer and Blood Diseases Institute, Cincinnati, OH
| | - Despina Moshous
- Department of Pediatric Immunology, Hematology and Rheumatology, Necker Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, CEREDIH, French National Reference Centre for Primary Immunodeficiencies, Paris, France
- Imagine Institute, INSERM UMR 1163, University Paris Cité, Paris, France
| | - Benedicte Neven
- Imagine Institute, INSERM UMR 1163, University Paris Cité, Paris, France
| | - Catharina Schuetz
- Department of Pediatrics and Adolescent Medicine, University Hospital Ulm, Ulm, Germany
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Raif S. Geha
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Maurizio Miano
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Krisztian Csomos
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Wenjie Wang
- Department of Clinical Immunology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Ji-Yang Wang
- Department of Immunology, School of Basic Medical Sciences, Fudan University, Shanghai, China
- Shanghai Huashen Institute of Microbes and Infections, Shanghai, China
| | - Xiaochuan Wang
- Department of Clinical Immunology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Jolan E. Walter
- Department of Pediatric Allergy and Immunology, University of South Florida at Johns Hopkins All Children’s Hospital, St. Petersburg, FL
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5
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Karaatmaca B, Cagdas D, Esenboga S, Erman B, Tan C, Turul Ozgur T, Boztug K, van der Burg M, Sanal O, Tezcan I. Heterogeneity in RAG1 and RAG2 deficiency: 35 cases from a single-centre. Clin Exp Immunol 2024; 215:160-176. [PMID: 37724703 PMCID: PMC10847812 DOI: 10.1093/cei/uxad110] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/03/2023] [Accepted: 09/17/2023] [Indexed: 09/21/2023] Open
Abstract
Recombination activating genes (RAG)1 and RAG2 deficiency leads to combined T/B-cell deficiency with varying clinical presentations. This study aimed to define the clinical/laboratory spectrum of RAG1 and RAG2 deficiency. We retrospectively reviewed the clinical/laboratory data of 35 patients, grouped them as severe combined immunodeficiency (SCID), Omenn syndrome (OS), and delayed-onset combined immunodeficiency (CID) and reported nine novel mutations. The male/female ratio was 23/12. Median age of clinical manifestations was 1 months (mo) (0.5-2), 2 mo (1.25-5), and 14 mo (3.63-27), age at diagnosis was 4 mo (3-6), 4.5 mo (2.5-9.75), and 27 mo (14.5-70) in SCID (n = 25; 71.4%), OS (n = 5; 14.3%), and CID (n = 5; 14.3%) patients, respectively. Common clinical manifestations were recurrent sinopulmonary infections 82.9%, oral moniliasis 62.9%, diarrhea 51.4%, and eczema/dermatitis 42.9%. Autoimmune features were present in 31.4% of the patients; 80% were in CID patients. Lymphopenia was present in 92% of SCID, 80% of OS, and 80% of CID patients. All SCID and CID patients had low T (CD3, CD4, and CD8), low B, and increased NK cell numbers. Twenty-eight patients underwent hematopoietic stem cell transplantation (HSCT), whereas seven patients died before HSCT. Median age at HSCT was 7 mo (4-13.5). Survival differed in groups; maximum in SCID patients who had an HLA-matched family donor, minimum in OS. Totally 19 (54.3%) patients survived. Early molecular genetic studies will give both individualized therapy options, and a survival advantage because of timely diagnosis and treatment. Further improvement in therapeutic outcomes will be possible if clinicians gain time for HSCT.
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Affiliation(s)
- Betul Karaatmaca
- Hacettepe University School of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ankara, Turkey
- Department of Pediatric Allergy and Immunology, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Deniz Cagdas
- Hacettepe University School of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ankara, Turkey
- Section of Pediatric Immunology, Institute of Child Health, Hacettepe University, Ankara, Turkey
| | - Saliha Esenboga
- Hacettepe University School of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ankara, Turkey
| | - Baran Erman
- Section of Pediatric Immunology, Institute of Child Health, Hacettepe University, Ankara, Turkey
| | - Cagman Tan
- Section of Pediatric Immunology, Institute of Child Health, Hacettepe University, Ankara, Turkey
| | - Tuba Turul Ozgur
- Hacettepe University School of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ankara, Turkey
| | - Kaan Boztug
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics and Adolescent Medicine, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
- St. Anna Children's Hospital, Vienna, Austria
| | - Mirjam van der Burg
- Department of Pediatrics, Laboratory for Pediatric Immunology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Ozden Sanal
- Hacettepe University School of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ankara, Turkey
| | - Ilhan Tezcan
- Hacettepe University School of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ankara, Turkey
- Section of Pediatric Immunology, Institute of Child Health, Hacettepe University, Ankara, Turkey
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6
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Haque N, Kawai T, Ratnasinghe BD, Wagenknecht JB, Urrutia R, Notarangelo LD, Zimmermann MT. RAG genomic variation causes autoimmune diseases through specific structure-based mechanisms of enzyme dysregulation. iScience 2023; 26:108040. [PMID: 37854700 PMCID: PMC10579426 DOI: 10.1016/j.isci.2023.108040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/14/2023] [Accepted: 09/21/2023] [Indexed: 10/20/2023] Open
Abstract
Interpreting genetic changes observed in individual patients is a critical challenge. The array of immune deficiency syndromes is typically caused by genetic variation unique to individuals. Therefore, new approaches are needed to interpret functional variation and accelerate genomics interpretation. We constructed the first full-length structural model of human RAG recombinase across four functional states of the recombination process. We functionally tested 182 clinically observed RAG missense mutations. These experiments revealed dysfunction due to recombinase dysfunction and altered chromatin interactions. Structural modeling identified mechanical and energetic roles for each mutation. We built regression models for RAG1 (R2 = 0.91) and RAG2 (R2 = 0.97) to predict RAG activity changes. We applied our model to 711 additional RAG variants observed in population studies and identified a subset that may impair RAG function. Thus, we demonstrated a fundamental advance in the mechanistic interpretation of human genetic variations spanning from rare and undiagnosed diseases to population health.
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Affiliation(s)
- Neshatul Haque
- Bioinformatics Research and Development Laboratory, Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tomoki Kawai
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20817, USA
| | - Brian D. Ratnasinghe
- Bioinformatics Research and Development Laboratory, Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Jessica B. Wagenknecht
- Bioinformatics Research and Development Laboratory, Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Raul Urrutia
- Bioinformatics Research and Development Laboratory, Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Biochemistry, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Luigi D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20817, USA
| | - Michael T. Zimmermann
- Bioinformatics Research and Development Laboratory, Linda T. and John A. Mellowes Center for Genomic Sciences and Precision Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Biochemistry, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Clinical and Translational Sciences Institute, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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7
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Braams M, Pike-Overzet K, Staal FJT. The recombinase activating genes: architects of immune diversity during lymphocyte development. Front Immunol 2023; 14:1210818. [PMID: 37497222 PMCID: PMC10367010 DOI: 10.3389/fimmu.2023.1210818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023] Open
Abstract
The mature lymphocyte population of a healthy individual has the remarkable ability to recognise an immense variety of antigens. Instead of encoding a unique gene for each potential antigen receptor, evolution has used gene rearrangements, also known as variable, diversity, and joining gene segment (V(D)J) recombination. This process is critical for lymphocyte development and relies on recombination-activating genes-1 (RAG1) and RAG2, here collectively referred to as RAG. RAG serves as powerful genome editing tools for lymphocytes and is strictly regulated to prevent dysregulation. However, in the case of dysregulation, RAG has been implicated in cases of cancer, autoimmunity and severe combined immunodeficiency (SCID). This review examines functional protein domains and motifs of RAG, describes advances in our understanding of the function and (dys)regulation of RAG, discuss new therapeutic options, such as gene therapy, for RAG deficiencies, and explore in vitro and in vivo methods for determining RAG activity and target specificity.
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Affiliation(s)
- Merijn Braams
- Department of Immunology, Leiden University Medical Centre, Leiden, Netherlands
| | - Karin Pike-Overzet
- Department of Immunology, Leiden University Medical Centre, Leiden, Netherlands
| | - Frank J. T. Staal
- Department of Immunology, Leiden University Medical Centre, Leiden, Netherlands
- Novo Nordisk Foundation Centre for Stem Cell Medicine (reNEW), Leiden University Medical Centre, Leiden, Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
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8
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Schuetz C, Gerke J, Ege M, Walter J, Kusters M, Worth A, Kanakry JA, Dimitrova D, Wolska-Kuśnierz B, Chen K, Unal E, Karakukcu M, Pashchenko O, Leiding J, Kawai T, Amrolia PJ, Berghuis D, Buechner J, Buchbinder D, Cowan MJ, Gennery AR, Güngör T, Heimall J, Miano M, Meyts I, Morris EC, Rivière J, Sharapova SO, Shaw PJ, Slatter M, Honig M, Veys P, Fischer A, Cavazzana M, Moshous D, Schulz A, Albert MH, Puck JM, Lankester AC, Notarangelo LD, Neven B. Hypomorphic RAG deficiency: impact of disease burden on survival and thymic recovery argues for early diagnosis and HSCT. Blood 2023; 141:713-724. [PMID: 36279417 PMCID: PMC10082356 DOI: 10.1182/blood.2022017667] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/19/2022] [Accepted: 10/04/2022] [Indexed: 11/20/2022] Open
Abstract
Patients with hypomorphic mutations in the RAG1 or RAG2 gene present with either Omenn syndrome or atypical combined immunodeficiency with a wide phenotypic range. Hematopoietic stem cell transplantation (HSCT) is potentially curative, but data are scarce. We report on a worldwide cohort of 60 patients with hypomorphic RAG variants who underwent HSCT, 78% of whom experienced infections (29% active at HSCT), 72% had autoimmunity, and 18% had granulomas pretransplant. These complications are frequently associated with organ damage. Eight individuals (13%) were diagnosed by newborn screening or family history. HSCT was performed at a median of 3.4 years (range 0.3-42.9 years) from matched unrelated donors, matched sibling or matched family donors, or mismatched donors in 48%, 22%, and 30% of the patients, respectively. Grafts were T-cell depleted in 15 cases (25%). Overall survival at 1 and 4 years was 77.5% and 67.5% (median follow-up of 39 months). Infection was the main cause of death. In univariable analysis, active infection, organ damage pre-HSCT, T-cell depletion of the graft, and transplant from a mismatched family donor were predictive of worse outcome, whereas organ damage and T-cell depletion remained significant in multivariable analysis (hazard ratio [HR] = 6.01, HR = 8.46, respectively). All patients diagnosed by newborn screening or family history survived. Cumulative incidences of acute and chronic graft-versus-host disease were 35% and 22%, respectively. Cumulative incidences of new-onset autoimmunity was 15%. Immune reconstitution, particularly recovery of naïve CD4+ T cells, was faster and more robust in patients transplanted before 3.5 years of age, and without organ damage. These findings support the indication for early transplantation.
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Affiliation(s)
- C. Schuetz
- Department of Paediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - J. Gerke
- Department of Paediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M. Ege
- Dr. von Hauner Children’s Hospital at Ludwig-Maximilians-Universität, München, Germany
- Helmholtz Zentrum München, Neuherberg, Germany
| | - J. Walter
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL
- Division of Allergy and Immunology, Department of Medicine, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - M. Kusters
- Department of Immunology and Gene therapy, Great Ormond Street Hospital, NHS Foundation trust, London, United Kingdom
| | - A. Worth
- Department of Immunology and Gene therapy, Great Ormond Street Hospital, NHS Foundation trust, London, United Kingdom
| | - J. A. Kanakry
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - D. Dimitrova
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - B. Wolska-Kuśnierz
- Department of Immunology, Children's Memorial Health Institute, Warsaw, Poland
| | - K. Chen
- Division of Allergy and Immunology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - E. Unal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Erciyes University, Kayseri, Turkey
| | - M. Karakukcu
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Erciyes University, Kayseri, Turkey
| | - O. Pashchenko
- Department of Immunology, Pirogov Russian National Research Medical University, Moscow, Russia
| | - J. Leiding
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Orlando Health Arnold Pamer Hospital for Children, Orlando, FL
| | - T. Kawai
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - P. J. Amrolia
- Bone Marrow Transplant Unit, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - D. Berghuis
- Department of Pediatrics, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - J. Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - D. Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, CA
| | - M. J. Cowan
- Division of Allergy, Immunology, and Blood and Marrow Transplant, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - A. R. Gennery
- Translational and Clinical Research Institute, Newcastle University, Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
| | - T. Güngör
- Department of Hematology/Oncology/Immunology, Gene-therapy, and Stem Cell Transplantation, University Children’s Hospital Zurich–Eleonore Foundation & Children’s Research Center, Zürich, Switzerland
| | - J. Heimall
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - M. Miano
- IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - I. Meyts
- Department of Pediatrics, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
| | - E. C. Morris
- UCL Institute of Immunity & Transplantation, University College London Hospitals NHS Foundation Trust, Royal Free London Hospital NHS Foundation Trust, London, United Kingdom
| | - J. Rivière
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron Research Institute, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - S. O. Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - P. J. Shaw
- Blood Transplant and Cell Therapies, Children’s Hospital at Westmead, Sydney, Australia
| | - M. Slatter
- Paediatric Immunology & HSCT, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - M. Honig
- Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - P. Veys
- Bone Marrow Transplant Unit, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - A. Fischer
- Paediatric Immunology, Department of Immunology, Haematology and Rheumatology, Necker-Enfants Malades, Paris, France
- Institut Imagine, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Collège de France, Paris, France
| | - M. Cavazzana
- Institut Imagine, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Département de Biothérapie, Hôpital Universitaire Necker-Enfants Malades, Groupe Hospitalier Paris Centre, Assistance Publique–Hopitaux de Paris, Paris, France
- Centre d’Investigation Clinique Biothérapie, Groupe hospitalier Universitaire paris centre, Assistance Publique-Hôpitaux de Paris, INSERM CIC 1416, Paris, France
| | - D. Moshous
- Paediatric Immunology, Department of Immunology, Haematology and Rheumatology, Necker-Enfants Malades, Paris, France
- Institut Imagine, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - A. Schulz
- Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - M. H. Albert
- Pediatric SCT Program, Dr. von Hauner University Children’s Hospital, Ludwig-Maximilians Universität, München, Germany
| | - J. M. Puck
- Division of Allergy, Immunology, and Blood and Marrow Transplant, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - A. C. Lankester
- Department of Pediatrics, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - L. D. Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - B. Neven
- Paediatric Immunology, Department of Immunology, Haematology and Rheumatology, Necker-Enfants Malades, Paris, France
| | - Inborn Errors Working Party (IEWP) of the European Society for Immunodeficiencies (ESID) and European Society for Blood and Marrow Transplantation (EBMT) and the Primary Immune Deficiency Treatment Consortium (PIDTC)
- Department of Paediatrics, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dr. von Hauner Children’s Hospital at Ludwig-Maximilians-Universität, München, Germany
- Helmholtz Zentrum München, Neuherberg, Germany
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL
- Division of Allergy and Immunology, Department of Medicine, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Immunology and Gene therapy, Great Ormond Street Hospital, NHS Foundation trust, London, United Kingdom
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
- Department of Immunology, Children's Memorial Health Institute, Warsaw, Poland
- Division of Allergy and Immunology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Erciyes University, Kayseri, Turkey
- Department of Immunology, Pirogov Russian National Research Medical University, Moscow, Russia
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Orlando Health Arnold Pamer Hospital for Children, Orlando, FL
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
- Bone Marrow Transplant Unit, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
- Department of Pediatrics, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
- Division of Hematology, Children's Hospital of Orange County, Orange, CA
- Division of Allergy, Immunology, and Blood and Marrow Transplant, Department of Pediatrics, University of California San Francisco, San Francisco, CA
- Translational and Clinical Research Institute, Newcastle University, Paediatric Haematopoietic Stem Cell Transplant Unit, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
- Department of Hematology/Oncology/Immunology, Gene-therapy, and Stem Cell Transplantation, University Children’s Hospital Zurich–Eleonore Foundation & Children’s Research Center, Zürich, Switzerland
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
- IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Pediatrics, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
- UCL Institute of Immunity & Transplantation, University College London Hospitals NHS Foundation Trust, Royal Free London Hospital NHS Foundation Trust, London, United Kingdom
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron Research Institute, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
- Blood Transplant and Cell Therapies, Children’s Hospital at Westmead, Sydney, Australia
- Paediatric Immunology & HSCT, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
- Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
- Bone Marrow Transplant Unit, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
- Paediatric Immunology, Department of Immunology, Haematology and Rheumatology, Necker-Enfants Malades, Paris, France
- Institut Imagine, Paris Descartes-Sorbonne Paris Cité University, Paris, France
- Collège de France, Paris, France
- Département de Biothérapie, Hôpital Universitaire Necker-Enfants Malades, Groupe Hospitalier Paris Centre, Assistance Publique–Hopitaux de Paris, Paris, France
- Centre d’Investigation Clinique Biothérapie, Groupe hospitalier Universitaire paris centre, Assistance Publique-Hôpitaux de Paris, INSERM CIC 1416, Paris, France
- Pediatric SCT Program, Dr. von Hauner University Children’s Hospital, Ludwig-Maximilians Universität, München, Germany
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
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9
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Pavel-Dinu M, Borna S, Bacchetta R. Rare immune diseases paving the road for genome editing-based precision medicine. Front Genome Ed 2023; 5:1114996. [PMID: 36846437 PMCID: PMC9945114 DOI: 10.3389/fgeed.2023.1114996] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023] Open
Abstract
Clustered regularly interspaced short palindromic repeats (CRISPR) genome editing platform heralds a new era of gene therapy. Innovative treatments for life-threatening monogenic diseases of the blood and immune system are transitioning from semi-random gene addition to precise modification of defective genes. As these therapies enter first-in-human clinical trials, their long-term safety and efficacy will inform the future generation of genome editing-based medicine. Here we discuss the significance of Inborn Errors of Immunity as disease prototypes for establishing and advancing precision medicine. We will review the feasibility of clustered regularly interspaced short palindromic repeats-based genome editing platforms to modify the DNA sequence of primary cells and describe two emerging genome editing approaches to treat RAG2 deficiency, a primary immunodeficiency, and FOXP3 deficiency, a primary immune regulatory disorder.
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Affiliation(s)
- Mara Pavel-Dinu
- Division of Hematology-Oncology-Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford Medical School, Palo Alto, CA, United States
| | - Simon Borna
- Division of Hematology-Oncology-Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford Medical School, Palo Alto, CA, United States
| | - Rosa Bacchetta
- Division of Hematology-Oncology-Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford Medical School, Palo Alto, CA, United States,Center for Definitive and Curative Medicine, Stanford University School of Medicine, Palo Alto, CA, United States,*Correspondence: Rosa Bacchetta,
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10
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Castiello MC, Brandas C, Capo V, Villa A. HyperIgE in hypomorphic recombination-activating gene defects. Curr Opin Immunol 2023; 80:102279. [PMID: 36529093 DOI: 10.1016/j.coi.2022.102279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
Increased immunogloblulin-E (IgE) levels associated with eosinophilia represent a common finding observed in Omenn syndrome, a severe immunodeficiency caused by decreased V(D)J recombination, leading to restricted T- and B-cell receptor repertoire. V(D)J recombination is initiated by the lymphoid-restricted recombination-activating gene (RAG) recombinases. The lack of RAG proteins causes a block in lymphocyte differentiation, resulting in T-B- severe combined immunodeficiency. Conversely, hypomorphic mutations allow the generation of few T and B cells, leading to a spectrum of immunological phenotypes, in which immunodeficiency associates to inflammation, immune dysregulation, and autoimmunity. Elevated IgE levels are frequently observed in hypomorphic RAG patients. Here, we describe the role of RAG genes in lymphocyte differentiation and maintenance of immune tolerance.
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Affiliation(s)
- Maria Carmina Castiello
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Institute of Genetic and Biomedical Research, Milan Unit, National Research Council, Milan, Italy
| | - Chiara Brandas
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Translational and Molecular Medicine (DIMET), University of Milano-Bicocca, Monza, Italy
| | - Valentina Capo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Institute of Genetic and Biomedical Research, Milan Unit, National Research Council, Milan, Italy
| | - Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy; Institute of Genetic and Biomedical Research, Milan Unit, National Research Council, Milan, Italy.
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11
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Gaigne L, Piperoglou C, Banzet N, Ghellab L, Vély F, Schleinitz N, Ebbo M. [Anti-cytokine autoantibodies: Review of the literature]. Rev Med Interne 2022; 43:528-536. [PMID: 35820937 DOI: 10.1016/j.revmed.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/23/2022] [Accepted: 06/12/2022] [Indexed: 11/28/2022]
Abstract
Anti-cytokine antibodies (ACA) are an emerging cause of acquired immunodeficiency, especially in previously healthy adults. The most frequently reported are anti-IFN-γ responsible for disseminated non-tuberculous mycobacteria infections, and anti-GM-CSF mainly in mycobacteria, cryptococcosis and nocardiosis infections. The presence of anti-IFN-α in severe COVID-19 infections has recently been described. The search for and detection of these ACAs in an unusual infection situation makes it possible to set up specific therapies in addition to the anti-infective treatment. ACAs are also frequent in various autoimmune pathologies where, in addition to being indicators of the breakdown of immune tolerance, they can modulate the activity of the disease according to their cytokine target. In this review of the literature, we will focus on the epidemiology and the clinical impact of these ACAs in healthy subjects and in infectious or dysimmune diseases.
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Affiliation(s)
- L Gaigne
- Département de médecine interne, hôpital La Timone, CHU de Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France.
| | - C Piperoglou
- Marseille immunopôle, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France
| | - N Banzet
- Marseille immunopôle, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France
| | - L Ghellab
- Marseille immunopôle, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France
| | - F Vély
- Marseille immunopôle, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France; CNRS, Inserm, CIML, Aix Marseille université, Marseille, France
| | - N Schleinitz
- Département de médecine interne, hôpital La Timone, CHU de Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France; Marseille immunopôle, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France
| | - M Ebbo
- Département de médecine interne, hôpital La Timone, CHU de Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France; Marseille immunopôle, hôpital de la Timone, Assistance publique-Hôpitaux de Marseille, Aix-Marseille université, Marseille, France
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12
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Christie SM, Fijen C, Rothenberg E. V(D)J Recombination: Recent Insights in Formation of the Recombinase Complex and Recruitment of DNA Repair Machinery. Front Cell Dev Biol 2022; 10:886718. [PMID: 35573672 PMCID: PMC9099191 DOI: 10.3389/fcell.2022.886718] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
V(D)J recombination is an essential mechanism of the adaptive immune system, producing a diverse set of antigen receptors in developing lymphocytes via regulated double strand DNA break and subsequent repair. DNA cleavage is initiated by the recombinase complex, consisting of lymphocyte specific proteins RAG1 and RAG2, while the repair phase is completed by classical non-homologous end joining (NHEJ). Many of the individual steps of this process have been well described and new research has increased the scale to understand the mechanisms of initiation and intermediate stages of the pathway. In this review we discuss 1) the regulatory functions of RAGs, 2) recruitment of RAGs to the site of recombination and formation of a paired complex, 3) the transition from a post-cleavage complex containing RAGs and cleaved DNA ends to the NHEJ repair phase, and 4) the potential redundant roles of certain factors in repairing the break. Regulatory (non-core) domains of RAGs are not necessary for catalytic activity, but likely influence recruitment and stabilization through interaction with modified histones and conformational changes. To form long range paired complexes, recent studies have found evidence in support of large scale chromosomal contraction through various factors to utilize diverse gene segments. Following the paired cleavage event, four broken DNA ends must now make a regulated transition to the repair phase, which can be controlled by dynamic conformational changes and post-translational modification of the factors involved. Additionally, we examine the overlapping roles of certain NHEJ factors which allows for prevention of genomic instability due to incomplete repair in the absence of one, but are lethal in combined knockouts. To conclude, we focus on the importance of understanding the detail of these processes in regards to off-target recombination or deficiency-mediated clinical manifestations.
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Affiliation(s)
- Shaun M. Christie
- *Correspondence: Shaun M. Christie, ; Carel Fijen, ; Eli Rothenberg,
| | - Carel Fijen
- *Correspondence: Shaun M. Christie, ; Carel Fijen, ; Eli Rothenberg,
| | - Eli Rothenberg
- *Correspondence: Shaun M. Christie, ; Carel Fijen, ; Eli Rothenberg,
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13
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Seth N, Tuano KS, Chinen J. Inborn errors of immunity: Recent progress. J Allergy Clin Immunol 2021; 148:1442-1450. [PMID: 34688776 DOI: 10.1016/j.jaci.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Abstract
Recent advances in the field of inborn errors of immunity (IEIs) have been wide in scope, including progress in mechanisms of disease, diagnosis, and management. New gene defects affecting the immune response continue to be reported, as many as 26 in the year 2020. It was noted that the presentation of IEIs might not include recurrent infections in 9% of cases, and that current diagnostic methods can identify molecular causes in 92% of patients with severe combined immunodeficiency. Progress in immunopathogenesis explained mechanisms leading to symptoms of autosomal-recessive hyper-IgE syndrome. There was an emphasis on research in primary antibody deficiencies. The benefit of antibiotic prophylaxis to reduce the frequency of infections was demonstrated in these patients. The regimen of rituximab and azathioprine or mycophenolate was proven effective for chronic granulocytic interstitial pneumonia. The efficacy and adverse events of hematopoietic stem cell transplant in different IEI conditions were reported, as well as different strategies to improve outcomes, supporting its use in immunodeficiency and immunodysregulatory syndromes. The recent pandemic of coronavirus disease 2019 affected patients with IEIs, in particular those with deficiency in the interferon-mediated activation of the immune response. Initial data suggest that coronavirus disease 2019 vaccines might elicit anti-coronavirus disease 2019-neutralizing antibody responses in some patients with IEI conditions.
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Affiliation(s)
- Neha Seth
- Division of Immunology, Allergy and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, The Woodlands, Tex
| | - Karen S Tuano
- Division of Immunology, Allergy and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, The Woodlands, Tex
| | - Javier Chinen
- Division of Immunology, Allergy and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, The Woodlands, Tex.
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14
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Baloh CH, Borkar SA, Chang KF, Yao J, Hershfield MS, Parikh SH, Kohn DB, Goodenow MM, Sleasman JW, Yin L. Normal IgH Repertoire Diversity in an Infant with ADA Deficiency After Gene Therapy. J Clin Immunol 2021; 41:1597-1606. [PMID: 34184208 PMCID: PMC9906566 DOI: 10.1007/s10875-021-01034-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Adenosine deaminase (ADA) deficiency causes severe combined immunodeficiency (SCID) through an accumulation of toxic metabolites within lymphocytes. Recently, ADA deficiency has been successfully treated using lentiviral-transduced autologous CD34+ cells carrying the ADA gene. T and B cell function appears to be fully restored, but in many patients' B cell numbers remain low, and assessments of the immunoglobulin heavy (IgHV) repertoire following gene therapy are lacking. METHODS We performed deep sequencing of IgHV repertoire in peripheral blood lymphocytes from a child following lentivirus-based gene therapy for ADA deficiency and compared to the IgHV repertoire in healthy infants and adults. RESULTS After gene therapy, Ig diversity increased over time as evidenced by V, D, and J gene usage, N-additions, CDR3 length, extent of somatic hypermutation, and Ig class switching. There was the emergence of predominant IgHM, IgHG, and IgHA CDR3 lengths after gene therapy indicating successful oligoclonal expansion in response to antigens. This provides proof of concept for the feasibility and utility of molecular monitoring in following B cell reconstitution following gene therapy for ADA deficiency. CONCLUSION Based on deep sequencing, gene therapy resulted in an IgHV repertoire with molecular diversity similar to healthy infants.
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Affiliation(s)
- Carolyn H Baloh
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Samiksha A Borkar
- Molecular HIV Host Interaction Section, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Kai-Fen Chang
- Molecular HIV Host Interaction Section, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Jiqiang Yao
- Department of Biostatistics and bioinformatics, Moffitt Cancer Center, Tampa, FL
| | - Michael S Hershfield
- Division of Rheumatology and Immunology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Suhag H Parikh
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Donald B Kohn
- Division of Hematology & Oncology, Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA
| | - Maureen M Goodenow
- Molecular HIV Host Interaction Section, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - John W Sleasman
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
| | - Li Yin
- Molecular HIV Host Interaction Section, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
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15
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Bosticardo M, Pala F, Notarangelo LD. RAG deficiencies: Recent advances in disease pathogenesis and novel therapeutic approaches. Eur J Immunol 2021; 51:1028-1038. [PMID: 33682138 PMCID: PMC8325549 DOI: 10.1002/eji.202048880] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/13/2021] [Accepted: 03/03/2021] [Indexed: 12/26/2022]
Abstract
The RAG1 and RAG2 proteins initiate the process of V(D)J recombination and therefore play an essential role in adaptive immunity. While null mutations in the RAG genes cause severe combined immune deficiency with lack of T and B cells (T- B- SCID) and susceptibility to life-threatening, early-onset infections, studies in humans and mice have demonstrated that hypomorphic RAG mutations are associated with defects of central and peripheral tolerance resulting in immune dysregulation. In this review, we provide an overview of the extended spectrum of RAG deficiencies and their associated clinical and immunological phenotypes in humans. We discuss recent advances in the mechanisms that control RAG expression and function, the effects of perturbed RAG activity on lymphoid development and immune homeostasis, and propose novel approaches to correct this group of disorders.
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Affiliation(s)
- Marita Bosticardo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Francesca Pala
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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16
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Exploring genetic defects in adults who were clinically diagnosed as severe combined immune deficiency during infancy. Immunol Res 2021; 69:145-152. [PMID: 33599911 DOI: 10.1007/s12026-021-09179-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/03/2021] [Indexed: 12/16/2022]
Abstract
Genetic diagnostic tools including whole-exome sequencing (WES) have advanced our understanding in human diseases and become common practice in diagnosing patients with suspected primary immune deficiencies. Establishing a genetic diagnosis is of paramount importance for tailoring adequate therapeutic regimens, including identifying the need for hematopoietic stem cell transplantation (HSCT) and genetic-based therapies. Here, we genetically studied two adult patients who were clinically diagnosed during infancy with severe combined immune deficiency (SCID). Two unrelated patients, both of consanguineous kindred, underwent WES in adulthood, 2 decades after their initial clinical manifestations. Upon clinical presentation, immunological workup was performed, which led to a diagnosis of SCID. The patients presented during infancy with failure to thrive, generalized erythematous rash, and recurrent gastrointestinal and respiratory tract infections, including episodes of Pneumocystis pneumonia infection and Candida albicans fungemia. Hypogammaglobulinemia and T-cell lymphopenia were detected. Both patients were treated with a 10/10 HLA matched sibling donor unconditioned HSCT. Retrospective genetic workup revealed homozygous bi-allelic mutations in IL7RA in one patient and in RAG2 in the other. Our study exemplifies the impact of retrospectively establishing a genetic diagnosis. Pinpointing the genetic cause raises several issues including optimized surveillance and treatment, understanding disease mechanisms and outcomes, future family planning, and social and psychological considerations.
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17
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Villa A, Capo V, Castiello MC. Innovative Cell-Based Therapies and Conditioning to Cure RAG Deficiency. Front Immunol 2020; 11:607926. [PMID: 33329604 PMCID: PMC7711106 DOI: 10.3389/fimmu.2020.607926] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Genetic defects in recombination activating genes (RAG) 1 and 2 cause a broad spectrum of severe immune defects ranging from early severe and repeated infections to inflammation and autoimmune manifestations. A correlation between in vitro recombination activity and immune phenotype has been described. Hematopoietic cell transplantation is the treatment of care; however, the availability of next generation sequencing and whole genome sequencing has allowed the identification of novel genetic RAG variants in immunodeficient patients at various ages, raising therapeutic questions. This review addresses the recent advances of novel therapeutic approaches for RAG deficiency. As conventional myeloablative conditioning regimens are associated with acute toxicities and transplanted-related mortality, innovative minimal conditioning regimens based on the use of monoclonal antibodies are now emerging and show promising results. To overcome shortage of compatible donors, gene therapy has been developed in various RAG preclinical models. Overall, the transplantation of autologous gene corrected hematopoietic precursors and the use of non-genotoxic conditioning will open a new era, offering a cure to an increasing number of RAG patients regardless of donor availability and severity of clinical conditions.
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Affiliation(s)
- Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy.,Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche (IRGB-CNR), Milan, Italy
| | - Valentina Capo
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy.,Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche (IRGB-CNR), Milan, Italy
| | - Maria Carmina Castiello
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy.,Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche (IRGB-CNR), Milan, Italy
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18
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Geier CB, Farmer JR, Foldvari Z, Ujhazi B, Steininger J, Sleasman JW, Parikh S, Dilley MA, Pai SY, Henderson L, Hazen M, Neven B, Moshous D, Sharapova SO, Mihailova S, Yankova P, Naumova E, Özen S, Byram K, Fernandez J, Wolf HM, Eibl MM, Notarangelo LD, Calabrese LH, Walter JE. Vasculitis as a Major Morbidity Factor in Patients With Partial RAG Deficiency. Front Immunol 2020; 11:574738. [PMID: 33193364 PMCID: PMC7609967 DOI: 10.3389/fimmu.2020.574738] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/31/2020] [Indexed: 12/30/2022] Open
Abstract
Vasculitis can be a life-threatening complication associated with high mortality and morbidity among patients with primary immunodeficiencies (PIDs), including variants of severe and combined immunodeficiencies ((S)CID). Our understanding of vasculitis in partial defects in recombination activating gene (RAG) deficiency, a prototype of (S)CIDs, is limited with no published systematic evaluation of diagnostic and therapeutic modalities. In this report, we sought to establish the clinical, laboratory features, and treatment outcome of patients with vasculitis due to partial RAG deficiency. Vasculitis was a major complication in eight (13%) of 62 patients in our cohort with partial RAG deficiency with features of infections and immune dysregulation. Vasculitis occurred early in life, often as first sign of disease (50%) and was complicated by significant end organ damage. Viral infections often preceded the onset of predominately non-granulomatous-small vessel vasculitis. Autoantibodies against cytokines (IFN-α, -ω, and IL-12) were detected in a large fraction of the cases tested (80%), whereas the majority of patients were anti-neutrophil cytoplasmic antibodies (ANCA) negative (>80%). Genetic diagnosis of RAG deficiency was delayed up to 2 years from the onset of vasculitis. Clinical cases with sole skin manifestation responded well to first-line steroid treatment, whereas systemic vasculitis with severe end-organ complications required second-line immunosuppression and/or hematopoietic stem cell transplantation (HSCT) for definitive management. In conclusion, our data suggest that vasculitis in partial RAG deficiency is prevalent among patients with partial RAG deficiency and is associated with high morbidity. Therefore, partial RAG deficiency should be included in the differential diagnosis of patients with early-onset systemic vasculitis. Diagnostic serology may be misleading with ANCA negative findings, and search for conventional autoantibodies should be extended to include those targeting cytokines.
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Affiliation(s)
| | - Jocelyn R Farmer
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Zsofia Foldvari
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Boglarka Ujhazi
- University of South Florida and Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States
| | | | - John W Sleasman
- Division of Allergy, Immunology and Pulmonary Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Suhag Parikh
- Emory University School of Medicine, Atlanta, GA, United States
| | - Meredith A Dilley
- Department of Immunology, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Sung-Yun Pai
- Division of Hematology-Oncology, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Lauren Henderson
- Division of Immunology, Department of Rheumatology, Boston Children's Hospital, Boston, MA, United States
| | - Melissa Hazen
- Division of Immunology, Department of Rheumatology, Boston Children's Hospital, Boston, MA, United States
| | - Benedicte Neven
- Imagine Institute, Paris Descartes-Sorbonne Paris Cité University, Paris, France.,Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratory "Immunogenetics of Pediatric autoimmune diseases", INSERM UMR1163, Institut Imagine, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Despina Moshous
- Imagine Institute, Paris Descartes-Sorbonne Paris Cité University, Paris, France.,Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratory of Genome Dynamics in The Immune System, Paris, France
| | - Svetlana O Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Snezhina Mihailova
- Department of Clinical Immunology Medical University of Sofia, Sofia, Bulgaria
| | - Petya Yankova
- Department of Clinical Immunology Medical University of Sofia, Sofia, Bulgaria
| | - Elisaveta Naumova
- Department of Clinical Immunology Medical University of Sofia, Sofia, Bulgaria
| | - Seza Özen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kevin Byram
- Cleveland Clinic Center for Vasculitis Care and Research, Cleveland, OH, United States
| | - James Fernandez
- Cleveland Clinic Center for Vasculitis Care and Research, Cleveland, OH, United States
| | - Hermann M Wolf
- Immunology Outpatient Clinic, Vienna, Austria.,Sigmund Freud Private University- Medical School, Vienna, Austria
| | - Martha M Eibl
- Immunology Outpatient Clinic, Vienna, Austria.,Biomedizinische Forschungs GmbH, Vienna, Austria
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, NIAID, National Institutes of Health, Bethesda, MD, United States
| | - Leonard H Calabrese
- Cleveland Clinic Center for Vasculitis Care and Research, Cleveland, OH, United States
| | - Jolan E Walter
- University of South Florida at Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States.,Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, MA, United States
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19
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May MR, Bettridge JT, Desiderio S. Binding and allosteric transmission of histone H3 Lys-4 trimethylation to the recombinase RAG-1 are separable functions of the RAG-2 plant homeodomain finger. J Biol Chem 2020; 295:9052-9060. [PMID: 32414844 PMCID: PMC7335790 DOI: 10.1074/jbc.ra120.014382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 05/15/2020] [Indexed: 11/06/2022] Open
Abstract
V(D)J recombination is initiated by the recombination-activating gene protein (RAG) recombinase, consisting of RAG-1 and RAG-2 subunits. The susceptibility of gene segments to cleavage by RAG is associated with gene transcription and with epigenetic marks characteristic of active chromatin, including histone H3 trimethylated at lysine 4 (H3K4me3). Binding of H3K4me3 by a plant homeodomain (PHD) in RAG-2 induces conformational changes in RAG-1, allosterically stimulating substrate binding and catalysis. To better understand the path of allostery from the RAG-2 PHD finger to RAG-1, here we employed phylogenetic substitution. We observed that a chimeric RAG-2 protein in which the mouse PHD finger is replaced by the corresponding domain from the shark Chiloscyllium punctatum binds H3K4me3 but fails to transmit an allosteric signal, indicating that binding of H3K4me3 by RAG-2 is insufficient to support recombination. By substituting residues in the C. punctatum PHD with the corresponding residues in the mouse PHD and testing for rescue of allostery, we demonstrate that H3K4me3 binding and transmission of an allosteric signal to RAG-1 are separable functions of the RAG-2 PHD finger.
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Affiliation(s)
- Meiling R May
- Department of Molecular Biology and Genetics and Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John T Bettridge
- Department of Molecular Biology and Genetics and Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephen Desiderio
- Department of Molecular Biology and Genetics and Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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20
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Sharapova SO, Skomska-Pawliszak M, Rodina YA, Wolska-Kuśnierz B, Dabrowska-Leonik N, Mikołuć B, Pashchenko OE, Pasic S, Freiberger T, Milota T, Formánková R, Szaflarska A, Siedlar M, Avčin T, Markelj G, Ciznar P, Kalwak K, Kołtan S, Jackowska T, Drabko K, Gagro A, Pac M, Naumova E, Kandilarova S, Babol-Pokora K, Varabyou DS, Barendregt BH, Raykina EV, Varlamova TV, Pavlova AV, Grombirikova H, Debeljak M, Mersiyanova IV, Bondarenko AV, Chernyshova LI, Kostyuchenko LV, Guseva MN, Rascon J, Muleviciene A, Preiksaitiene E, Geier CB, Leiss-Piller A, Yamazaki Y, Kawai T, Walter JE, Kondratenko IV, Šedivá A, van der Burg M, Kuzmenko NB, Notarangelo LD, Bernatowska E, Aleinikova OV. The Clinical and Genetic Spectrum of 82 Patients With RAG Deficiency Including a c.256_257delAA Founder Variant in Slavic Countries. Front Immunol 2020; 11:900. [PMID: 32655540 PMCID: PMC7325958 DOI: 10.3389/fimmu.2020.00900] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/20/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Variants in recombination-activating genes (RAG) are common genetic causes of autosomal recessive forms of combined immunodeficiencies (CID) ranging from severe combined immunodeficiency (SCID), Omenn syndrome (OS), leaky SCID, and CID with granulomas and/or autoimmunity (CID-G/AI), and even milder presentation with antibody deficiency. Objective: We aim to estimate the incidence, clinical presentation, genetic variability, and treatment outcome with geographic distribution of patients with the RAG defects in populations inhabiting South, West, and East Slavic countries. Methods: Demographic, clinical, and laboratory data were collected from RAG-deficient patients of Slavic origin via chart review, retrospectively. Recombinase activity was determined in vitro by flow cytometry-based assay. Results: Based on the clinical and immunologic phenotype, our cohort of 82 patients from 68 families represented a wide spectrum of RAG deficiencies, including SCID (n = 20), OS (n = 37), and LS/CID (n = 25) phenotypes. Sixty-seven (81.7%) patients carried RAG1 and 15 patients (18.3%) carried RAG2 biallelic variants. We estimate that the minimal annual incidence of RAG deficiency in Slavic countries varies between 1 in 180,000 and 1 in 300,000 live births, and it may vary secondary to health care disparities in these regions. In our cohort, 70% (n = 47) of patients with RAG1 variants carried p.K86Vfs*33 (c.256_257delAA) allele, either in homozygous (n = 18, 27%) or in compound heterozygous (n = 29, 43%) form. The majority (77%) of patients with homozygous RAG1 p.K86Vfs*33 variant originated from Vistula watershed area in Central and Eastern Poland, and compound heterozygote cases were distributed among all Slavic countries except Bulgaria. Clinical and immunological presentation of homozygous RAG1 p.K86Vfs*33 cases was highly diverse (SCID, OS, and AS/CID) suggestive of strong influence of additional genetic and/or epigenetic factors in shaping the final phenotype. Conclusion: We propose that RAG1 p.K86Vfs*33 is a founder variant originating from the Vistula watershed region in Poland, which may explain a high proportion of homozygous cases from Central and Eastern Poland and the presence of the variant in all Slavs. Our studies in this cohort of RAG1 founder variants confirm that clinical and immunological phenotypes only partially depend on the underlying genetic defect. As access to HSCT is improving among RAG-deficient patients in Eastern Europe, we anticipate improvements in survival.
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Affiliation(s)
- Svetlana O. Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk Region, Belarus
| | | | - Yulia A. Rodina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | | | | | - Bozena Mikołuć
- Department of Pediatrics, Rheumatology, Immunology and Metabolic Bone Diseases, Medical University of Bialystok, Bialystok, Poland
| | - Olga E. Pashchenko
- Immunology Department, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Srdjan Pasic
- Pediatric Immunology, Medical Faculty, Mother and Child Health Institute, University of Belgrade, Belgrade, Serbia
| | - Tomáš Freiberger
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Tomáš Milota
- Department of Immunology, University Hospital Motol, Prague, Czechia
- Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Renata Formánková
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague, Czechia
- Faculty of Medicine, Charles University, Prague, Czechia
| | - Anna Szaflarska
- Department of Clinical Immunology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej Siedlar
- Department of Clinical Immunology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Clinical Immunology, University Children's Hospital, Krakow, Poland
| | - Tadej Avčin
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gašper Markelj
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Ciznar
- Pediatric Department, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Krzysztof Kalwak
- Department of Pediatric Hematology/Oncology and BMT, Wroclaw Medical University, Wroclaw, Poland
| | - Sylwia Kołtan
- Department of Pediatrics, Hematology and Oncology Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
- Nicolaus Copernicus University in Torun, Torun, Poland
| | - Teresa Jackowska
- Department of Pediatrics, Medical Center of Postgraduate Education, Warsaw, Poland
| | - Katarzyna Drabko
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Alenka Gagro
- Department of Pediatrics, School of Medicine, Zagreb Children's Hospital, University of Zagreb, Zagreb, Croatia
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Małgorzata Pac
- Department of Immunology, Children's Memorial Health Institute, Warsaw, Poland
| | - Elissaveta Naumova
- Department of Clinical Immunology, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Snezhina Kandilarova
- Department of Clinical Immunology, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Katarzyna Babol-Pokora
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Dzmitry S. Varabyou
- Department of Geographical Ecology, Belarusian State University, Minsk, Belarus
| | - Barbara H. Barendregt
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Elena V. Raykina
- Laboratory of Molecular Biology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Tatiana V. Varlamova
- Laboratory of Molecular Biology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna V. Pavlova
- Laboratory of Molecular Biology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Hana Grombirikova
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Maruša Debeljak
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Irina V. Mersiyanova
- Laboratory of Molecular Biology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anastasiia V. Bondarenko
- Department of Pediatric Infectious Diseases and Pediatric Immunology, Shupyk National Medical Academy for Postgraduate Education, Kiev, Ukraine
| | - Liudmyla I. Chernyshova
- Department of Pediatric Infectious Diseases and Pediatric Immunology, Shupyk National Medical Academy for Postgraduate Education, Kiev, Ukraine
| | - Larysa V. Kostyuchenko
- Pediatric Department, West-Ukrainian Specialized Children's Medical Center, Lviv, Ukraine
| | - Marina N. Guseva
- Consulting Center of Pediatric Medical Academy, St. Petersburg, Russia
| | - Jelena Rascon
- Center for Pediatric Oncology and Hematology, Vilnius University, Vilnius, Lithuania
| | - Audrone Muleviciene
- Center for Pediatric Oncology and Hematology, Vilnius University, Vilnius, Lithuania
| | - Egle Preiksaitiene
- Hematology, Oncology and Transfusion Medicine Center, Vilnius University, Vilnius, Lithuania
| | | | | | - Yasuhiro Yamazaki
- 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
| | - Tomoki Kawai
- 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
| | - Jolan E. Walter
- University of South Florida at Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States
- Massachusetts General Hospital for Children, Boston, MA, United States
| | - Irina V. Kondratenko
- Department of Clinical Immunology, Russian Clinical Children's Hospital by Pirogov Russian National Research Medical University, Moscow, Russia
| | - Anna Šedivá
- Department of Immunology, University Hospital Motol, Prague, Czechia
- Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Mirjam van der Burg
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Pediatric, Laboratory for Pediatric Immunology, Willem Alexander Children's Hospital, LUMC, Leiden, Netherlands
| | - Natalia B. Kuzmenko
- Department of Epidemiology and Monitoring of Primary Immunodeficiencies, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Luigi D. 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
| | - Ewa Bernatowska
- Department of Immunology, Children's Memorial Health Institute, Warsaw, Poland
| | - Olga V. Aleinikova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk Region, Belarus
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21
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Ben-Ali M, Kechout N, Mekki N, Yang J, Chan KW, Barakat A, Aadam Z, Gamara J, Gargouri L, Largueche B, BelHadj-Hmida N, Nedri A, Ameur HB, Mellouli F, Boukari R, Bejaoui M, Bousfiha A, Ben-Mustapha I, Lau YL, Barbouche MR. Genetic Approaches for Definitive Diagnosis of Agammaglobulinemia in Consanguineous Families. J Clin Immunol 2019; 40:96-104. [PMID: 31696364 DOI: 10.1007/s10875-019-00706-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022]
Abstract
Autosomal recessive agammaglobulinemia (ARA) is a primary immunodeficiency characterized by absent peripheral B cells, severe hypogammaglobulinemia, and absent BTK gene mutations. In ARA, mutations occur in genes encoding the pre-B cell receptor (pre-BCR) or downstream signaling proteins. In this work, we used candidate gene and whole-exome sequencing to investigate the molecular basis of ARA in 6 patients from 4 consanguineous North-African families. Sanger sequencing of candidate genes encoding the pre-BCR components (ΙGΗΜ, CD79A, CD79B, IGLL1, and VPREB1) was initially performed and determined the genetic defect in five patients. Two novel mutations in IGHM (p.Val378Alafs*1 and p.Ile184Serfs*21) were identified in three patients from two unrelated kindred and a novel nonsense mutation was identified in CD79A (p.Trp66*) in two siblings from a third kindred. Whole-exome sequencing (WES) was performed on the sixth patient who harbored a homozygous stop mutation at position 407 in the RAG2 gene (p.Glu407*). We concluded that conventional gene sequencing, especially when multiple genes are involved in the defect as is the case in ARA, is costly and time-consuming, resulting in delayed diagnosis that contributes to increased morbidity and mortality. In addition, it fails to identify the involvement of novel and unsuspected gene defects when the phenotype of the patients is atypical. WES has the potential to provide a rapid and more accurate genetic diagnosis in ARA, which is crucial for the treatment of the patients.
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Affiliation(s)
- Meriem Ben-Ali
- Laboratory of Transmission, Control and Immunobiology of Infections, LR11IPT02 (LTCII), Institut Pasteur de Tunis, 13, place Pasteur, BP74, 1002, Tunis-Belvédère, Tunisia.,Université Tunis El Manar, 1068, Tunis, Tunisia
| | - Nadia Kechout
- Department of Immunology, Institut Pasteur d'Algérie, Algiers, Algeria.,Faculty of Medicine of Algiers, Algiers, Algeria
| | - Najla Mekki
- Laboratory of Transmission, Control and Immunobiology of Infections, LR11IPT02 (LTCII), Institut Pasteur de Tunis, 13, place Pasteur, BP74, 1002, Tunis-Belvédère, Tunisia.,Université Tunis El Manar, 1068, Tunis, Tunisia
| | - Jing Yang
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Koon Wing Chan
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Abdelhamid Barakat
- Laboratory of Molecular and Human Genetics, Department of Scientific Research, Institut Pasteur du Maroc, Casablanca, Morocco
| | - Zahra Aadam
- Laboratory of Molecular and Human Genetics, Department of Scientific Research, Institut Pasteur du Maroc, Casablanca, Morocco
| | - Jouda Gamara
- Laboratory of Transmission, Control and Immunobiology of Infections, LR11IPT02 (LTCII), Institut Pasteur de Tunis, 13, place Pasteur, BP74, 1002, Tunis-Belvédère, Tunisia.,Université Tunis El Manar, 1068, Tunis, Tunisia
| | - Lamia Gargouri
- Department of Paediatrics, Habib Bourguiba Hospital, Sfax, Tunisia
| | - Beya Largueche
- Laboratory of Transmission, Control and Immunobiology of Infections, LR11IPT02 (LTCII), Institut Pasteur de Tunis, 13, place Pasteur, BP74, 1002, Tunis-Belvédère, Tunisia.,Université Tunis El Manar, 1068, Tunis, Tunisia
| | - Nabil BelHadj-Hmida
- Laboratory of Transmission, Control and Immunobiology of Infections, LR11IPT02 (LTCII), Institut Pasteur de Tunis, 13, place Pasteur, BP74, 1002, Tunis-Belvédère, Tunisia.,Université Tunis El Manar, 1068, Tunis, Tunisia
| | - Amel Nedri
- Department of Paediatrics, Medenine Hospital, Medenine, Tunisia
| | | | - Fethi Mellouli
- National Bone Marrow Transplantation Center, Jebel Lakhdar, Tunis, Tunisia
| | - Rachida Boukari
- Department of Pediatrics, CHU Mustapha-Bacha, Faculty of Medicine of Algiers, Algiers, Algeria
| | - Mohamed Bejaoui
- National Bone Marrow Transplantation Center, Jebel Lakhdar, Tunis, Tunisia
| | - Aziz Bousfiha
- Clinical Immunology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Ibn Rochd, King Hassan II University, Casablanca, Morocco
| | - Imen Ben-Mustapha
- Laboratory of Transmission, Control and Immunobiology of Infections, LR11IPT02 (LTCII), Institut Pasteur de Tunis, 13, place Pasteur, BP74, 1002, Tunis-Belvédère, Tunisia.,Université Tunis El Manar, 1068, Tunis, Tunisia
| | - Yu-Lung Lau
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
| | - Mohamed-Ridha Barbouche
- Laboratory of Transmission, Control and Immunobiology of Infections, LR11IPT02 (LTCII), Institut Pasteur de Tunis, 13, place Pasteur, BP74, 1002, Tunis-Belvédère, Tunisia. .,Université Tunis El Manar, 1068, Tunis, Tunisia.
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22
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Bulkhi AA, Dasso JF, Schuetz C, Walter JE. Approaches to patients with variants in RAG genes: from diagnosis to timely treatment. Expert Rev Clin Immunol 2019; 15:1033-1046. [PMID: 31535575 DOI: 10.1080/1744666x.2020.1670060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Patients with primary immunodeficiency secondary to abnormal recombinase activating genes (RAG) can present with broad clinical phenotypes ranging from early severe infections to autoimmune complications and inflammation. Immunological phenotype may also vary from T-B- severe combined immunodeficiency to combined immunodeficiency or antibody deficiencies with near-normal T and B cell counts and even preserved specific antibody response to pathogens. It is not uncommon that RAG variants of uncertain significance are identified by serendipity during a broad genetic screening process and pathogenic RAG variants are increasingly recognized among all age groups, including adults. Establishing the pathogenicity and clinical relevance of novel RAG variants can be challenging since RAG genes are highly polymorphic. This review paper aims to summarize clinical phenotypes of RAG deficiencies and provide practical guidance for confirming the direct link between specific RAG variants and clinical disease. Lastly, we will review the current understanding of treatment option for patients with varying severity of RAG deficiencies. Area covered: This review discusses the different phenotypes and immunological aspects of RAG deficiencies, the diagnosis dilemma facing clinicians, and an overview of current and advancement in treatments. Expert opinion: A careful analysis of immunological and clinical data and their correlation with genetic findings helps to determine the significance of the genetic polymorphism. Advances in functional assays, as well as anti-cytokine antibodies, make it easier to resolve the diagnostic dilemma.
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Affiliation(s)
- Adeeb A Bulkhi
- Department of Internal Medicine, College of Medicine, Umm Al-Qura University , Makkah , Saudi Arabia.,Division of Allergy and Immunology, Department of Internal Medicine, Morsani College of Medicine, University of South Florida , Tampa , FL , USA
| | - Joseph F Dasso
- Department of Pediatrics, Medical Faculty Carl Gustav Carus, Technical University Dresden , Dresden , Germany
| | - Catharina Schuetz
- Department of Pediatrics, Medical Faculty Carl Gustav Carus, Technical University Dresden , Dresden , Germany
| | - Jolan E Walter
- Division of Allergy and Immunology, Department of Pediatrics, Morsani College of Medicine, University of South Florida , Tampa , FL , USA.,Division of Allergy and Immunology, Department of Medicine, Johns Hopkins All Children's Hospital , St. Petersburg , FL , USA.,Division of Allergy and Immunology, Massachusetts General Hospital for Children , Boston , MA , USA
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23
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Abstract
While widespread genome sequencing ushers in a new era of preventive medicine, the tools for predictive genomics are still lacking. Time and resource limitations mean that human diseases remain uncharacterized because of an inability to predict clinically relevant genetic variants. A strategy of targeting highly conserved protein regions is used commonly in functional studies. However, this benefit is lost for rare diseases where the attributable genes are mostly conserved. An immunological disorder exemplifying this challenge occurs through damaging mutations in RAG1 and RAG2 which presents at an early age with a distinct phenotype of life-threatening immunodeficiency or autoimmunity. Many tools exist for variant pathogenicity prediction, but these cannot account for the probability of variant occurrence. Here, we present a method that predicts the likelihood of mutation for every amino acid residue in the RAG1 and RAG2 proteins. Population genetics data from approximately 146,000 individuals was used for rare variant analysis. Forty-four known pathogenic variants reported in patients and recombination activity measurements from 110 RAG1/2 mutants were used to validate calculated scores. Probabilities were compared with 98 currently known human cases of disease. A genome sequence dataset of 558 patients who have primary immunodeficiency but that are negative for RAG deficiency were also used as validation controls. We compared the difference between mutation likelihood and pathogenicity prediction. Our method builds a map of most probable mutations allowing pre-emptive functional analysis. This method may be applied to other diseases with hopes of improving preparedness for clinical diagnosis.
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24
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Farmer JR, Foldvari Z, Ujhazi B, De Ravin SS, Chen K, Bleesing JJH, Schuetz C, Al-Herz W, Abraham RS, Joshi AY, Costa-Carvalho BT, Buchbinder D, Booth C, Reiff A, Ferguson PJ, Aghamohammadi A, Abolhassani H, Puck JM, Adeli M, Cancrini C, Palma P, Bertaina A, Locatelli F, Di Matteo G, Geha RS, Kanariou MG, Lycopoulou L, Tzanoudaki M, Sleasman JW, Parikh S, Pinero G, Fischer BM, Dbaibo G, Unal E, Patiroglu T, Karakukcu M, Al-Saad KK, Dilley MA, Pai SY, Dutmer CM, Gelfand EW, Geier CB, Eibl MM, Wolf HM, Henderson LA, Hazen MM, Bonfim C, Wolska-Kuśnierz B, Butte MJ, Hernandez JD, Nicholas SK, Stepensky P, Chandrakasan S, Miano M, Westermann-Clark E, Goda V, Kriván G, Holland SM, Fadugba O, Henrickson SE, Ozen A, Karakoc-Aydiner E, Baris S, Kiykim A, Bredius R, Hoeger B, Boztug K, Pashchenko O, Neven B, Moshous D, Villartay JPD, Bousfiha AA, Hill HR, Notarangelo LD, Walter JE. Outcomes and Treatment Strategies for Autoimmunity and Hyperinflammation in Patients with RAG Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:1970-1985.e4. [PMID: 30877075 PMCID: PMC6612449 DOI: 10.1016/j.jaip.2019.02.038] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although autoimmunity and hyperinflammation secondary to recombination activating gene (RAG) deficiency have been associated with delayed diagnosis and even death, our current understanding is limited primarily to small case series. OBJECTIVE Understand the frequency, severity, and treatment responsiveness of autoimmunity and hyperinflammation in RAG deficiency. METHODS In reviewing the literature and our own database, we identified 85 patients with RAG deficiency, reported between 2001 and 2016, and compiled the largest case series to date of 63 patients with prominent autoimmune and/or hyperinflammatory pathology. RESULTS Diagnosis of RAG deficiency was delayed a median of 5 years from the first clinical signs of immune dysregulation. Most patients (55.6%) presented with more than 1 autoimmune or hyperinflammatory complication, with the most common etiologies being cytopenias (84.1%), granulomas (23.8%), and inflammatory skin disorders (19.0%). Infections, including live viral vaccinations, closely preceded the onset of autoimmunity in 28.6% of cases. Autoimmune cytopenias had early onset (median, 1.9, 2.1, and 2.6 years for autoimmune hemolytic anemia, immune thrombocytopenia, and autoimmune neutropenia, respectively) and were refractory to intravenous immunoglobulin, steroids, and rituximab in most cases (64.7%, 73.7%, and 71.4% for autoimmune hemolytic anemia, immune thrombocytopenia, and autoimmune neutropenia, respectively). Evans syndrome specifically was associated with lack of response to first-line therapy. Treatment-refractory autoimmunity/hyperinflammation prompted hematopoietic stem cell transplantation in 20 patients. CONCLUSIONS Autoimmunity/hyperinflammation can be a presenting sign of RAG deficiency and should prompt further evaluation. Multilineage cytopenias are often refractory to immunosuppressive treatment and may require hematopoietic cell transplantation for definitive management.
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Affiliation(s)
- Jocelyn R Farmer
- Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Zsofia Foldvari
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Radiumhospitalet, Oslo, Norway
| | - Boglarka Ujhazi
- University of South Florida and Johns Hopkins All Children's Hospital, Saint Petersburg, Fla
| | - Suk See De Ravin
- Laboratory of Host Defenses, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, Md
| | - Karin Chen
- Division of Allergy and Immunology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jack J H Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Catharina Schuetz
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Waleed Al-Herz
- Faculty of Medicine, Pediatrics Department, Kuwait University, Kuwait City, Kuwait; Allergy and Clinical Immunology Unit, Pediatrics Department, Alsabah Hospital, Kuwait City, Kuwait
| | - Roshini S Abraham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Avni Y Joshi
- Division of Pediatric Allergy/Immunology, Mayo Clinic Children's Center Rochester, Rochester, Minn
| | | | - David Buchbinder
- Pediatrics/Hematology, CHOC Children's Hospital - UC Irvine, Irvine, Calif
| | - Claire Booth
- Department of Paediatric Immunology, Great Ormond Street Hospital, London, United Kingdom
| | - Andreas Reiff
- Division of Rheumatology, Children's Hospital Los Angeles, Keck School of Medicine, USC, Los Angeles, Calif
| | - Polly J Ferguson
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jennifer M Puck
- Department of Pediatrics, University of California San Francisco and UCSF Benioff Children's Hospital, San Francisco, Calif
| | - Mehdi Adeli
- Sidra Medicine, Weill Cornell Medicine, and Hamad Medical Corporation, Doha, Qatar
| | - Caterina Cancrini
- Academic Department of Pediatrics (DPUO), Unit of Immune and Infectious Diseases, Childrens' Hospital Bambino Gesù, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Paolo Palma
- Academic Department of Pediatrics (DPUO), Research Unit in Congenital and Perinatal Infection, Children's Hospital Bambino Gesù, Rome, Italy
| | - Alice Bertaina
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS, Ospedale Bambino Gesù, Rome, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS, Ospedale Bambino Gesù, Rome, Italy; Department of Pediatrics, Sapienza, University of Rome, Rome, Italy
| | - Gigliola Di Matteo
- Academic Department of Pediatrics (DPUO), Unit of Immune and Infectious Diseases, Childrens' Hospital Bambino Gesù, Rome, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Raif S Geha
- Immunology Division, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Maria G Kanariou
- Department of Immunology - Histocompatibility, Specialized Center & Referral Center for Primary Immunodeficiencies - Paediatric Immunology, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Lilia Lycopoulou
- 1st Department of Pediatrics, University of Athens, Aghia Sofia Children's Hospital, Athens, Greece
| | - Marianna Tzanoudaki
- Department of Immunology - Histocompatibility, Specialized Center & Referral Center for Primary Immunodeficiencies - Paediatric Immunology, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - John W Sleasman
- Division of Allergy, Immunology and Pulmonary Medicine, Duke University School of Medicine, Durham, NC
| | - Suhag Parikh
- Division of Pediatric Blood and Marrow Transplantation, Duke University School of Medicine, Durham, NC
| | - Gloria Pinero
- Division of Allergy, Immunology and Pulmonary Medicine, Duke University School of Medicine, Durham, NC
| | - Bernard M Fischer
- Division of Allergy, Immunology and Pulmonary Medicine, Duke University School of Medicine, Durham, NC
| | - Ghassan Dbaibo
- Department of Pediatrics and Adolescent Medicine, Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon
| | - Ekrem Unal
- Division of Pediatric Hematology and Oncology & HCST Unit, Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Turkan Patiroglu
- Division of Pediatric Hematology and Oncology & HCST Unit, Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey; Division of Pediatric Immunology, Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Musa Karakukcu
- Division of Pediatric Hematology and Oncology & HCST Unit, Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Khulood Khalifa Al-Saad
- Salmanyia Medical Complex, Department of Pediatrics, Division of Pediatric Hematology and Oncology, Manama, Bahrain
| | - Meredith A Dilley
- Department of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sung-Yun Pai
- Division of Hematology-Oncology, Boston Children's Hospital, Boston, Mass; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Cullen M Dutmer
- Division of Allergy & Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Erwin W Gelfand
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | | | - Martha M Eibl
- Immunology Outpatient Clinic, Vienna, Austria; Biomedizinische Forschungs GmbH, Vienna, Austria
| | - Hermann M Wolf
- Immunology Outpatient Clinic, Vienna, Austria; Sigmund Freud Private University-Medical School, Vienna, Austria
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Melissa M Hazen
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Carmem Bonfim
- Hospital Infantil Pequeno Principe, Curitiba, Brazil
| | | | - Manish J Butte
- Division of Immunology, Allergy, and Rheumatology, Department of Pediatrics and Jeffrey Modell Diagnostic and Research Center, University of California, Los Angeles, Los Angeles, Calif
| | - Joseph D Hernandez
- Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, Calif
| | - Sarah K Nicholas
- Section of Immunology, Allergy, and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Polina Stepensky
- Department of Bone Marrow Transplantation, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Shanmuganathan Chandrakasan
- Division of Bone Marrow Transplant, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Maurizio Miano
- Haematology Unit, Department of Pediatric Haematology-Oncology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Emma Westermann-Clark
- Department of Internal Medicine, Division of Allergy/Immunology, University of South Florida Morsani College of Medicine, Tampa, Fla
| | - Vera Goda
- Department for Pediatric Hematology and Hemopoietic Stem Cell Transplantation, Central Hospital of Southern Pest- National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Gergely Kriván
- Department for Pediatric Hematology and Hemopoietic Stem Cell Transplantation, Central Hospital of Southern Pest- National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Md
| | - Olajumoke Fadugba
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Sarah E Henrickson
- Allergy Immunology Division, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa; Institute for Immunology, the University of Pennsylvania, Philadelphia, Pa
| | - Ahmet Ozen
- Marmara University School of Medicine, Division of Pediatric Allergy and Immunology, Istanbul, Turkey
| | - Elif Karakoc-Aydiner
- Marmara University School of Medicine, Division of Pediatric Allergy and Immunology, Istanbul, Turkey
| | - Safa Baris
- Marmara University School of Medicine, Division of Pediatric Allergy and Immunology, Istanbul, Turkey
| | - Ayca Kiykim
- Ministry of Health, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Robbert Bredius
- Department of Pediatrics, Section Pediatric Immunology, Infections and Stem Cell Transplantation, Leiden University Medical Center, Leiden, the Netherlands
| | - Birgit Hoeger
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria; CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - 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; St Anna Kinderspital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Vienna, Austria; Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Olga Pashchenko
- Department of Immunology, Pirogov Russian National Research Medical University, Russian Clinical Children's Hospital, Moscow, Russia
| | - Benedicte Neven
- Paris Descartes Sorbonne Paris Cité University, Imagine Institute, Paris, France; Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Laboratory "Immunogenetics of Pediatric Autoimmune Diseases", INSERM UMR1163, Université Paris Descartes Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Despina Moshous
- Paris Descartes Sorbonne Paris Cité University, Imagine Institute, Paris, France; Pediatric Hematology-Immunology and Rheumatology Unit, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Laboratory "Genome Dynamics in The Immune System", INSERM UMR1163, Université Paris Descartes Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Jean-Pierre de Villartay
- Laboratory "Genome Dynamics in The Immune System", INSERM UMR1163, Université Paris Descartes Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Ahmed Aziz Bousfiha
- Laboratoire d'Immunologie Clinique, d'Inflammation et d'Allergie LICIA, Faculty of Medicine and Pharmacy, Hassan II University, Casablanca, Morocco; Clinical Immunology Unit, Casablanca Children's Hospital, Ibn Rochd Medical School, Hassan II University, Casablanca, Morocco
| | - Harry R Hill
- Division of Clinical Immunology, Departments of Pathology, Pediatrics and Medicine, University of Utah, Salt Lake City, Utah
| | - Luigi D Notarangelo
- Haematology Unit, Department of Pediatric Haematology-Oncology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Jolan E Walter
- University of South Florida and Johns Hopkins All Children's Hospital, Saint Petersburg, Fla; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston, Mass.
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25
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Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Immunol 2019; 30:259-268. [PMID: 30702169 DOI: 10.1111/pai.13032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 12/25/2022]
Abstract
Neonatal and infantile erythroderma (NIE) represents the common clinical phenotype of heterogeneous diseases ranging from benign and transient skin conditions to fatal multiorgan disorders. NIE regularly demands a comprehensive diagnostic workup in a multiprofessional setting, especially if newborns and young infants with the disease develop a failure to thrive and concomitant infectious, neurologic, or metabolic complications. By obtaining a detailed medical history and performing a thorough clinical examination, targeted diagnostic steps can be scheduled for most affected children. If NIE occurs in the early neonatal period, lesional skin biopsy and histology are often indicated. Likewise, if monogenic skin or immunologic diseases are suspected, genetic testing with customized panels of potentially underlying genes is mandatory. Of note, if acute symptoms such as severe infections, metabolic acidosis, or seizures occur, rapid microbiologic and metabolic investigations are warranted to rule out immunodeficiency and inborn errors of metabolism.
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Affiliation(s)
- Hagen Ott
- Division of Pediatric Dermatology, Children's Hospital AUF DER BULT, Hannover, Germany.,Epidermolysis bullosa Centre, Hannover, Germany
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26
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Daley SR, Koay HF, Dobbs K, Bosticardo M, Wirasinha RC, Pala F, Castagnoli R, Rowe JH, Ott de Bruin LM, Keles S, Lee YN, Somech R, Holland SM, Delmonte OM, Draper D, Maxwell S, Niemela J, Stoddard J, Rosenzweig SD, Poliani PL, Capo V, Villa A, Godfrey DI, Notarangelo LD. Cysteine and hydrophobic residues in CDR3 serve as distinct T-cell self-reactivity indices. J Allergy Clin Immunol 2019; 144:333-336. [PMID: 31053347 DOI: 10.1016/j.jaci.2019.03.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Stephen R Daley
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Melbourne, Australia.
| | - Hui-Fern Koay
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia; Australian Research Council Centre of Excellence in Advanced Molecular Imaging, University of Melbourne, Melbourne, Australia
| | - Kerry Dobbs
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Marita Bosticardo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Rushika C Wirasinha
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Melbourne, Australia
| | - Francesca Pala
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - 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
| | - Jared H Rowe
- Division of Hematology-Oncology, Boston Children's Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, Mass
| | - Lisa M Ott de Bruin
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Sevgi Keles
- Division of Pediatric Immunology and Allergy, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Yu Nee Lee
- Immunology Service, Edmond and Lily Safra Children's Hospital Sheba Medical Center, Tel Hashomer, Israel
| | - Raz Somech
- Immunology Service, Edmond and Lily Safra Children's Hospital Sheba Medical Center, Tel Hashomer, Israel
| | - Steven M Holland
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Debbie Draper
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Sandra Maxwell
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Julie Niemela
- Immunology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Jennifer Stoddard
- Immunology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Md
| | - Pietro Luigi Poliani
- Department of Molecular and Translational Medicine, Pathology Unit, University of Brescia, Brescia, Italy
| | - Valentina Capo
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Anna Villa
- San Raffaele Telethon Institute for Gene Therapy, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy; Istituto di Ricerca Genetica e Biomedica (IRGB), Consiglio Nazionale delle Ricerche (CNR), Milan Unit, Milan, Italy
| | - Dale I Godfrey
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia; Australian Research Council Centre of Excellence in Advanced Molecular Imaging, University of Melbourne, Melbourne, Australia
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
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27
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Abstract
Recombination-activating genes (
RAG)
1 and
RAG2 initiate the molecular processes that lead to lymphocyte receptor formation through VDJ recombination. Nonsense mutations in
RAG1/
RAG2 cause the most profound immunodeficiency syndrome, severe combined immunodeficiency (SCID). Other severe and less-severe clinical phenotypes due to mutations in
RAG genes are now recognized. The degree of residual protein function may permit some lymphocyte receptor formation, which confers a less-severe clinical phenotype. Many of the non-SCID phenotypes are associated with autoimmunity. New findings into the effect of mutations in
RAG1/2 on the developing T- and B-lymphocyte receptor give insight into the development of autoimmunity. This article summarizes recent findings and places the genetic and molecular findings in a clinical context.
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Affiliation(s)
- Andrew Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, UK.,Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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28
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Heimall J. Genetic Testing to Diagnose Primary Immunodeficiency Disorders and to Identify Targeted Therapy. Immunol Allergy Clin North Am 2019; 39:129-140. [DOI: 10.1016/j.iac.2018.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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29
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Now Is the Time to Use Molecular Gene Testing for the Diagnosis of Primary Immune Deficiencies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:833-838. [PMID: 30639929 DOI: 10.1016/j.jaip.2018.12.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/26/2018] [Accepted: 12/26/2018] [Indexed: 12/11/2022]
Abstract
The discovery of chromosomes, genes, and DNA in the early 20th century paved the way for the development of techniques to examine the role of these elements in disease pathogenesis. Since the start of the 21st century, genetic testing and particularly next-generation sequencing has allowed for a rapid rate of gene disease associations for a broad range of primary immunodeficiency patients. At the same time, biologic and small molecule-based therapies targeting specific molecular pathways have been developed and are being applied clinically and in research settings to treat genetically defined immunodeficiencies. In recent years, both the American Academy of Allergy Asthma and Immunology and the Clinical Immunology Society have recommended the use of genetic testing for diagnosis, therapy guidance, and genetic counseling in patients with clinical symptoms of primary immunodeficiency.
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Villa A, Notarangelo LD. RAG gene defects at the verge of immunodeficiency and immune dysregulation. Immunol Rev 2019; 287:73-90. [PMID: 30565244 PMCID: PMC6309314 DOI: 10.1111/imr.12713] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
Abstract
Mutations of the recombinase activating genes (RAG) in humans underlie a broad spectrum of clinical and immunological phenotypes that reflect different degrees of impairment of T- and B-cell development and alterations of mechanisms of central and peripheral tolerance. Recent studies have shown that this phenotypic heterogeneity correlates, albeit imperfectly, with different levels of recombination activity of the mutant RAG proteins. Furthermore, studies in patients and in newly developed animal models carrying hypomorphic RAG mutations have disclosed various mechanisms underlying immune dysregulation in this condition. Careful annotation of clinical outcome and immune reconstitution in RAG-deficient patients who have received hematopoietic stem cell transplantation has shown that progress has been made in the treatment of this disease, but new approaches remain to be tested to improve stem cell engraftment and durable immune reconstitution. Finally, initial attempts have been made to treat RAG deficiency with gene therapy.
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Affiliation(s)
- Anna Villa
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), Division of Regenerative Medicine, Stem Cell and Gene Therapy, San Raffaele Scientific Institute, Milan, Italy
- Milan Unit, Istituto di Ricerca Genetica e Biomedica, Consiglio Nazionale delle Ricerche, Milan, Italy
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Delmonte OM, Schuetz C, Notarangelo LD. RAG Deficiency: Two Genes, Many Diseases. J Clin Immunol 2018; 38:646-655. [PMID: 30046960 PMCID: PMC6643099 DOI: 10.1007/s10875-018-0537-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/17/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE To review the clinical and laboratory spectrum of RAG gene defects in humans, and discuss the mechanisms underlying phenotypic heterogeneity, the basis of immune dysregulation, and the current and perspective treatment modalities. METHODS Literature review and analysis of medical records RESULTS: RAG gene defects in humans are associated with a surprisingly broad spectrum of clinical and immunological phenotypes. Correlation between in vitro recombination activity of the mutant RAG proteins and the clinical phenotype has been observed. Altered T and B cell development in this disease is associated with defects of immune tolerance. Hematopoietic cell transplantation is the treatment of choice for the most severe forms of the disease, but a high rate of graft failure has been observed. CONCLUSIONS Phenotypic heterogeneity of RAG gene defects in humans may represent a diagnostic challenge. There is a need to improve treatment for severe, early-onset forms of the disease. Optimal treatment modalities for patients with delayed-onset disease presenting with autoimmunity and/or inflammation remain to be defined.
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Affiliation(s)
- Ottavia M Delmonte
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Catharina Schuetz
- Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany
| | - Luigi D Notarangelo
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA.
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