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Fasshauer M, Dinges S, Staudacher O, Völler M, Stittrich A, von Bernuth H, Wahn V, Krüger R. Monogenic Inborn Errors of Immunity with impaired IgG response to polysaccharide antigens but normal IgG levels and normal IgG response to protein antigens. Front Pediatr 2024; 12:1386959. [PMID: 38933494 PMCID: PMC11203071 DOI: 10.3389/fped.2024.1386959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
In patients with severe and recurrent infections, minimal diagnostic workup to test for Inborn Errors of Immunity (IEI) includes a full blood count, IgG, IgA and IgM. Vaccine antibodies against tetanus toxoid are also frequently measured, whereas testing for anti-polysaccharide IgG antibodies and IgG subclasses is not routinely performed by primary care physicians. This basic approach may cause a significant delay in diagnosing monogenic IEI that can present with an impaired IgG response to polysaccharide antigens with or without IgG subclass deficiency at an early stage. Our article reviews genetically defined IEI, that may initially present with an impaired IgG response to polysaccharide antigens, but normal or only slightly decreased IgG levels and normal responses to protein or conjugate vaccine antigens. We summarize clinical, genetic, and immunological findings characteristic for these IEI. This review may help clinicians to identify patients that require extended immunologic and genetic evaluations despite unremarkable basic immunologic findings. We recommend the inclusion of anti-polysaccharide IgG antibodies as part of the initial routine work-up for possible IEI.
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Affiliation(s)
- Maria Fasshauer
- Immuno Deficiency Center Leipzig, Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiency Diseases, Hospital St. Georg, Leipzig, Germany
| | - Sarah Dinges
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Berlin, Germany
| | - Olga Staudacher
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Berlin, Germany
| | - Mirjam Völler
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Berlin, Germany
| | - Anna Stittrich
- Department of Human Genetics, Labor Berlin - Charité Vivantes GmbH, Berlin, Germany
| | - Horst von Bernuth
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Berlin, Germany
- Department of Immunology, Labor Berlin - Charité VivantesGmbH, Berlin, Germany
- Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Volker Wahn
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Berlin, Germany
| | - Renate Krüger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health (BIH), Berlin, Germany
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Lougaris V, Piane FL, Cancrini C, Conti F, Tommasini A, Badolato R, Trizzino A, Zecca M, De Rosa A, Barzaghi F, Pignata C. Activated phosphoinositde 3-kinase (PI3Kδ) syndrome: an Italian point of view on diagnosis and new advances in treatment. Ital J Pediatr 2024; 50:103. [PMID: 38769568 PMCID: PMC11106885 DOI: 10.1186/s13052-024-01662-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024] Open
Abstract
Activated phosphoinositide 3-kinase (PI3Kδ) Syndrome (APDS) is an inborn error of immunity (IEI) with a variable clinical presentation, characterized by infection susceptibility and immune dysregulation that may overlaps with other Primary Immune Regulatory Disorders (PIRDs). The rarity of the disease, its recent discovery, and the multiform /multifaced clinical presentation make it difficult to establish a correct diagnosis, especially at an early stage. As a result, the true prevalence of the pathology remains unknown. There is no treatment protocol for APDS, and drug therapy is primarily focused on treating symptoms. The most common therapies include immunoglobulin replacement therapy, antimicrobial prophylaxis, and immunosuppressive drugs. Hematopoietic stem cell transplantation (HSCT) has been used in some cases, but the risk-benefit balance remains unclear. With the upcoming introduction of specific medications, such as selective inhibitors for PI3Kδ, clinicians are shifting their attention towards target therapy.This review provides a comprehensive overview of APDS with a focus on diagnostic and treatments procedures available. This review may be useful in implementing strategies for a more efficient patients' management and therapeutic interventions.Main Text.
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Affiliation(s)
- Vassilios Lougaris
- Pediatrics Clinic, Department of Clinical and Experimental Sciences, University of Brescia, Azienda Socio Sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | | | - Caterina Cancrini
- Department of System Medicine, Pediatric Chair, University of Tor Vergata, Rome, Italy
- Research and Clinical Unit of Primary Immunodeficiencies, IRCCS Bambin Gesù Children Hospital, Rome, Italy
| | - Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Alberto Tommasini
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, 34137, Italy
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, 34137, Italy
| | - Raffaele Badolato
- Department of Pediatrics, Università di Brescia, Istituto di Medicina Molecolare Angelo Nocivelli", ASST Spedali Civili, Brescia, Italy
| | - Antonino Trizzino
- Department of Pediatric Hematology and Oncology, ARNAS Ospedali Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Marco Zecca
- Paediatric Haematology and Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Antonio De Rosa
- Department of Translational Medical Sciences, Università degli Studi di Napoli "Federico II", Naples, 80125, Italy
| | - Federica Barzaghi
- San Raffaele Telethon Institute for Gene Therapy (Sr-Tiget), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
| | - Claudio Pignata
- Department of Translational Medical Sciences, Università degli Studi di Napoli "Federico II", Naples, 80125, Italy.
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De SK. Leniolisib: a novel treatment for activated phosphoinositide-3 kinase delta syndrome. Front Pharmacol 2024; 15:1337436. [PMID: 38410131 PMCID: PMC10894968 DOI: 10.3389/fphar.2024.1337436] [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: 11/13/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024] Open
Abstract
IC50 = 11 nM (PI3Kδ); 244 nM (PI3Kα); 424 nM (PI3Kβ), 2,230 nM (PI3Kγ).
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Affiliation(s)
- Surya K De
- Conju-Probe, San Diego, CA, United States
- Bharath University, Department of Chemistry, Chennai, Tamil Nadu, India
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Rao VK, Kulm E, Šedivá A, Plebani A, Schuetz C, Shcherbina A, Dalm VA, Trizzino A, Zharankova Y, Webster S, Orpia A, Körholz J, Lougaris V, Rodina Y, Radford K, Bradt J, Relan A, Holland SM, Lenardo MJ, Uzel G. Interim analysis: Open-label extension study of leniolisib for patients with APDS. J Allergy Clin Immunol 2024; 153:265-274.e9. [PMID: 37797893 PMCID: PMC10841669 DOI: 10.1016/j.jaci.2023.09.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/01/2023] [Accepted: 09/22/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Activated phosphoinositide 3-kinase delta (PI3Kδ) syndrome (APDS; or p110δ-activating mutations causing senescent T cells, lymphadenopathy, and immunodeficiency) is an inborn error of immunity caused by PI3Kδ hyperactivity. Resultant immune deficiency and dysregulation lead to recurrent sinopulmonary infections, herpes viremia, autoimmunity, and lymphoproliferation. OBJECTIVE Leniolisib, a selective PI3Kδ inhibitor, demonstrated favorable impact on immune cell subsets and lymphoproliferation over placebo in patients with APDS over 12 weeks. Here, we report results from an interim analysis of an ongoing open-label, single-arm extension study. METHODS Patients with APDS aged 12 years or older who completed NCT02435173 or had previous exposure to PI3Kδ inhibitors were eligible. The primary end point was safety, assessed via investigator-reported adverse events (AEs) and clinical/laboratory evaluations. Secondary and exploratory end points included health-related quality of life, inflammatory markers, frequency of infections, and lymphoproliferation. RESULTS Between September 2016 and August 2021, 37 patients (median age, 20 years; 42.3% female) were enrolled. Of these 37 patients, 26, 9, and 2 patients had previously received leniolisib, placebo, or other PI3Kδ inhibitors, respectively. At the data cutoff date (December 13, 2021), median leniolisib exposure was 102 weeks. Overall, 32 patients (87%) experienced an AE. Most AEs were grades 1 to 3; none were grade 4. One patient with severe baseline comorbidities experienced a grade 5 AE, determined as unrelated to leniolisib treatment. While on leniolisib, patients had reduced annualized infection rates (P = .004), and reductions in immunoglobulin replacement therapy occurred in 10 of 27 patients. Other observations include reduced lymphadenopathy and splenomegaly, improved cytopenias, and normalized lymphocyte subsets. CONCLUSIONS Leniolisib was well tolerated and maintained durable outcomes with up to 5 years of exposure in 37 patients with APDS. CLINICALTRIALS gov identifier: NCT02859727.
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Affiliation(s)
- V Koneti Rao
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
| | - Elaine Kulm
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Bethesda, Md
| | - Anna Šedivá
- Department of Immunology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Alessandro Plebani
- Pediatrics Clinic, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Catharina Schuetz
- Department of Pediatric Immunology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anna Shcherbina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Virgil A Dalm
- Division of Allergy & Clinical Immunology, Department of Internal Medicine, Rotterdam, The Netherlands; Department of Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Antonino Trizzino
- Department of Pediatric Hematology and Oncology, ARNAS Civico Di Cristina Benfratelli Hospital, Palermo, Italy
| | - Yulia Zharankova
- Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Sharon Webster
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Alanvin Orpia
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Julia Körholz
- Department of Pediatric Immunology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Vassilios Lougaris
- Pediatrics Clinic, Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Yulia Rodina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Kath Radford
- Novartis Pharmaceuticals UK Ltd, London, United Kingdom
| | | | | | - Steven M Holland
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Michael J Lenardo
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
| | - Gulbu Uzel
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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Berglund LJ. Modulating the PI3K Signalling Pathway in Activated PI3K Delta Syndrome: a Clinical Perspective. J Clin Immunol 2023; 44:34. [PMID: 38148368 PMCID: PMC10751257 DOI: 10.1007/s10875-023-01626-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/09/2023] [Indexed: 12/28/2023]
Abstract
Activated phosphoinositide-3-kinase (PI3K) δ syndrome (APDS) is an inborn error of immunity characterised by immune dysregulation. Since the discovery of genetic mutations resulting in PI3Kδ overactivation, treatment of APDS patients has begun to focus on modulation of the PI3K pathway in addition to supportive therapies. The mTOR inhibitor sirolimus has been used effectively for some clinical manifestations of this condition, however the arrival of specific PI3Kδ inhibitor leniolisib has shown promising early results and may provide a more targeted approach. This review summarizes key aspects of PI3K pathway biology and discusses potential options for nuanced modulation of the PI3K pathway in APDS from a clinical perspective, highlighting differences from PI3K inhibition in haematological malignancies.
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Affiliation(s)
- Lucinda J Berglund
- Faculty of Medicine, University of Sydney, Sydney, NSW, Australia.
- Department of Immunopathology, Westmead Hospital, NSW Health Pathology, Westmead, Sydney, NSW, Australia.
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