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Remiker A, Bolling K, Verbsky J. Common Variable Immunodeficiency. Med Clin North Am 2024; 108:107-121. [PMID: 37951645 DOI: 10.1016/j.mcna.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Common variable immunodeficiency (CVID) is the most common primary immune deficiency characterized by impaired production of specific immunoglobulin. The clinical manifestations are heterogeneous including acquisition of recurrent bacterial infections after a period of wellness, lymphoproliferation, autoimmunity, pulmonary disease, liver disease, enteropathy, granulomas, and an increased risk of malignancy. The etiology of CVID is largely unknown, with a considerable number of patients having an underlying genetic defect causing immune dysregulation. The antibody deficiency found in CVID is treated with lifelong immunoglobulin therapy, which is preventative of the majority of infections when given regularly.
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Affiliation(s)
- Allison Remiker
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, and Children's Wisconsin, Milwaukee, WI, USA.
| | - Kristina Bolling
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, and Children's Wisconsin, Milwaukee, WI, USA
| | - James Verbsky
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, and Children's Wisconsin, Milwaukee, WI, USA; Division of Rheumatology, Department of Pediatrics, Medical College of Wisconsin, and Children's Wisconsin, Milwaukee, WI, USA
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2
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Rofael S, Leboreiro Babe C, Davrandi M, Kondratiuk AL, Cleaver L, Ahmed N, Atkinson C, McHugh T, Lowe DM. Antibiotic resistance, bacterial transmission and improved prediction of bacterial infection in patients with antibody deficiency. JAC Antimicrob Resist 2023; 5:dlad135. [PMID: 38098890 PMCID: PMC10720947 DOI: 10.1093/jacamr/dlad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023] Open
Abstract
Background Antibody-deficient patients are at high risk of respiratory tract infections. Many therefore receive antibiotic prophylaxis and have access to antibiotics for self-administration in the event of breakthrough infections, which may increase antimicrobial resistance (AMR). Objectives To understand AMR in the respiratory tract of patients with antibody deficiency. Methods Sputum samples were collected from antibody-deficient patients in a cross-sectional and prospective study; bacteriology culture, 16S rRNA profiling and PCR detecting macrolide resistance genes were performed. Bacterial isolates were identified using MALDI-TOF, antimicrobial susceptibility was determined by disc diffusion and WGS of selected isolates was done using Illumina NextSeq with analysis for resistome and potential cross-transmission. Neutrophil elastase was measured by a ProteaseTag immunoassay. Results Three hundred and forty-three bacterial isolates from sputum of 43 patients were tested. Macrolide and tetracycline resistance were common (82% and 35% of isolates). erm(B) and mef(A) were the most frequent determinants of macrolide resistance. WGS revealed viridans streptococci as the source of AMR genes, of which 23% also carried conjugative plasmids linked with AMR genes and other mobile genetic elements. Phylogenetic analysis of Haemophilus influenzae isolates suggested possible transmission between patients attending clinic.In the prospective study, a negative correlation between sputum neutrophil elastase concentration and Shannon entropy α-diversity (Spearman's ρ = -0.306, P = 0.005) and a positive relationship with Berger-Parker dominance index (ρ = 0.502, P < 0.001) were found. Similar relationships were noted for the change in elastase concentration between consecutive samples, increases in elastase associating with reduced α-diversity. Conclusions Measures to limit antibiotic usage and spread of AMR should be implemented in immunodeficiency clinics. Sputum neutrophil elastase may be a useful marker to guide use of antibiotics for respiratory infection.
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Affiliation(s)
- Sylvia Rofael
- Centre for Clinical Microbiology, University College London, Royal Free Campus, Pond Street, London, UK
- Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Clara Leboreiro Babe
- Centre for Clinical Microbiology, University College London, Royal Free Campus, Pond Street, London, UK
| | - Mehmet Davrandi
- Centre for Clinical Microbiology, University College London, Royal Free Campus, Pond Street, London, UK
| | - Alexandra L Kondratiuk
- Institute for Immunity and Transplantation, Division of Infection and Immunity, University College London, Pears Building, Rowland Hill Street, London, UK
| | - Leanne Cleaver
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, Guy’s Campus, King’s College London, London, UK
| | - Naseem Ahmed
- Centre for Clinical Microbiology, University College London, Royal Free Campus, Pond Street, London, UK
| | - Claire Atkinson
- Institute for Immunity and Transplantation, Division of Infection and Immunity, University College London, Pears Building, Rowland Hill Street, London, UK
- Cancer Biology and Therapy Research Group, Divisionof Human Sciences, School of Applied Sciences, London South Bank University, London, UK
| | - Timothy McHugh
- Centre for Clinical Microbiology, University College London, Royal Free Campus, Pond Street, London, UK
| | - David M Lowe
- Institute for Immunity and Transplantation, Division of Infection and Immunity, University College London, Pears Building, Rowland Hill Street, London, UK
- Department of Clinical Immunology, Royal Free London NHS Foundation Trust, Pond Street, London, UK
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3
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Gray PE, David C. Inborn Errors of Immunity and Autoimmune Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1602-1622. [PMID: 37119983 DOI: 10.1016/j.jaip.2023.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/01/2023] [Accepted: 04/21/2023] [Indexed: 05/01/2023]
Abstract
Autoimmunity may be a manifestation of inborn errors of immunity, specifically as part of the subgroup of primary immunodeficiency known as primary immune regulatory disorders. However, although making a single gene diagnosis can have important implications for prognosis and management, picking patients to screen can be difficult, against a background of a high prevalence of autoimmune disease in the population. This review compares the genetics of common polygenic and rare monogenic autoimmunity, and explores the molecular mechanisms, phenotypes, and inheritance of autoimmunity associated with primary immune regulatory disorders, highlighting the emerging importance of gain-of-function and non-germline somatic mutations. A novel framework for identifying rare monogenic cases of common diseases in children is presented, highlighting important clinical and immunologic features that favor single gene disease and guides clinicians in selecting appropriate patients for genomic screening. In addition, there will be a review of autoimmunity in non-genetically defined primary immunodeficiency such as common variable immunodeficiency, and of instances where primary autoimmunity can result in clinical phenocopies of inborn errors of immunity.
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Affiliation(s)
- Paul Edgar Gray
- Sydney Children's Hospital, Randwick, NSW, Australia; Western Sydney University, Penrith, NSW, Australia.
| | - Clementine David
- Sydney Children's Hospital, Randwick, NSW, Australia; The School of Women's & Children's Health, University of New South Wales, Randwick, NSW, Australia
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Wu D, Daniel BS, Lai AJX, Wong N, Lim DKA, Murrell DF, Lim BXH, Mehta JS, Lim CHL. Dupilumab-associated ocular manifestations: A review of clinical presentations and management. Surv Ophthalmol 2022; 67:1419-1442. [PMID: 35181280 DOI: 10.1016/j.survophthal.2022.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 10/19/2022]
Abstract
Dupilumab is a first-in-class biologic approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (US FDA) for the treatment of multiple atopic diseases, including atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis. Since gaining traction as an effective treatment modality, multiple reports have highlighted the many ocular side effects associated with dupilumab usage. These range from mild diseases such as conjunctivitis, dry eyes, and blepharitis, to more severe manifestations such as intraocular inflammation and cicatrising conjunctivitis. The pathogenesis behind these manifestations remains controversial but are likely multi-factorial. We review the current evidence surrounding ocular manifestations of dupilumab-associated disease and proposed treatments to provide an overview of this unique disease entity. With increasing usage of dupilumab, formal recommendations regarding the treatment of dupilumab-associated ocular disease are warranted to provide standardised clinical guidance. Furthermore, it is important for healthcare practitioners to remain abreast with existing literature to adequately counsel and empower patients with the knowledge surrounding contemporary treatments for atopic diseases and their associated side-effects.
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Affiliation(s)
- Duoduo Wu
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Benjamin S Daniel
- St George Hospital, Kogarah, Sydney, NSW, Australia; St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Andre J X Lai
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Nathan Wong
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Dawn K A Lim
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Ophthalmology, National University Health System, Singapore
| | - Dedee F Murrell
- St George Hospital, Kogarah, Sydney, NSW, Australia; School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Blanche X H Lim
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Ophthalmology, National University Health System, Singapore
| | - Jodhbir S Mehta
- Duke-NUS Graduate Medical School, Singapore; Singapore Eye Research Institute, Singapore; Singapore National Eye Centre, Singapore
| | - Chris H L Lim
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Ophthalmology, National University Health System, Singapore; Singapore Eye Research Institute, Singapore; School of Optometry and Vision Science, University of New South Wales, Sydney, NSW, Australia.
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5
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Thoré P, Jaïs X, Savale L, Dorfmuller P, Boucly A, Devilder M, Meyrignac O, Pichon J, Mankikian J, Riou M, Boiffard E, Boissin C, De Groote P, Chabanne C, Gagnadoux F, Bergeron A, Noel N, Sitbon O, Humbert M, Montani D. Pulmonary Hypertension in Patients with Common Variable Immunodeficiency. J Clin Immunol 2021; 41:1549-1562. [PMID: 34110542 DOI: 10.1007/s10875-021-01064-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Common variable immunodeficiency (CVID) is known to cause infectious, inflammatory, and autoimmune manifestations. Pulmonary hypertension (PH) is an unusual complication of CVID with largely unknown characteristics and mechanisms. METHODS We report the clinical, functional, hemodynamics, radiologic and histologic characteristics, and outcomes of CVID-associated PH patients from the French PH Network. RESULTS Ten patients were identified. The median (range) age at CVID diagnosis was 36.5 (4-49) years and the median delay between CVID and PH diagnosis was 12 (0-30) years. CVID-associated PH affected predominantly women (female-to-male ratio 9:1). Most patients were New York Heart Association functional class III with a severe hemodynamic profile and frequent portal hypertension (n = 6). Pulmonary function tests were almost normal in 70% of patients and showed a mild restrictive syndrome in 30% of patients while the diffusing capacity for carbon monoxide was decreased in all but one patient. High-resolution computed tomography found enlarged mediastinal nodes, mild interstitial infiltration with reticulations and nodules. Two patients had a CIVD-interstitial lung disease, and one presented with bronchiectasis. Pathologic assessment of lymph nodes performed in 5 patients revealed the presence of granulomas (n = 5) and follicular lymphoid hyperplasia (n = 3). At last follow-up (median 24.5 months), 9 patients were alive, and one patient died of Hodgkin disease. CONCLUSION PH is a possible complication of CVID whose pathophysiological mechanisms, while still unclear, would be due to the inflammatory nature of CVID. CVID-associated PH presents as precapillary PH with multiple possible causes, acting in concert in some patients: a portal hypertension, a pulmonary vascular remodeling, sometimes a pulmonary parenchymal involvement and occasionally an extrinsic compression by mediastinal lymphadenopathies, which would be consistent with its classification in group 5 of the current PH classification.
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Affiliation(s)
- Pierre Thoré
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Department of Pneumology, Hôpital Brabois, Vandoeuvre-lès-Nancy, France.,INSERM UMR_S 1116 "Défaillance Cardiovasculaire Aigüe Et Chronique", School of Medicine of Nancy, University of Lorraine, Nancy, France
| | - Xavier Jaïs
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Laurent Savale
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Peter Dorfmuller
- Department of Pathology, University Hospital of Giessen and Marburg (UKGM), Giessen, Germany
| | - Athénaïs Boucly
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Matthieu Devilder
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Radiology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Meyrignac
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Radiology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Jérémie Pichon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Julie Mankikian
- Centre Hospitalier Régional Universitaire (CHRU) de Tours, Department of Pneumology, Hôpital Bretonneau, Tours, France
| | - Marianne Riou
- Department of Pneumology, Centre Hospitalier Universitaire (CHU) de Strasbourg, Nouvel Hôpital Civil (NHC) de Strasbourg, Strasbourg, France
| | - Emmanuel Boiffard
- Centre Hospitalier Départemental (CHD) de Vendée, Department of Cardiology, Hôpital de La Roche sur Yon, La Roche sur Yon, France
| | - Clément Boissin
- Centre Hospitalier Universitaire (CHU) de Montpellier, Department of Pneumology, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Pascal De Groote
- Centre Hospitalier Universitaire (CHU) de Lille, Department of Cardiology, Hôpital Albert Calmette, Lille, France.,Inserm U1167, Institut Pasteur de Lille, Lille, France
| | - Céline Chabanne
- Department of Cardiology and Vascular Diseases, Cardio-pneumologic Center, Centre Hospitalier Universitaire (CHU) de Rennes, Rennes, France
| | - Frédéric Gagnadoux
- Department of Pneumology, Centre Hospitalier Universitaire (CHU) D'Angers, Angers, France.,INSERM U1063, School of Medicine, Angers, France
| | - Anne Bergeron
- Université de Paris, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Pneumology, Hôpital Saint-Louis, Paris, France.,INSERM UMR_S 1153 "Centre de Recherche Épidémiologie Et Statistique Sorbonne Paris Cité (CRESS)", Hôpital Saint-Louis, Paris, France
| | - Nicolas Noel
- School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Internal Medicine and Immunology, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,UMR INSERM/CEA 1184, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - David Montani
- Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Hôpital Bicêtre, Le Kremlin-Bicêtre, France. .,School of Medicine, University Paris-Saclay, Le Kremlin-Bicêtre, France. .,INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
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Increased Respiratory Viral Detection and Symptom Burden Among Patients with Primary Antibody Deficiency: Results from the BIPAD Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:735-744.e6. [PMID: 32841749 PMCID: PMC7442926 DOI: 10.1016/j.jaip.2020.08.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with primary antibody deficiency (PAD) are at increased risk of respiratory tract infections, but our understanding of their nature and consequences remains limited. OBJECTIVE To define the symptomatic and microbial burden of upper airway infection in adults with PAD relative to age-matched controls. METHODS Prospective 12-month observational study consisting of a daily upper and lower airway symptom score alongside fortnightly nasal swab with molecular detection of 19 pathogen targets. RESULTS A total of 44 patients and 42 controls (including 34 household pairs) were recruited, providing more than 22,500 days of symptom scores and 1,496 nasal swabs. Swab and questionnaire compliance exceeded 70%. At enrollment, 64% of patients received prophylactic antibiotics, with a 34% prevalence of bronchiectasis. On average, patients with PAD experienced symptomatic respiratory exacerbations every 6 days compared with 6 weeks for controls, associated with significant impairment of respiratory-specific quality-of-life scores. Viral detections were associated with worsening of symptom scores from a participant's baseline. Patients with PAD had increased odds ratio (OR) for pathogen detection, particularly viral (OR, 2.73; 95% CI, 2.09-3.57), specifically human rhinovirus (OR, 3.60; 95% CI, 2.53-5.13) and parainfluenza (OR, 3.06; 95% CI, 1.25-7.50). Haemophilus influenzae and Streptococcus pneumoniae were also more frequent in PAD. Young child exposure, IgM deficiency, and presence of bronchiectasis were independent risk factors for viral detection. Prophylactic antibiotic use was associated with a lower risk of bacterial detection by PCR. CONCLUSIONS Patients with PAD have a significant respiratory symptom burden associated with increased viral infection frequency despite immunoglobulin replacement and prophylactic antibiotic use. This highlights a clear need for future therapeutic trials in the population with PAD, and informs future study design.
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Evaluation of pulmonary findings in patients with humoral immunodeficiency. Turk Arch Pediatr 2020; 55:174-183. [PMID: 32684763 PMCID: PMC7344133 DOI: 10.14744/turkpediatriars.2020.46656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 01/07/2020] [Indexed: 11/20/2022]
Abstract
Aim: To determine the frequency of sinopulmonary infections, detect changes in the respiratory system, and measure functional capacity of the lungs in our patients with humoral immunodeficiency. Material and Methods: Fifty-six patients with humoral immunodeficiency were enrolled in this study. The clinical, laboratory, and radiologic data, and pulmonary function tests of the subjects were evaluated from their file records, retrospectively. Results: The distribution of our patients was as follows: 25 patients had common variable immune deficiency, three patients had X-linked agammaglobulinemia, five patients had hyper immunoglobulin M syndrome, 19 patients had deficiency of immunoglobulin G subset, and four patients had selective immunoglobulin A deficiency. The most common symptom of the patients was chronic cough (n=47, 83.9%). The most common pathologies on high-resolution computed tomography of the chest were atelectasis and bronchiectasis (27.7%). The most common pathology in pulmonary function tests was the presence of moderate obstructive patterns along with restrictive patterns (n=6,12.5%). The FEV 1, FVC, and FEF 25–75 values were significantly lower in patients with common variable immunodeficiency compared with the patients who had IgG subset deficiencies (p=0.001, p=0.01, p=0.01). Among the patients who were treated with intravenous immunoglobulin, the age at the diagnosis of immunodeficiency was higher in patients with bronchiectasis (14.2±8.4 years) compared with those without bronchiectasis (10.1±11.4 years) (p=0.04). Conclusion: Clinical findings are not sufficient to monitor the structural and functional changes in the respiratory system, and patients should be evaluated using high-resolution computed tomography of the chest and pulmonary function tests.
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8
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Immunological and Clinical Phenotyping in Primary Antibody Deficiencies: a Growing Disease Spectrum. J Clin Immunol 2020; 40:592-601. [PMID: 32239366 DOI: 10.1007/s10875-020-00773-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/20/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Although common variable immunodeficiency (CVID) is considered the most prevalent symptomatic primary antibody deficiency (PAD), there is a population with symptomatic PADs that do not meet criteria for CVID. We analyzed clinical and immunological profiles of patients with different PADs to better understand the differences and similarities between CVID and other PADs. METHODS We extracted clinical and laboratory data of patients with PADs from electronic medical records. Patients were categorized into CVID, IgG subclass 2 deficiency (IgG2D), IgG deficiency (IgGD), and specific antibody deficiency (sAbD) based on basal immunoglobulin levels and pneumococcal vaccine responses. We compared clinical and immunological characteristics in these groups. RESULTS All patients, regardless of PAD types, showed similar frequencies of infections, bronchiectasis, and interstitial lung disease (ILD). Hematopoietic malignancies were more frequently found in the CVID than in the IgG2D, IgGD, and sAbD groups, while the latter groups trended towards an increased frequency of connective tissue diseases (CTD). Low counts of natural killer (NK) cells were associated with malignancy, autoimmunity, and ILD in CVID but not in other PAD groups. CONCLUSIONS Higher frequency of hematopoietic malignancy in CVID than in the other PADs and association of lower NK cell counts with non-infectious complications in CVID suggest a relationship between immune alterations and the development of non-infectious manifestations in PADs.
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9
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Moazzami B, Mohayeji Nasrabadi MA, Abolhassani H, Olbrich P, Azizi G, Shirzadi R, Modaresi M, Sohani M, Delavari S, Shahkarami S, Yazdani R, Aghamohammadi A. Comprehensive assessment of respiratory complications in patients with common variable immunodeficiency. Ann Allergy Asthma Immunol 2020; 124:505-511.e3. [PMID: 32007567 DOI: 10.1016/j.anai.2020.01.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/18/2020] [Accepted: 01/23/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is a heterogeneous group of disorders, characterized by recurrent upper and lower respiratory tract infections and some noninfectious clinical complications. OBJECTIVE To provide a detailed evaluation of respiratory presentations and complications in a cohort of Iranian patients with CVID. METHODS A retrospective cohort study was conducted on 245 CVID patients who were recorded in the Iranian primary immunodeficiency disorders registry network. Respiratory manifestations were evaluated by reviewing clinical hospital records, immunologic findings, pulmonary function tests (PFT), and high-resolution computed tomography (HRCT) scans. RESULTS Most of the patients (n = 208, 85.2%) had experienced at least 1 episode of acute respiratory manifestation, and pneumonia was observed in 31.6 % (n = 77) of cases as a first disease manifestation. During the follow-up, pneumonia, sinusitis, and otitis media were documented in 166 (68.6%), 125 (51.2%), and 103 (42.6%) cases, respectively. Abnormal PFT measurements were documented in 53.8% of patients. Among these patients, 21.5% showed restrictive changes, whereas 18.4% of patients showed an obstructive pattern. Bronchiectasis was the most frequent radiological finding, confirmed in 27.2% of patients. Patients with bronchiectasis were older at the time of immunodeficiency diagnosis (P < .001) and had longer diagnosis delay (P < .001) when compared with patients without bronchiectasis. CONCLUSION This study highlights the importance of monitoring the respiratory tract system even in asymptomatic patients. Pulmonary function tests and CT scans are the most commonly used techniques aiming to identify these patients early, aiming to reduce the rate of long-term respiratory complications.
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Affiliation(s)
- Bobak Moazzami
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Mohammad Ali Mohayeji Nasrabadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Hassan Abolhassani
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at the Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Peter Olbrich
- Sección de Infectología e Inmunopatología, Unidad de Pediatría, Hospital Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Gholamreza Azizi
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Rohola Shirzadi
- Department of Pediatric Pulmonary and Sleep Medicine, Children Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Modaresi
- Department of Pediatric Pulmonary and Sleep Medicine, Children Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Sohani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Samaneh Delavari
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Sepideh Shahkarami
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Reza Yazdani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran.
| | - Asghar Aghamohammadi
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran.
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Hwangpo T, Wang Z, Ghably J, Bhatt SP, Cui X, Schroeder HW. Use of FEF25-75% to Guide IgG Dosing to Protect Pulmonary Function in CVID. J Clin Immunol 2020; 40:310-320. [PMID: 31897777 DOI: 10.1007/s10875-019-00730-4] [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: 03/28/2019] [Accepted: 11/26/2019] [Indexed: 10/25/2022]
Abstract
Immunoglobulin replacement therapy (IGRT) can protect against lung function decline in CVID. We tested whether increasing IgG dosage was beneficial in patients who exhibited a decline in forced expiratory flow at 25-75% (FEF25-75%) even though they were receiving IgG doses within the therapeutic range. Of 189 CVID patients seen over 12 years, 38 patients met inclusion criteria, were seen on ≥ 3 visits, and demonstrated a ≥ 10% decrease in FEF25-75% from visits 1 to 2. FEF25-75%, forced expiratory flow at 1 s (FEV1), and FEV1/FVC at visit 3 were compared among those with non-dose adjustment (non-DA) versus additional IgG dose adjustment (DA). Three FEF25-75% tiers were identified: top (> 80% predicted), middle (50-80%), and bottom (< 50%). DA and non-DA groups did not differ in clinical infections or bronchodilator use, although the non-DA group tended to use more antibiotics. In the top, normal tier, FEF25-75% increased in DA, but the change did not achieve statistical significance. In the middle moderate obstruction tier, visit 3 FEF25-75% increased among DA but not non-DA sets (11.8 ± 12.4%, p = 0.003 vs. 0.3 ± 9.9%, p = 0.94). Improvement in FEV1/FVC at visit 3 was also significant among DA vs. non-DA (7.2 ± 12.4%, p = 0.04 vs. - 0.2 ± 2.7%, p = 0.85). In the bottom, severe tier, FEF25-75% was unchanged in DA (- 0.5 ± 5.2%, p = 0.79), but increased in non-DA (5.1 ± 5.2%, p = 0.02). Among IGRT CVID patients with moderate but not severe obstruction as assessed by spirometry, increasing IgG dosage led to an increase in FEF25-75% and FEV1/FVC.
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Affiliation(s)
- Tracy Hwangpo
- Department of Medicine, University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA
| | - Zhixin Wang
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jack Ghably
- Department of Medicine, University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA
| | - Surya P Bhatt
- Department of Medicine, University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA
| | - Xiangqin Cui
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA.,The Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | - Harry W Schroeder
- Department of Medicine, University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA.
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Cunningham-Rundles C. Common variable immune deficiency: Dissection of the variable. Immunol Rev 2019; 287:145-161. [PMID: 30565247 PMCID: PMC6435035 DOI: 10.1111/imr.12728] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
Abstract
Starting about 60 years ago, a number of reports appeared that outlined the severe clinical course of a few adult subjects with profound hypogammaglobinemia. Puzzled by the lack of family history and adult onset of symptoms in most, the name "acquired" hypogammaglobinemia was given, but later altered to the current name common variable immune deficiency. Pathology reports remarked on the loss of lymph node architecture and paucity of plasma cells in lymphoid tissues in these subjects. While characterized by reduced serum IgG and IgA and often IgM, and thus classified among the B-cell defects, an increasing number of cellular defects in these patients have been recognized over time. In the early years, severe respiratory tract infections commonly led to a shortened life span, but the wide spread availability of immune globulin concentrates for the last 25 years has improved survival. However, chronic non-infectious inflammatory and autoimmune conditions have now emerged as challenging clinical problems; these require further immunologic understanding and additional therapeutic measures. Recent study of this phenotypic syndrome have provided an increasingly fertile ground for the identification of autosomal recessive and now more commonly, autosomal dominant gene defects which lead to the loss of B-cell development in this syndrome.
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Song J, Lleo A, Yang GX, Zhang W, Bowlus CL, Gershwin ME, Leung PSC. Common Variable Immunodeficiency and Liver Involvement. Clin Rev Allergy Immunol 2018; 55:340-351. [PMID: 28785926 PMCID: PMC5803456 DOI: 10.1007/s12016-017-8638-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Common variable immunodeficiency (CVID) is a primary B-cell immunodeficiency disorder, characterized by remarkable hypogammaglobulinemia. The disease can develop at any age without gender predominance. The prevalence of CVID varies widely worldwide. The underlying causes of CVID remain largely unknown; primary B-cell dysfunctions, defects in T cells and antigen-presenting cells are involved. Although some monogenetic defects have been identified in some CVID patients, it is likely that CVID is polygenic. Patients with CVID develop recurrent and chronic infections (e.g., bacterial infections of the respiratory or gastrointestinal tract), autoimmune diseases, lymphoproliferation, malignancies, and granulomatous lesions. Interestingly, autoimmunity can be the only clinical manifestation of CVID at the time of diagnosis and may even develop prior to hypogammaglobulinemia. The diagnosis of CVID is largely based on the criteria established by European Society for Immunodeficiencies and Pan-American Group for Immunodeficiency (ESID/PAGID) and with some recent modifications. The disease can affect multiple organs, including the liver. Clinical features of CVID patients with liver involvement include abnormal liver biochemistries, primarily elevation of alkaline phosphatase (ALP), nodular regenerative hyperplasia (NRH), or liver cirrhosis and its complications. Replacement therapy with immunoglobulin (Ig) and anti-infection therapy are the primary treatment regimen for CVID patients. No specific therapy for liver involvement of CVID is currently available, and liver transplantation is an option only in select cases. The prognosis of CVID varies widely. Further understanding in the etiology and pathophysiology will facilitate early diagnosis and treatments to improve prognosis.
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Affiliation(s)
- Junmin Song
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, People's Republic of China
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Guo Xiang Yang
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
| | - Weici Zhang
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California, Davis, CA, 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA
| | - Patrick S C Leung
- Division of Rheumatology/Allergy and Clinical Immunology, University of California at Davis School of Medicine, 451 Health Sciences Drive, Davis, CA, 95616, USA.
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Najem CE, Springer J, Prayson R, Culver DA, Fernandez J, Tavee J, Hajj-Ali RA. Intra cranial granulomatous disease in common variable immunodeficiency: Case series and review of the literature. Semin Arthritis Rheum 2017; 47:890-896. [PMID: 29277461 DOI: 10.1016/j.semarthrit.2017.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/26/2017] [Accepted: 10/17/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND/PURPOSE Common variable immunodeficiency (CVID) is typically characterized by hypogammaglobulinemia and often but not always recurrent infections. Paradoxically, 8-22% of patients with CVID develop granulomatous disease. Granulomata have been described in many organs including the lungs, skin, liver, spleen, kidneys, eyes, lymph nodes, and intestines. Data about central nervous system (CNS) involvement in CVID are extremely rare. We aim to describe a case series and include an extensive literature review of CNS involvement in CVID to understand the different features and patterns of the disease. METHODS We searched the English Pubmed database for relevant articles between 1950 and 2014 using the Key Words "common variable immunodeficiency", "granulomatous disease", "brain", "sarcoidosis", and "sarcoid-like syndrome". Data from all case series, surveys, systematic reviews, and individual case reports, as well as retrospective studies were extracted. A total of 15 patients were reported in the literature. We combined our experience with four additional patients from The Cleveland Clinic between 2009 and 2014. Demographics, clinical features, laboratory and imaging findings, treatment and follow-up were extracted for the 19 patients and summarized descriptively. RESULTS Female sex and Caucasian race represented 63.2% (12/19), and 80% of the patients, respectively. The mean age of CVID diagnosis was 24 years; mean age when the CNS disease was diagnosed was 21.5 years. 68.4% of the patients (13/19) had granulomas involving ≥2 organs including the central nervous system, 31.6% (6/19) had CNS granulomas only. Associated granulomatous diseases occurred in lungs (72.7%), lymph nodes (27.2%), spleen (27.2%), eyes (18.1%), liver (18.1%), parotid glands (9%), and skin (9%). Fifty-three percent (10/19) of the patients had documented recurrent infections, all of them being upper respiratory tract infections. CNS manifestations included seizures (31.6%), headaches (21%), vision loss (15.7%), decreased cognition (10.5%), focal weakness (5.2%), nystagmus (5.2%), ataxia (5.2%), coma (5.2%), polyuria, and polydipsia (5.2%). Brain mass was the most common radiologic finding (70%) followed by leptomeningeal enhancement (10%), non-specific white matter lesions (10%) and absence of normal signal of the neurohypophysis (10%). Brain pathology was available in 12 patients: findings included granulomatous disease in 83.3%, angiocentric granulomas in 50%, vasculitis without granulomas in 8.3%, and lymphocytic infiltrate of the meninges with diffuse non-caseating granulomas in 8.3%. Cerebrospinal fluid analysis revealed elevated total proteins with/or without lymphocytic pleocytosis in 80%. CONCLUSION CNS disease is a rare challenging complication of CVID. Patients with brain involvement are generally female, Caucasian, and likely have lung involvement. Although immunoglobulin and steroids remain the first line of treatment, other immunosuppressive agents have shown some promise with regards to recurrent relapsing presentations.
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Affiliation(s)
- Catherine E Najem
- Division of Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jason Springer
- Division of Allergy, Clinical Immunology and Rheumatology, University of Kansas Medical Center, Kansas, KS
| | | | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | - Jinny Tavee
- Department of Neurology, Northwestern University, Chicago, IL
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Janssen WJ, Stefanski AL, Bochner BS, Evans CM. Control of lung defence by mucins and macrophages: ancient defence mechanisms with modern functions. Eur Respir J 2016; 48:1201-1214. [PMID: 27587549 DOI: 10.1183/13993003.00120-2015] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 06/12/2016] [Indexed: 12/14/2022]
Abstract
Owing to the need to balance the requirement for efficient respiration in the face of tremendous levels of exposure to endogenous and environmental challenges, it is crucial for the lungs to maintain a sustainable defence that minimises damage caused by this exposure and the detrimental effects of inflammation to delicate gas exchange surfaces. Accordingly, epithelial and macrophage defences constitute essential first and second lines of protection that prevent the accumulation of potentially harmful agents in the lungs, and under homeostatic conditions do so effectively without inducing inflammation. Though epithelial and macrophage-mediated defences are seemingly distinct, recent data show that they are linked through their shared reliance on airway mucins, in particular the polymeric mucin MUC5B. This review highlights our understanding of novel mechanisms that link mucus and macrophage defences. We discuss the roles of phagocytosis and the effects of factors contained within mucus on phagocytosis, as well as newly identified roles for mucin glycoproteins in the direct regulation of leukocyte functions. The emergence of this nascent field of glycoimmunobiology sets forth a new paradigm for considering how homeostasis is maintained under healthy conditions and how it is restored in disease.
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Affiliation(s)
- William J Janssen
- Dept of Medicine, National Jewish Health, Denver, CO, USA Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Bruce S Bochner
- Dept of Medicine, Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher M Evans
- Dept of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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15
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Abstract
BACKGROUND Common variable immunodeficiency (CVID) is characterized by hypogammaglobulinemia, defective antibody production and recurrent upper and lower respiratory tract infections. The diagnosis in adult patients is often thought to be rare, and thus misdiagnosis often occurs. A limited number of cases of adult-onset CVID have been reported in China, and the features of the syndrome remain unclear. The objective of this study was to describe the main characteristics of CVID, and evaluate the treatment of adult patients who present with CVID. MATERIALS AND METHODS This was a retrospective analysis of 8 patients with CVID from different departments in 1 center in China. Patients were diagnosed according to the diagnostic criteria of the European Society for Immunodeficiency Diseases. Demographics, clinical and immunological data from each patient were collected and a statistical analysis was undertaken. RESULTS The mean age at diagnosis was 43 ± 13.7 years, whereas the mean duration of diagnostic delay was 10.5 years. The median total serum levels of immunoglobulin (Ig) G, IgA and IgM at diagnosis were 2.5 ± 0.59, 0.23 ± 0.05 and 0.17 ± 0.05g/L, respectively. A total of 7 patients also had a low CD4(+)/CD8(+) ratio. All patients presented with recurrent respiratory infections. Regular infusions of intravenous immunoglobulin every 3 weeks substantially reduced pneumonic episodes. CONCLUSIONS Diagnosis is often delayed in adult CVID. Pulmonary infections and diseases were the most frequent presentations at onset of the disease. Regular intravenous immunoglobulin infusions were beneficial in controlling recurrent infections.
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17
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Pagovich OE, Lebastchi AH, Romberg N. Peri-operative considerations in the patient with primary immune deficiency: a review. Surg Infect (Larchmt) 2015; 15:672-8. [PMID: 25317569 DOI: 10.1089/sur.2013.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with inherited immune deficiency diseases often require surgical procedures, and their immune defects may predispose them to surgical complications. METHODS A thorough review of pertinent literature and current practice guidelines on surgery in patients with immune deficiency. RESULTS Peri-operative infections are a key, but not a singular, consideration in managing patients with a primary immune deficiency. Bleeding diathesis, gastrointestinal complications, pulmonary complications, and poor incision healing may also be idiosyncratic features unique to particular immune deficiency diseases. Patients with complex genetic syndromes that include immune deficiency also may display non-immunologic abnormalities that are equally important to surgical care. CONCLUSION Greater awareness of primary immune deficiencies and a comprehensive evaluation of such patients in close consultation with an immunologist can minimize surgical complications and optimize patient outcomes.
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Affiliation(s)
- Odelya E Pagovich
- 1 Section of Allergy and Clinical Immunology, Department of Internal Medicine and Pediatrics, Yale University School of Medicine , New Haven, Connecticut
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18
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Common Variable Immunodeficiency and Pulmonary Amyloidosis: A Case Report. J Clin Immunol 2015; 35:344-7. [DOI: 10.1007/s10875-015-0151-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
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19
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Stevens WW, Peters AT. Immunodeficiency in Chronic Sinusitis: Recognition and Treatment. Am J Rhinol Allergy 2015; 29:115-8. [DOI: 10.2500/ajra.2015.29.4144] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Chronic rhinosinusitis (CRS) is estimated to affect over 35 million people. However, not all patients with the diagnosis respond to standard medical and surgical treatments. Although there are a variety of reasons a patient may be refractory to therapy, one possible etiology is the presence of an underlying immunodeficiency. This review will focus on the description, recognition, and treatment of several antibody deficiencies associated with CRS, including common variable immunodeficiency (CVID), selective IgA deficiency, IgG subclass deficiency, and specific antibody deficiency (SAD). The diagnosis of antibody deficiency in patients with CRS is important because of the large clinical implications it can have on sinus disease management. CVID is treated with immunoglobulin replacement, whereas SAD may be managed symptomatically and sometimes with prophylactic antibiotics and/or immunoglobulin replacement.
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Affiliation(s)
- Whitney W. Stevens
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anju T. Peters
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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20
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Vitale J, Convers KD, Goretzke S, Guzman M, Noyes B, Parkar N, Knutsen AP. Serum IL-12 and soluble IL-2 receptor levels as possible biomarkers of granulomatous and lymphocytic interstitial lung disease in common variable immunodeficiency: A case report. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:273-6. [DOI: 10.1016/j.jaip.2014.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 09/15/2014] [Accepted: 09/18/2014] [Indexed: 11/28/2022]
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Migratory pneumonia caused by common variable immunodeficiency disorder. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abolhassani H, Sagvand BT, Shokuhfar T, Mirminachi B, Rezaei N, Aghamohammadi A. A review on guidelines for management and treatment of common variable immunodeficiency. Expert Rev Clin Immunol 2014; 9:561-74; quiz 575. [PMID: 23730886 DOI: 10.1586/eci.13.30] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in adults. As symptoms of CVID are usually heterogeneous and unspecific, diagnosis and follow-up of CVID can be challenging. In light of this, a broad review of advances in management and treatment of CVID is performed here in order to reach a distinct protocol. However, it should be noted that owing to the nature of the disease, it can only be treated symptomatically but not cured. There is little evidence to guide appropriate or universal guidelines to improve the current status of management of the disease. The most satisfactory treatments of CVID could be achieved by the use of immunoglobulin replacement, antibiotics, immunosuppressants and hematopoietic stem cell transplantation. This review is written based on the importance of clinical surveillance of asymptomatic CVID cases and early recognition of different clinical complications. Moreover, for each complication, appropriate interventions for improving outcomes are mentioned.
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Affiliation(s)
- Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Jesenak M, Banovcin P, Jesenakova B, Babusikova E. Pulmonary manifestations of primary immunodeficiency disorders in children. Front Pediatr 2014; 2:77. [PMID: 25121077 PMCID: PMC4110629 DOI: 10.3389/fped.2014.00077] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/07/2014] [Indexed: 12/17/2022] Open
Abstract
Primary immunodeficiencies (PIDs) are inherited disorders in which one or several components of immune system are decreased, missing, or of non-appropriate function. These diseases affect the development, function, or morphology of the immune system. The group of PID comprises more than 200 different disorders and syndromes and the number of newly recognized and revealed deficiencies is still increasing. Their clinical presentation and complications depend on the type of defects and there is a great variability in the relationship between genotypes and phenotypes. A variation of clinical presentation across various age categories is also presented and children could widely differ from adult patients with PID. Respiratory symptoms and complications present a significant cause of morbidity and also mortality among patients suffering from different forms of PIDs and they are observed both in children and adults. They can affect primarily either upper airways (e.g., sinusitis and otitis media) or lower respiratory tract [e.g., pneumonia, bronchitis, bronchiectasis, and interstitial lung diseases (ILDs)]. The complications from lower respiratory tract are usually considered to be more important and also more specific for PIDs and they determinate patients' prognosis. The spectrum of the causal pathogens usually demonstrates typical pattern characteristic for each PID category. The respiratory signs of PIDs can be divided into infectious (upper and lower respiratory tract infections and complications) and non-infectious (ILDs, bronchial abnormalities - especially bronchiectasis, malignancies, and benign lymphoproliferation). Early diagnosis and appropriate therapy can prevent or at least slow down the development and course of respiratory complications of PIDs.
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Affiliation(s)
- Milos Jesenak
- Center for Diagnosis and Treatment of Primary Immunodeficiencies, Department of Pediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava , Martin , Slovakia
| | - Peter Banovcin
- Center for Diagnosis and Treatment of Primary Immunodeficiencies, Department of Pediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava , Martin , Slovakia
| | - Barbora Jesenakova
- Center for Diagnosis and Treatment of Primary Immunodeficiencies, Department of Pediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava , Martin , Slovakia
| | - Eva Babusikova
- Department of Medical Biochemistry, Jessenius Faculty of Medicine, Comenius University in Bratislava , Martin , Slovakia
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McGrath-Morrow SA, Lederman HM, Aherrera AD, Lefton-Greif MA, Crawford TO, Ryan T, Wright J, Collaco JM. Pulmonary function in children and young adults with ataxia telangiectasia. Pediatr Pulmonol 2014; 49:84-90. [PMID: 23401357 PMCID: PMC4423797 DOI: 10.1002/ppul.22760] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 01/03/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pulmonary disease contributes to significant morbidity and mortality in people with ataxia telangiectasia (A-T). To determine the association between age and lung function in children and young adults with A-T and to identify factors associated with decreased lung function, pulmonary function tests were performed in 100 consecutive people with A-T. METHODS Children and adults ranging from 6 to 29 years of age and with the diagnosis of A-T were recruited, and underwent pulmonary function tests. RESULTS The mean forced vital capacity % predicted (FVC %) in the population was 56.6 ± 20.0. Males and females between 6 and 10 years of age had similar pulmonary function. Older females were found to have significantly lower FVCs % than both older males (P < 0.02) and younger females (P < 0.001). The use of supplemental gamma globulin was associated with significantly lower FVC %. A modest correlation was found between higher radiation-induced chromosomal breakage and lower FVC % in males. No significant change in FVC % was found in a subset of subjects (n = 25) who underwent pulmonary function testing on two or more occasions over an average of 2 years. CONCLUSION In children and young adults with A-T, older females and people who required supplemental gamma globulin had significantly lower lung function by cross-sectional analysis. Stable lung function is possible over a 2-year period. Recognition of groups who are at higher risk for lower pulmonary function may help direct care and improve clinical outcomes in people with A-T.
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Affiliation(s)
- Sharon A McGrath-Morrow
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
Common variable immunodeficiency (CVID) is a common primary immunodeficiency characterized by a failure in B-cell differentiation with defective immunoglobulin production. Affected patients are uniquely susceptible to recurrent infection with encapsulated organisms and have an increased propensity for the development of inflammatory and autoimmune manifestations. The diagnosis of CVID is commonly delayed and the underlying cause of the disorder is not understood. Replacement antibody therapy reduces the risk of serious infections. However, optimal treatment regimens for the uncommon manifestations associated with this disease, such as granulomatous lymphocytic interstitial lung disease, require further research.
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Affiliation(s)
- Jonathan S Tam
- Section of Allergy and Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Gregersen S, Holm AM, Fevang B, Ueland T, Sikkeland LIB, Aaløkken TM, Mynarek G, Kongerud J, Aukrust P, Johansen B, Frøland SS. Lung disease, T-cells and inflammation in common variable immunodeficiency disorders. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:514-22. [PMID: 23957371 DOI: 10.3109/00365513.2013.819523] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Besides hypogammaglobulinemia and recurrent infections, abnormalities of T-cells might contribute to lung damage in common variable immunodeficiency disorders (CVID). MATERIALS AND METHODS In 16 adult patients, the majority of whom had pulmonary abnormalities, we studied T-cell subsets and markers of inflammation in bronchoalveolar lavage fluid (BALF) and blood and their relations with pulmonary function and high resolution computed tomography (HRCT). RESULTS We demonstrated that some of the lymphocyte abnormalities previously demonstrated in peripheral blood from CVID patients, such as low CD4/CD8 T-cell ratio, were also present in BALF. Moreover, low BALF CD4/CD8 ratio (≤ 1), found in seven patients, was significantly associated with higher blood CD8⁺ cell count and to lower values of the lung function variables; forced expiratory volume (FVC), total lung capacity (TLC), vital capacity (VC) and residual volume (RV) in % of predicted. The expression of the inflammatory markers HLA-DR and CCR5 on T-cells was significantly higher, and the expression of CCR7 significantly lower, in BALF compared to blood, possibly reflecting an inflammatory/cytotoxic T-cell phenotype within pulmonary tissue in CVID. Furthermore, patients with bronchiectasis had higher concentrations of the pro-inflammatory cytokine TNFα in plasma, compared to those without. CONCLUSION Our findings suggest that inflammation and T-cell activation may be involved in the immunopathogenesis of pulmonary complications in CVID.
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Heterozygous alterations of TNFRSF13B/TACI in tonsillar hypertrophy and sarcoidosis. Clin Dev Immunol 2013; 2013:532437. [PMID: 23956760 PMCID: PMC3727192 DOI: 10.1155/2013/532437] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 06/12/2013] [Accepted: 06/19/2013] [Indexed: 12/02/2022]
Abstract
TNFRSF13B/TACI defects have been associated with CVID pathogenesis and/or phenotype, especially the development of benign lymphoproliferation and autoimmunity. Our purpose was to investigate the role of TNFRSF13B/TACI defects in the pathogenesis of two common lymphoproliferative disorders, namely, sarcoidosis and tonsillar hypertrophy (TH). 105 patients (71 with sarcoidosis and 34 with TH, including 19 without infectious causative and 15 due to Haemophilus influenzae) were analyzed for TNFRSF13B/TACI defects. Two out of 19 TH patients without infectious cause (10.5%) and 2 patients with sarcoidosis (2.8%) displayed rare TNFRSF13B/TACI defects (I87N, L69TfsX12, E36L, and R202H, resp.). Both mutations identified in TH patients have been assessed as deleterious for protein function, while the patient with the R202H mutation and sarcoidosis exhibited also sIgG4D. Our study further supports the notion that TNFRSF13B/TACI defects alone do not result in CVID but may be also found frequently in distinct clinical phenotypes, including benign lymphoproliferation and IgG subclass deficiencies.
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Capolunghi F, Rosado MM, Sinibaldi M, Aranburu A, Carsetti R. Why do we need IgM memory B cells? Immunol Lett 2013; 152:114-20. [PMID: 23660557 DOI: 10.1016/j.imlet.2013.04.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 04/24/2013] [Accepted: 04/26/2013] [Indexed: 12/22/2022]
Abstract
Immunological memory is our reservoir of ready-to-use antibodies and memory B cells. Because of immunological memory a secondary infection will be very light or not occur at all. Antibodies and cells, generated in the germinal center in response to the first encounter with antigen, are highly specific, remain in the organism virtually forever and are mostly of IgG isotype. Long lived plasma cells homing to the bone marrow ensure the constant production of protective antibodies, whereas switched memory B cells proliferate and differentiate in response to secondary challenge. IgM memory B cells represent our first-line defense against infections. They are generated by a T-cell independent mechanism probably triggered by Toll-like receptor-9. They produce natural antibodies with anti-bacterial specificity and the spleen is indispensable for their maintenance. We will review the characteristics and functions of IgM memory B cells that explain their importance in the immediate protection from pathogens. IgM memory B cells, similar to mouse B-1a B cells, may be a remnant of a primitive immune system that developed in the spleen of cartilaginous fish and persisted throughout evolution notwithstanding the sophisticated tools of the adaptive immune system.
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Affiliation(s)
- Federica Capolunghi
- Department of Laboratories, Children Hospital Bambino Gesù (IRCCS), Piazza S.Onofrio 4, 00165 Rome, Italy
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Fuss IJ, Friend J, Yang Z, He JP, Hooda L, Boyer J, Xi L, Raffeld M, Kleiner DE, Heller T, Strober W. Nodular regenerative hyperplasia in common variable immunodeficiency. J Clin Immunol 2013; 33:748-58. [PMID: 23420139 DOI: 10.1007/s10875-013-9873-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/23/2013] [Indexed: 01/21/2023]
Abstract
PURPOSE Patients with Common Variable Immunodeficiency (CVID) are subject to the development of a liver disease syndrome known as nodular regenerative hyperplasia (NRH). The purpose of this study was to define the characteristics and course of this complication of CVID. METHODS CVID patients were evaluated by retrospective and prospective clinical course review. Liver biopsy specimens were evaluated for evidence of NRH and studied via RT-PCR for cytokine analysis. RESULTS NRH in our CVID patient population occurred in approximately 5 % of the 261 patients in our total CVID study group, initially presenting in most cases with an elevated alkaline phosphatase level. While in some patients the disease remained static, in a larger proportion a more severe disease developed characterized by portal hypertension, the latter leading to hypersplenism with neutropenia and thrombocytopenia and, in some cases, to ascites. In addition, a substantial proportion of patients either developed or presented initially with an autoimmune hepatitis-like (AIH-like) liver disease that resulted in severe liver dysfunction and, in most cases to death due to infections. The liver histologic findings in these AIH-like patients were characterized by underlying NRH pattern with superimposed interface hepatitis, lymphocytic infiltration and fibrosis. Immunologic studies of biopsies of NRH patients demonstrated the presence of infiltrating T cells producing IFN-γ, suggesting that the NRH is due to an autoimmune process. CONCLUSION Overall, these studies provide evidence that NRH may not be benign but, can be a severe and potentially fatal disease complication of CVID that merits close monitoring and intervention.
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Affiliation(s)
- Ivan J Fuss
- Mucosal Immunity Section, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
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Maarschalk-Ellerbroek LJ, Hoepelman AIM, van Montfrans JM, Ellerbroek PM. The spectrum of disease manifestations in patients with common variable immunodeficiency disorders and partial antibody deficiency in a university hospital. J Clin Immunol 2012; 32:907-21. [PMID: 22526591 PMCID: PMC3443482 DOI: 10.1007/s10875-012-9671-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 02/14/2012] [Indexed: 11/26/2022]
Abstract
Background Common variable immunodeficiency disorders (CVIDs) represents a heterogeneous disease spectrum that includes recurrent infections and complications such as autoimmunity, inflammatory organ disease and an increased risk of cancer. A diagnostic delay is common in CVIDs patients. Purpose To determine the spectrum of clinical manifestations, immunological characteristics, and the time to diagnosis of 61 adult CVIDs and 18 patients with a partial antibody deficiency (SADNI and IgG subclass deficiency). Methods A retrospective cohort study was performed in patients who met the ESID/PAGID for CVIDs, IgG subclass deficiency and SADNI. Medical records were reviewed to obtain patient demographics, clinical and laboratory data. Results Infections were the main presentation of all antibody deficient patients and the number of patients with infections declined during IgG therapy. The development of bronchiectasis continued despite IgG therapy, as well as the development of autoinflammatory conditions. Non-infectious disease complications were present in 30% of CVIDs patients at the time of diagnosis and this increased to 51% during follow up despite IgG therapy. The most common complications were autoimmunity or lymphoproliferative disease. The median time to diagnosis was 10 years and in the patients with non-infectious complications the time to diagnosis was considerably longer when compared to the group of patients without complications (17.6 vs. 10.2 years, p = 0.026). Conclusion In contrast to the partial antibody deficiencies we found a considerable delay in the diagnosis of CVIDs, especially in those patients who were dominated by non-infectious complications, and thus increased awareness would be beneficial. Pulmonary and other complications may continue despite adequate IgG replacement therapy suggesting other causes responsible for these complications. Electronic supplementary material The online version of this article (doi:10.1007/s10875-012-9671-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L J Maarschalk-Ellerbroek
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
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van de Ven AAJM, de Jong PA, Hoytema van Konijnenburg DP, Kessels OAM, Boes M, Sanders EAM, Terheggen-Lagro SWJ, van Montfrans JM. Airway and interstitial lung disease are distinct entities in paediatric common variable immunodeficiency. Clin Exp Immunol 2011; 165:235-42. [PMID: 21635229 DOI: 10.1111/j.1365-2249.2011.04425.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Common variable immunodeficiency (CVID) is a common primary immune deficiency, caused by undefined defects in lymphocyte function, and is treated routinely by immunoglobulin substitution. CVID complications include airway disease (AD) and interstitial lung disease (ILD). It was not known if AD and ILD in CVID have a common immunological aetiology and should be considered separate features of the same disease, or as distinct syndromes that require specialized monitoring and treatment. We used high-resolution computed tomography (CT) to diagnose AD or ILD in paediatric CVID patients. Spirometry and body plethysmography did not differentiate between ILD and AD. Patients with AD (n = 11, 20%) developed more pneumonias while children with ILD (n = 8, 15%) showed immune dysregulation characterized by autoimmune complications, more severe memory B cell reduction and expansion of non-naive cytotoxic T cells. In conclusion, ILD and AD in CVID have dissimilar clinical and immunological characteristics, suggesting distinct aetiology requiring tailored monitoring and treatment of these patient subgroups.
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Affiliation(s)
- A A J M van de Ven
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht and Wilhelmina Children's Hospital, Utrecht, the Netherlands
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Orange JS, Grossman WJ, Navickis RJ, Wilkes MM. Impact of trough IgG on pneumonia incidence in primary immunodeficiency: A meta-analysis of clinical studies. Clin Immunol 2010; 137:21-30. [PMID: 20675197 DOI: 10.1016/j.clim.2010.06.012] [Citation(s) in RCA: 292] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Revised: 06/22/2010] [Accepted: 06/23/2010] [Indexed: 01/05/2023]
Abstract
Primary immunodeficiency disease (PIDD) associated with hypogammaglobulinemia is typically treated with immunoglobulin replacement therapy. When administered as intravenous immunoglobulin (IVIG), an IgG trough occurs prior to the next replacement dose. While frequently measured, IgG trough levels required to minimize infection risk are not established. To address this question, all available studies evaluating trough IgG and pneumonia incidence in PIDD patients with hypogammaglobulinemia receiving IVIG were quantitatively combined by meta-analysis. Seventeen studies with 676 total patients and 2,127 patient-years of follow-up were included. Pneumonia incidence declined by 27% with each 100mg/dL increment in trough IgG (incidence rate ratio, 0.726; 95% confidence interval, 0.658-0.801). Pneumonia incidence with maintenance of 500 mg/dL IgG trough levels (0.113 cases per patient-year) was 5-fold that with 1000 mg/dL (0.023 cases per patient-year). This meta-analysis provides evidence that pneumonia risk can be progressively reduced by higher trough IgG levels up to at least 1000 mg/dL.
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Affiliation(s)
- Jordan S Orange
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Touw CML, van de Ven AA, de Jong PA, Terheggen-Lagro S, Beek E, Sanders EAM, van Montfrans JM. Detection of pulmonary complications in common variable immunodeficiency. Pediatr Allergy Immunol 2010; 21:793-805. [PMID: 19912551 DOI: 10.1111/j.1399-3038.2009.00963.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Touw CML, van de Ven AA, de Jong PA, Terheggen-Lagro S, Beek E, Sanders EAM, van Montfrans JM. Detection of pulmonary complications in common variable immunodeficiency. Pediatr Allergy Immunol 2010: 21: 793-805. (c) 2009 John Wiley & Sons A/S Pulmonary complications are frequently observed in common variable immunodeficiency (CVID). We reviewed the literature related to radiologic imaging techniques and pulmonary function tests (PFT) for diagnosing pulmonary complications in CVID. Scientific publications related to CVID (or primary hypogammaglobulinemia), pulmonary complications, PFT, chest X-ray (CXR), and high-resolution computed tomography scan (HRCT) were detected in PubMed, Embase and in reference lists of selected articles. Twenty-six articles including 1047 patients (587 patients with CVID) were reviewed. Up to 73% of CVID patients develop chronic structural pulmonary complications, of which bronchiectasis and bronchial wall thickening are most frequently detected. HRCT is the most sensitive method for identification of structural abnormalities, detecting pulmonary complications that were missed on CXR and PFT in 2-59% of patients. On PFT, obstructive flow-volume curves were most commonly found, eventually occurring in 50-94% of patients. HRCT is an important diagnostic tool for pulmonary complications in CVID at the time of diagnosis and at regular time-points during follow-up, with the proper follow-up interval yet to be determined.
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Affiliation(s)
- Catharina M L Touw
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht and Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Common variable immunodeficiency: computed tomography evaluation of bronchopulmonary changes including nodular lesions in 40 patients. Correlation with clinical and immunological data. J Comput Assist Tomogr 2010; 34:395-401. [PMID: 20498543 DOI: 10.1097/rct.0b013e3181cad9da] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency characterized by recurrent respiratory tract infections, mainly sustained by encapsulated bacteria, that may cause irreversible changes in the lungs. METHODS Forty patients with CVID were evaluated by computed tomography of the lung; 20 of these underwent computed tomographic follow-up in a 5-year period, during which immunoglobulin replacement therapy was regularly performed. RESULTS Pulmonary changes were present in 65% of patients; bronchiectases were present in 65.38%. The incidence of pulmonary nodules was very high (38.46%) and correlated with splenomegaly (70%) and autoimmune phenomena (80%). CONCLUSIONS Our study underscores the essential role of imaging, in particular computed tomography, in the identification and monitoring of pulmonary lesions in a large cohort of CVID patients, contributing at the same time to select patients more at risk to develop nodular lesions and potentially to use more appropriate therapeutic strategies.
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Agondi RC, Barros MT, Rizzo LV, Kalil J, Giavina-Bianchi P. Allergic asthma in patients with common variable immunodeficiency. Allergy 2010; 65:510-5. [PMID: 19839975 DOI: 10.1111/j.1398-9995.2009.02211.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Many patients with common variable immunodeficiency (CVID) have a clinical history suggestive of allergic respiratory disease. However, in such individuals, the prevalence of asthma and the role of atopy have not been well established. The objective of this study was to evaluate pulmonary function and identify asthma in patients with CVID. We also investigated the role of IgE as a trigger of asthma in these patients. METHODS Sixty-two patients diagnosed with CVID underwent spirometry, as well as skin prick testing and in vitro determination of serum-specific IgE levels for aeroallergens, together with bronchial provocation with histamine and allergen. RESULTS The most common alteration identified through spirometry was obstructive lung disease, which was observed in 29 (47.5%) of the 62 patients evaluated. Eighteen (29.0%) of the 62 patients had a clinical history suggestive of allergic asthma. By the end of the study, asthma had been diagnosed in nine (14.5%) patients and atopy had been identified in six (9.7%). In addition, allergic asthma had been diagnosed in four patients (6.5% of the sample as a whole; 22.2% of the 18 patients with a clinical history suggestive of the diagnosis). CONCLUSION In this study, CVID patients testing negative for specific IgE antibodies and suspected of having allergic asthma presented a positive response to bronchial provocation tests with allergens. To our knowledge, this is the first such study. When CVID patients with a history suggestive of allergic asthma test negative on traditional tests, additional tests designed to identify allergic asthma might be conducted.
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Affiliation(s)
- R C Agondi
- Department of Clinical Immunology and Allergy, University of São Paulo, Brazil
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36
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van de Ven AAJM, van Montfrans JM, Terheggen-Lagro SWJ, Beek FJ, Hoytema van Konijnenburg DP, Kessels OAM, de Jong PA. A CT scan score for the assessment of lung disease in children with common variable immunodeficiency disorders. Chest 2010; 138:371-9. [PMID: 20299624 DOI: 10.1378/chest.09-2398] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The prevalence and severity of structural lung disease in children with common variable immunodeficiency (CVID) disorders is not well known, and a dedicated CT scanning protocol and CT scan scoring system have not been described in this category. METHODS This was a cohort study of 54 children (34 CVID, 20 CVID-like disorder) in a stable condition who underwent volumetric inspiratory and end-expiratory CT scans. Scans were scored for airway abnormalities, interstitial and parenchymal lung disease, and lymphadenopathy using a newly developed CT scan scoring system. Scores were normalized to a 0% to 100% scale. Observer agreement was assessed using an intraclass correlation coefficient (Ri). Prevalence and severity of CT scan abnormalities were calculated. RESULTS Structural lung disease was common (85%-93%), but usually mild as reflected in the relatively low scores (bronchiectasis score 2.8% +/- 6.4%). Moderate-to-severe bronchiectasis was found in three (5%) patients. Expiratory air trapping was the most common finding, found in 71% to 80%, but often in a mild form; application of a cut off level of > 10% reduced its prevalence to 33% to 38%. In 9% to 15% of all patients, air trapping was the only abnormality. Multiple lung nodules were seen in 24% to 25% and could disappear after corticosteroid treatment. Observer agreement was moderate (Ri 0.6-0.79) to good (Ri > 0.8) for all items and the composite scores, except airway wall thickening. CONCLUSION In children with CVID disorders, mild structural lung disease is common. Expiratory CT scans show the most frequent abnormality, air trapping. The occurrence of (silent) lung disease progression and the clinical impact of CT scans require further investigations.
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Affiliation(s)
- Annick A J M van de Ven
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht and Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Ballow M, Notarangelo L, Grimbacher B, Cunningham-Rundles C, Stein M, Helbert M, Gathmann B, Kindle G, Knight AK, Ochs HD, Sullivan K, Franco JL. Immunodeficiencies. Clin Exp Immunol 2010; 158 Suppl 1:14-22. [PMID: 19883420 DOI: 10.1111/j.1365-2249.2009.04023.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Primary immunodeficiencies (PIDs) are uncommon, chronic and severe disorders of the immune system in which patients cannot mount a sufficiently protective immune response, leading to an increased susceptibility to infections. The treatment of choice for PID patients with predominant antibody deficiency is intravenous immunoglobulin (Ig) replacement therapy. Despite major advances over the last 20 years in the molecular characterization of PIDs, many patients remain undiagnosed or are diagnosed too late, with severe consequences. Various strategies to ensure timely diagnosis of PIDs are in place, and novel approaches are being developed. In recent years, several patient registries have been established. Such registries shed light on the pathology and natural history of these varied disorders. Analyses of the registry data may also reveal which patients are likely to respond well to higher Ig infusion rates and may help to determine the optimal dosing of Ig products. Faster infusion rates may lead to improved convenience for patients and thus increase patient compliance, and may reduce nursing time and the need for hospital resources. Data from two recent studies suggest that Gamunex and Privigen are well tolerated at high infusion rates. Nevertheless, careful selection of patients for high infusion rates, based on co-morbid conditions and tolerance of the current infusion rate, is advisable. Based on the available data, intravenous Ig offers broad protection against encapsulated organisms. As vaccine trends change, careful monitoring of specific antibody levels in the general population, such as those against pneumococcal and meningococcal bacteria, should be implemented.
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Affiliation(s)
- M Ballow
- Women and Children's Hospital of Buffalo, State University of New York at Buffalo, Buffalo, NY 14222, USA.
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Sala Cunill A, Soler-Palacín P, Martín De Vicente C, Labrador Horrillo M, Luengo Sánchez O, Figueras Nadal C. [Common variable immunodeficiency. Prognostic factors for lung damage]. Med Clin (Barc) 2009; 134:64-7. [PMID: 19811791 DOI: 10.1016/j.medcli.2009.06.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 06/17/2009] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Lung damage is considered to be key to Common Variable Immunodeficiency (CVID) prognosis. We describe lung damage in pediatric CVID patients and assess its relationship with memory B cells (MB) phenotype, immunoglobulin G (IgG) levels at the time of diagnosis, and diagnostic delay. We also assessed the prevalence of allergy and autoimmune phenomena. PATIENTS AND METHOD Cross-sectional study of 17 CVID patients treated at Vall d'Hebron University Hospital. Prevalence ratio and prevalence odds ratio were used to assess the effect of MB cells phenotype, IgG levels and diagnostic delay on lung damage. RESULTS Five of seventeen patients presented bronchiectasis. Diagnostic delay >5 years was significantly associated with more severe lung damage. MBO phenotype and low IgG levels at the time of diagnosis showed a trend to more severe lung damage without reaching statistical signification. A higher prevalence of allergic or autoimmune phenomena was not observed. CONCLUSIONS Latter diagnosis is associated with greater lung damage in CVID patients. The study of MB cells should be included in the study of these patients.
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Affiliation(s)
- Anna Sala Cunill
- Sección de Alergia, Hospital Universitari Vall d'Hebron, Barcelona, España
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Ardeniz O, Cunningham-Rundles C. Granulomatous disease in common variable immunodeficiency. Clin Immunol 2009; 133:198-207. [PMID: 19716342 DOI: 10.1016/j.clim.2009.05.001] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 04/23/2009] [Accepted: 05/04/2009] [Indexed: 11/19/2022]
Abstract
Granulomatous disease occurs in 8-22% of patients with common variable immunodeficiency (CVID). We examined the clinical and immunologic information of all 37 of 455 (8.1%) CVID subjects with this complication. The median age at diagnosis of CVID was 26 (2-59). 14 had granulomas 1-18 years before diagnosis of CVID. In 6 detection of granulomas coincided with this diagnosis; for 17, granulomas were documented later. 54% had lung granulomas, 43% in lymph nodes and 32% in liver. 54% of the group had had autoimmune diseases, mostly immune thrombocytopenia and hemolytic anemia. 24% had had a splenectomy. Nineteen (51.3%) required steroid treatment for granulomas; other immune suppressants were used in some. Over 25 years 28.5% died (median age 37.5), but not significantly more when compared to our CVID patients without granulomas (19.8%). Those with lung granulomas had similar mortality to those with granulomas in other tissues.
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Affiliation(s)
- Omür Ardeniz
- Ege University Medical Faculty, Department of Internal Medicine, Division of Allergy and Clinical Immunology, Izmir, Turkey
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Deane S, Selmi C, Naguwa SM, Teuber SS, Gershwin ME. Common variable immunodeficiency: etiological and treatment issues. Int Arch Allergy Immunol 2009; 150:311-24. [PMID: 19571563 PMCID: PMC2814150 DOI: 10.1159/000226232] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
One of the great advances in clinical medicine was the recognition of the pleomorphism of the immune response and the multiple afferent and efferent limbs of antigen processing and responsiveness. A significant contribution to this understanding was derived from studies of human immunodeficiency states, including both inherited and acquired syndromes. Amongst these syndromes, one of the most common, and least understood, is common variable immune deficiency (CVID). CVID is a syndrome that leads to a reduction in serum immunoglobulins and complications including recurrent infections. Management includes immunoglobulin replacement therapy; however, patients with CVID are at risk for complications of exogenous immunoglobulin administration as well as CVID-associated diseases such as autoimmune processes and malignancies. To assess the current state of knowledge in the field, we performed a literature review of a total of 753 publications covering the period of 1968 until 2008. From this list, 189 publications were selected for discussion. In this review, we demonstrate that while the molecular basis of CVID in many cases remains incompletely understood, significant strides have been made and it is now clear that there is involvement of several pathways of immune activation, with contributions from both T and B cells. Furthermore, despite the current gaps in our knowledge of the molecular pathogenesis of the syndrome, there have been dramatic advances in management that have led to improved survival and significantly reduced morbidity in affected patients.
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Affiliation(s)
| | | | | | | | - M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California
at Davis School of Medicine, Davis, Calif., USA
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Gregersen S, Aaløkken TM, Mynarek G, Kongerud J, Aukrust P, Frøland SS, Johansen B. High resolution computed tomography and pulmonary function in common variable immunodeficiency. Respir Med 2009; 103:873-80. [PMID: 19181508 DOI: 10.1016/j.rmed.2008.12.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 12/04/2008] [Accepted: 12/18/2008] [Indexed: 01/07/2023]
Abstract
Patients with common variable immunodeficiency (CVID) have impaired production of immunoglobulins and hence recurrent airway infections, which in turn may lead to radiological changes and impaired lung function. Uncertainty exists about the nature and frequency of the radiological and the physiological abnormalities, and how they relate to each other. We reassessed high resolution computed tomography (HRCT) images in 65 patients, reported results from previously measured lung function tests, and studied relations between radiology, function and clinical variables. Airway obstruction, ventilatory restriction and impaired gas diffusion was found in 40, 34 and 21% of the patients, respectively. HRCT abnormalities were present in 94% of the subjects, mild changes being the most common. Bronchial wall thickening, found in two thirds of the patients, was related to airway obstruction and impaired gas diffusion. Linear and/or irregular opacities, the most frequent interstitial abnormality, was related to impaired gas diffusion. Bronchiectasis was found in more than half, but only severe bronchiectasis was related to airway obstruction. Since bronchial wall thickening and linear and/or irregular opacities are both frequent and important determinants of impaired pulmonary function, more attention should be given to these features in the follow up of CVID patients.
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Affiliation(s)
- Stina Gregersen
- University of Oslo, Rikshospitalet University Hospital, Department of Respiratory Medicine, 0027 Oslo, Norway.
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Pereira AC, Kokron CM, Romagnolo BMS, Yagi CSA, Saldiva PHN, Lorenzi Filho G, Negri EM. Analysis of the sputum and inflammatory alterations of the airways in patients with common variable immunodeficiency and bronchiectasis. Clinics (Sao Paulo) 2009; 64:1155-60. [PMID: 20037702 PMCID: PMC2797583 DOI: 10.1590/s1807-59322009001200004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 09/01/2009] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Common variable immunodeficiency is characterized by defective antibody production and recurrent pulmonary infections. Intravenous immunoglobulin is the treatment of choice, but the effects of Intravenous immunoglobulin on pulmonary defense mechanisms are poorly understood. OBJECTIVE The aim of this study was to verify the impact of intravenous immunoglobulin on the physical properties of the sputum and on inflammatory alterations in the airways of patients with Common variable immunodeficiency associated with bronchiectasis. METHOD The present study analyzed sputum physical properties, exhaled NO, inflammatory cells in the sputum, and IG titers in 7 patients with Common variable immunodeficiency and bronchiectasis with secretion, immediately before and 15 days after Intravenous immunoglobulin. A group of 6 patients with Common variable immunodeficiency and bronchiectasis but no sputum was also studied for comparison of the basal IgG level and blood count. The 13 patients were young (age=36+/-17 years) and comprised predominantly of females (n=11). RESULTS Patients with secretion presented significantly decreased IgG and IgM levels. Intravenous immunoglobulin was associated with a significant decrease in exhaled NO (54.7 vs. 40.1 ppb, p<0.05), sputum inflammatory cell counts (28.7 vs. 14.6 cells/mm(3), p<0.05), and a significant increase in respiratory mucus transportability by cough (42.5 vs. 65.0 mm, p < 0.05). CONCLUSION We concluded that immunoglobulin administration in Common variable immunodeficiency patients results in significant improvement in indexes of inflammation of the airways with improvement in the transportability of the respiratory mucus by cough.
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Affiliation(s)
- Andrea Cristina Pereira
- Pathology Department, Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil.
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Principles of and advances in immunoglobulin replacement therapy for primary immunodeficiency. Immunol Allergy Clin North Am 2008; 28:413-37, x. [PMID: 18424340 PMCID: PMC7127239 DOI: 10.1016/j.iac.2008.01.008] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
During the last 2 decades, the continued development and the large-scale production of polyclonal immune serum globulin (ISG) preparations with improved safety and tolerability profiles have allowed treatment to focus on quality of life and long-term freedom from the complications of primary immune deficiency disease, rather than just on freedom from severe acute infections and survival. Available ISG preparations allow routine therapy by a variety of routes and regimens that can be tailored to suit individual patients. Continued vigilance is required, however, because problems with emerging diseases, and the costs and availability of ISG are likely to present continuing challenges.
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Notarangelo LD, Plebani A, Mazzolari E, Soresina A, Bondioni MP. Genetic causes of bronchiectasis: primary immune deficiencies and the lung. Respiration 2007; 74:264-75. [PMID: 17534129 DOI: 10.1159/000101784] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Primary immune deficiencies (PID) comprise a heterogeneous group of genetically determined disorders that affect development and/or function of innate or adaptive immunity. Consequently, patients with PID suffer from recurrent and/or severe infections that frequently involve the lung. While the nature of the immune defect often dictates the type of pathogens that may cause lung infection, there is substantial overlap of radiological findings, so that appropriate laboratory tests are mandatory to define the nature of the immune defect and to prompt appropriate treatment. At the same time, the recent identification of a large number of PID-causing genes now allows early, even presymptomatic diagnosis, thus representing an essential tool for prevention of lung damage. This review article describes the most common forms of PID, their cellular and molecular bases, and the associated lung abnormalities, and reports on available treatment.
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Affiliation(s)
- Luigi D Notarangelo
- Division of Immunology, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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