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Hanitsch LG, Steiner S, Schumann M, Wittke K, Kedor C, Scheibenbogen C, Fischer A. Portal hypertension in common variable immunodeficiency disorders - a single center analysis on clinical and immunological parameter in 196 patients. Front Immunol 2023; 14:1268207. [PMID: 38187397 PMCID: PMC10769488 DOI: 10.3389/fimmu.2023.1268207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Liver manifestations and in particular portal hypertension (PH) contribute significantly to morbidity and mortality of patients with common variable immunodeficiency disorders (CVID). Screening strategies and early detection are limited due to the lack of specific diagnostic tools. Methods We evaluated clinical, immunological, histological, and imaging parameters in CVID patients with clinical manifestation of portal hypertension (CVID+PH). Results Portal hypertension was present in 5.6% of CVID patients and was associated with high clinical burden and increased mortality (18%). Longitudinal data on clinical and immunological parameters in patients before and during clinically manifest portal hypertension revealed a growing splenomegaly and increasing gamma-glutamyl transferase (GGT) and soluble interleukin 2 receptor (SIL-2R) levels with decreasing platelets over time. While ultrasound of the liver failed to detect signs of portal hypertension in most affected patients, transient elastography was elevated in all patients. All CVID+PH patients had reduced naïve CD45RA+CD4+ T-cells (mean of 6,2%). The frequency of severe B-lymphocytopenia (Euroclass B-) was higher in CVID+PH patients. The main histological findings included lymphocytic infiltration, nodular regenerative hyperplasia-like changes (NRH-LC), and porto(-septal) fibrosis. Conclusion CVID patients with lower naïve CD45RA+CD4+ T-cells or severely reduced B-cells might be at higher risk for portal hypertension. The combination of biochemical (increasing sIL-2R, GGT, and decreasing platelets) and imaging parameters (increasing splenomegaly) should raise suspicion of the beginning of portal hypertension.
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Affiliation(s)
- Leif G. Hanitsch
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Sophie Steiner
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Michael Schumann
- Department of Gastroenterology, Infectiology and Rheumatology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Kirsten Wittke
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Claudia Kedor
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Andreas Fischer
- Department of Internal Medicine and Gastroenterology, Caritas-Klinik Maria Heimsuchung Berlin-Pankow, Berlin, Germany
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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Bintalib HM, van de Ven A, Jacob J, Davidsen JR, Fevang B, Hanitsch LG, Malphettes M, van Montfrans J, Maglione PJ, Milito C, Routes J, Warnatz K, Hurst JR. Diagnostic testing for interstitial lung disease in common variable immunodeficiency: a systematic review. Front Immunol 2023; 14:1190235. [PMID: 37223103 PMCID: PMC10200864 DOI: 10.3389/fimmu.2023.1190235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 04/17/2023] [Indexed: 05/25/2023] Open
Abstract
Introduction Common variable immunodeficiency related interstitial lung disease (CVID-ILD, also referred to as GLILD) is generally considered a manifestation of systemic immune dysregulation occurring in up to 20% of people with CVID. There is a lack of evidence-based guidelines for the diagnosis and management of CVID-ILD. Aim To systematically review use of diagnostic tests for assessing patients with CVID for possible ILD, and to evaluate their utility and risks. Methods EMBASE, MEDLINE, PubMed and Cochrane databases were searched. Papers reporting information on the diagnosis of ILD in patients with CVID were included. Results 58 studies were included. Radiology was the investigation modality most commonly used. HRCT was the most reported test, as abnormal radiology often first raised suspicion of CVID-ILD. Lung biopsy was used in 42 (72%) of studies, and surgical lung biopsy had more conclusive results compared to trans-bronchial biopsy (TBB). Analysis of broncho-alveolar lavage was reported in 24 (41%) studies, primarily to exclude infection. Pulmonary function tests, most commonly gas transfer, were widely used. However, results varied from normal to severely impaired, typically with a restrictive pattern and reduced gas transfer. Conclusion Consensus diagnostic criteria are urgently required to support accurate assessment and monitoring in CVID-ILD. ESID and the ERS e-GLILDnet CRC have initiated a diagnostic and management guideline through international collaboration. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022276337.
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Affiliation(s)
- Heba M. Bintalib
- University College London (UCL) Respiratory, University College London, London, United Kingdom
- Department of Respiratory Care, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia
| | - Annick van de Ven
- Departments of Internal Medicine & Allergology, Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, Netherlands
| | - Joseph Jacob
- University College London (UCL) Respiratory, University College London, London, United Kingdom
- Satsuma Lab, Centre for Medical Image Computing, University College London (UCL), London, United Kingdom
| | - Jesper Rømhild Davidsen
- South Danish Center for Interstitial Lung Diseases (SCILS), Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Børre Fevang
- Centre for Rare Disorders, Division of Paediatric and Adolescent Health, Oslo University Hospital, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Leif G. Hanitsch
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1 and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, Berlin, Germany
| | - Marion Malphettes
- Department of Clinic Immunopathology, Hôpital Saint-Louis, Paris, France
| | - Joris van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, Wilhelmina Childrens Hospital, University Medical Center Utrecht (UMC), Utrecht, Netherlands
| | - Paul J. Maglione
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
| | - Cinzia Milito
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - John Routes
- Division of Allergy, Asthma and Immunology, Department of Pediatrics, Medicine, Microbiology and Immunology, Medical College Wisconsin, Milwaukee, WI, United States
| | - Klaus Warnatz
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - John R. Hurst
- University College London (UCL) Respiratory, University College London, London, United Kingdom
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Fevang B. Treatment of inflammatory complications in common variable immunodeficiency (CVID): current concepts and future perspectives. Expert Rev Clin Immunol 2023; 19:627-638. [PMID: 36996348 DOI: 10.1080/1744666x.2023.2198208] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Patients with Common variable immunodeficiency (CVID) have a high frequency of inflammatory complications like autoimmune cytopenias, interstitial lung disease and enteropathy. These patients have poor prognosis and effective, timely and safe treatment of inflammatory complications in CVID are essential, but guidelines and consensus on therapy are often lacking. AREAS COVERED This review will focus on current medical treatment of inflammatory complications in CVID and point out some future perspectives based on literature indexed in PubMed. There are a number of good observational studies and case reports on treatment of specific complications but randomized controlled trials are scarce. EXPERT OPINION In clinical practice, the most urgent issues that need to be addressed are the preferred treatment of GLILD, enteropathy and liver disease. Treating the underlying immune dysregulation and immune exhaustion in CVID is an alternative approach that potentially could alleviate these and other organ-specific inflammatory complications. Therapies of potential interest and wider use in CVID include mTOR-inhibitors like sirolimus, JAK-inhibitors like tofacitinib, the monoclonal IL-12/23 antibody ustekinumab, the anti-BAFF antibody belimumab and abatacept. For all inflammatory complications, there is a need for prospective therapeutic trials, preferably randomized controlled trials, and multi-center collaborations with larger cohorts of patients will be essential.
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Affiliation(s)
- Børre Fevang
- Centre for Rare Disorders, Oslo University Hospital, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Oslo, Norway
- Research Institute for Internal Medicine, Oslo University Hospital, Oslo, Norway
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Mustafa SS, Rider NL, Jolles S. Immunosuppression in Patients With Primary Immunodeficiency-Walking the Line. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3088-3096. [PMID: 36049628 DOI: 10.1016/j.jaip.2022.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022]
Abstract
Individuals with primary immunodeficiency (PIDD) experience not only infectious complications but also immune dysregulation leading to autoimmunity, inflammation, and lymphoproliferative manifestations. Management of these complications often requires treatment with additional immunosuppressive medications, which pose an additional risk of infectious complications. Immunosuppression in individuals with PIDD therefore requires careful assessment and consideration of risks and benefits. Medications should be closely monitored, and strategies for risk mitigation of adverse events considered, such as exposure reduction, appropriate vaccination, use of antibiotics/antivirals, and optimization of immunoglobulin replacement therapy. In a subset of individuals who are not tolerating immune modulation or experiencing disease progression despite appropriate interventions, hematopoietic stem-cell transplantation is a management option.
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Affiliation(s)
- S Shahzad Mustafa
- Rochester Regional Health, Division of Allergy, Immunology, and Rheumatology, University of Rochester School of Medicine and Dentistry, Rochester, NY; Liberty University College of Osteopathic Medicine and the Liberty Mountain, Chair, Division of Clinical Informatics; Associate Professor of Pediatrics, Allergy-Immunology Medical Group, Rochester, NY.
| | - Nicholas L Rider
- Liberty University College of Osteopathic Medicine and the Liberty Mountain Medical Group, Lynchburg, Va
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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An Expert Opinion/Approach: Clinical Presentations, Diagnostic Considerations, and Therapeutic Options for Gastrointestinal Manifestations of Common Variable Immune Deficiency. Am J Gastroenterol 2022; 117:1743-1752. [PMID: 36148549 DOI: 10.14309/ajg.0000000000002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/16/2022] [Indexed: 01/11/2023]
Abstract
Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency. It is characterized by impaired B-cell differentiation. Although patients can be diagnosed with CVID anytime during their lifetime, most patients have symptoms for 5-9 years before their diagnosis. The diagnosis of CVID starts with a detailed history focusing on the infectious and noninfectious manifestations of the disease. In patients who are suspected to experience CVID, quantitative immunoglobulins (Ig) should be checked to confirm the diagnosis. IgG should be at least 2 times less than the age-specific SD along with either a low IgA or IgM and with evidence of impaired vaccine response. CVID is usually associated with infectious and/or noninfectious conditions, the latter of which can be inflammatory, autoimmune, lymphoproliferative, or malignant, among other manifestations. Ig therapy has positively affected the disease course of patients with infectious complications but has limited effect on the noninfectious manifestations because the noninfectious complications are related to immune dysregulation involving B cells and T cells rather than primarily due to antibody deficiency. When the gastrointestinal (GI) system is involved, patients with CVID may display signs and symptoms that mimic several GI conditions such as celiac disease, pernicious anemia, or inflammatory bowel diseases. The inflammatory bowel disease-like condition is usually treated with steroids, 5-aminosalicylates, thiopurines, or biologic agents to control the inflammation. In this review, the clinical presentations, diagnostic considerations, and therapeutic options for GI manifestations of CVID will be discussed to facilitate the individualized management of these often-complex patients.
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Abubakar SD, Ihim SA, Farshchi A, Maleknia S, Abdullahi H, Sasaki T, Azizi G. The role of TNF-α and anti-TNF-α agents in the immunopathogenesis and management of immune dysregulation in primary immunodeficiency diseases. Immunopharmacol Immunotoxicol 2022; 44:147-156. [DOI: 10.1080/08923973.2021.2023173] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Sharafudeen Dahiru Abubakar
- Division of Molecular Pathology, Research Institute for Biomedical Sciences, Tokyo University of Science, Tokyo, Japan
- Department of Medical Laboratory Science, College of Medical Science, Ahmadu Bello University, Zaria, Nigeria
| | - Stella Amarachi Ihim
- Department of Molecular and Cellular Pharmacology, University of Shizuoka, Shizuoka, Japan
- Department of Pharmacology and Toxicology, University of Nigeria, Nsukka, Nigeria
| | - Amir Farshchi
- Biopharmaceutical Research Center, AryoGen Pharmed Inc, Alborz University of Medical Sciences, Karaj, Iran
| | - Shayan Maleknia
- Biopharmaceutical Research Center, AryoGen Pharmed Inc, Alborz University of Medical Sciences, Karaj, Iran
| | - Hamisu Abdullahi
- Department of Immunology, School of Medical Laboratory Sciences, Usmanu Danfodiyo University Sokoto, Sokoto, Nigeria
| | - Takanori Sasaki
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Gholamreza Azizi
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
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Rodina Y, Deripapa E, Shvets O, Mukhina A, Roppelt A, Yuhacheva D, Laberko A, Burlakov V, Abramov D, Tereshchenko G, Novichkova G, Shcherbina A. Rituximab and Abatacept Are Effective in Differential Treatment of Interstitial Lymphocytic Lung Disease in Children With Primary Immunodeficiencies. Front Immunol 2021; 12:704261. [PMID: 34566961 PMCID: PMC8458825 DOI: 10.3389/fimmu.2021.704261] [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: 05/02/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022] Open
Abstract
Background Interstitial lymphocytic lung disease (ILLD), a recently recognized complication of primary immunodeficiencies (PID), is caused by immune dysregulation, abnormal bronchus-associated lymphoid tissue (BALT) hyperplasia, with subsequent progressive loss of pulmonary function. Various modes of standard immunosuppressive therapy for ILLD have been shown as only partially effective. Objectives To retrospectively evaluate the safety and efficacy of abatacept or rituximab in treatment of ILLD in children with PID. Methods 29 children (median age 11 years) with various forms of PID received one of the two therapy regimens predominantly based on the lesions’ immunohistopathology: children with prevalent B-cell lung infiltration received rituximab (n = 16), and those with predominantly T-cell infiltration received abatacept (n = 17). Clinical and radiological symptoms were assessed using a severity scale developed for the study. Results The targeted therapy with abatacept (A) or rituximab (R) enabled long-term control of clinical (A 3.4 ± 1.3 vs. 0.6 ± 0.1; R 2.8 ± 1 vs. 0.7 ± 0.05, p < 0.01) and radiological (A 18.4 ± 3.1 vs. 6.0 ± 2.0; R 30 ± 7.1 vs. 10 ± 1.7, p < 0.01) symptoms of ILLD in both groups and significantly improved patients’ quality of life, as measured by the total scale (TS) score of 57 ± 2.1 in treatment recipients vs. 31.2 ± 1.9 before therapy (p < 0.01). Conclusions ILLD histopathology should be considered when selecting treatment. Abatacept and rituximab are effective and safe in differential treatment of ILLD in children.
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Affiliation(s)
- Yulia Rodina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - E Deripapa
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - O Shvets
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - A Mukhina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - A Roppelt
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - D Yuhacheva
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - A Laberko
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - V Burlakov
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - D Abramov
- Department of Pathology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - G Tereshchenko
- Department of Radiology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - G Novichkova
- Department of Hematology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Department of Immunology, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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Abstract
PURPOSE OF REVIEW Sarcoidosis is a chronic granulomatous disorder involving multiple systems and organs of undefined etiology. Although most of the morbidity relies upon lung disease, the function of several systems and organs can be affected. The natural history of lung disease consists of pulmonary involvement. An exaggerated and abnormal inflammatory response accompanies this aspect. There are noncaseating confluent epithelioid granulomas and, potentially, a progressive airway obstruction ab externo. As the disease is multisystemic, there is an increased likelihood of complications that may be serious and even fatal. RECENT FINDINGS The American Thoracic Society (ATS) Core Curriculum updates clinicians annually in adult and pediatric lung disease, critical medical care, and sleep medicine. In late 2020, the ATS targeted sarcoidosis. Also, in 2019, the French Sarcoidosis Group thoroughly revised the literature on pediatric sarcoidosis. Currently, staging is based on chest radiograph findings, and the most commonly used system is the Scadding classification, which has been applied to both children and adults alike. Treatment may consist of oral or pulsed intravenous corticosteroids, but it should be implemented in union with a rheumatologist, as there are no randomized controlled studies in children. SUMMARY Sarcoidosis is rare in childhood. Diagnosis is complex and relies on multiple diagnostic modalities with both staging and therapy progressively mirroring the sarcoidosis, which affects adults. In the majority of patients, spontaneous resolution will occur and observation is justified above treatment. Nevertheless, in case treatment is needed corticosteroids remain the mainstay of the treatment in some pediatric patients. Relapses are not uncommon and a long-term follow-up is essential.
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9
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Lamers OAC, Smits BM, Leavis HL, de Bree GJ, Cunningham-Rundles C, Dalm VASH, Ho HE, Hurst JR, IJspeert H, Prevaes SMPJ, Robinson A, van Stigt AC, Terheggen-Lagro S, van de Ven AAJM, Warnatz K, van de Wijgert JHHM, van Montfrans J. Treatment Strategies for GLILD in Common Variable Immunodeficiency: A Systematic Review. Front Immunol 2021; 12:606099. [PMID: 33936030 PMCID: PMC8086379 DOI: 10.3389/fimmu.2021.606099] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/24/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Besides recurrent infections, a proportion of patients with Common Variable Immunodeficiency Disorders (CVID) may suffer from immune dysregulation such as granulomatous-lymphocytic interstitial lung disease (GLILD). The optimal treatment of this complication is currently unknown. Experienced-based expert opinions have been produced, but a systematic review of published treatment studies is lacking. Goals To summarize and synthesize the published literature on the efficacy of treatments for GLILD in CVID. Methods We performed a systematic review using the PRISMA guidelines. Papers describing treatment and outcomes in CVID patients with radiographic and/or histologic evidence of GLILD were included. Treatment regimens and outcomes of treatment were summarized. Results 6124 papers were identified and 42, reporting information about 233 patients in total, were included for review. These papers described case series or small, uncontrolled studies of monotherapy with glucocorticoids or other immunosuppressants, rituximab monotherapy or rituximab plus azathioprine, abatacept, or hematopoietic stem cell transplantation (HSCT). Treatment response rates varied widely. Cross-study comparisons were complicated because different treatment regimens, follow-up periods, and outcome measures were used. There was a trend towards more frequent GLILD relapses in patients treated with corticosteroid monotherapy when compared to rituximab-containing treatment regimens based on qualitative endpoints. HSCT is a promising alternative to pharmacological treatment of GLILD, because it has the potential to not only contain symptoms, but also to resolve the underlying pathology. However, mortality, especially among immunocompromised patients, is high. Conclusions We could not draw definitive conclusions regarding optimal pharmacological treatment for GLILD in CVID from the current literature since quantitative, well-controlled evidence was lacking. While HSCT might be considered a treatment option for GLILD in CVID, the risks related to the procedure are high. Our findings highlight the need for further research with uniform, objective and quantifiable endpoints. This should include international registries with standardized data collection including regular pulmonary function tests (with carbon monoxide-diffusion), uniform high-resolution chest CT radiographic scoring, and uniform treatment regimens, to facilitate comparison of treatment outcomes and ultimately randomized clinical trials.
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Affiliation(s)
- Olivia A C Lamers
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Bas M Smits
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, Netherlands.,Department of Immunology and Rheumatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Helen Louisa Leavis
- Department of Immunology and Rheumatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Godelieve J de Bree
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Charlotte Cunningham-Rundles
- Department of Medicine, Division of Clinical Immunology and Department of Pediatrics, Mount Sinai Hospital, New York, NY, United States
| | - Virgil A S H Dalm
- Department of Internal Medicine, Division of Clinical Immunology and Department of Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hsi-En Ho
- Department of Medicine, Division of Clinical Immunology and Department of Pediatrics, Mount Sinai Hospital, New York, NY, United States
| | - John R Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Hanna IJspeert
- Department of Internal Medicine, Division of Clinical Immunology and Department of Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sabine M P J Prevaes
- Wilhelmina Children's Hospital, Department of Pediatric Pulmonology, Utrecht, Netherlands
| | - Alex Robinson
- UCL Respiratory, University College London, London, United Kingdom
| | - Astrid C van Stigt
- Department of Internal Medicine, Division of Clinical Immunology and Department of Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Terheggen-Lagro
- Department of Pediatric Pulmonology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Annick A J M van de Ven
- Departments of Rheumatology and Clinical Immunology, Internal Medicine and Allergology, University Medical Center Groningen, Groningen, Netherlands
| | - Klaus Warnatz
- Department of Immunology, Universitätsklinikum Freiburg, Freiburg, Germany.,Department of Rheumatology and Clinical Immunology, Division of Immunodeficiency, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Janneke H H M van de Wijgert
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Joris van Montfrans
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, Netherlands
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Viallard JF, Lebail B, Begueret H, Fieschi C. [Common variable immunodeficiency disorders: Part 2. Updated clinical manifestations and therapeutic management]. Rev Med Interne 2021; 42:473-481. [PMID: 33516581 DOI: 10.1016/j.revmed.2020.12.015] [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: 07/03/2020] [Revised: 12/04/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
Common variable immunodeficiency disorders (CVID) are the most common symptomatic primary antibody deficiency in adults with an estimated prevalence of 1/25,000. The most frequent clinical manifestations are upper respiratory tract infections (including pneumonia, bronchitis, and sinusitis) predominantly with Streptococcus pneumoniae or H. influenzae. However, CVID are complicated in 20 to 30 % of cases of non-infectious manifestations which have been well characterized in recent years. Several complications can be observed including autoimmune, lymphoproliferative, granulomatous or cancerous manifestations involving one or more organs. These complications, mostly antibody-mediated cytopenias, are correlated with a decrease in the number of circulating switched memory B cells. Replacement therapy with polyvalent gammaglobulins has greatly improved the prognosis of these patients but it remains poor in the presence of digestive complications (especially in the case of chronic enteropathy and/or porto-sinusoidal vascular disease), pulmonary complications (bronchiectasis and/or granulomatous lymphocytic interstitial lung disease) and when progression to lymphoma. Much progress is still to be made, in particular on the therapeutic management of non-infectious complications which should benefit in the future from targeted treatments based on knowledge of genetics and immunology.
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Affiliation(s)
- J F Viallard
- Service de médecine interne et maladies infectieuses, hôpital Haut-Lévêque, CHU de Bordeaux, 5, avenue de Magellan, 33604 Pessac, France; Université de Bordeaux, Bordeaux, France.
| | - B Lebail
- Université de Bordeaux, Bordeaux, France; Service d'anatomopathologie, hôpital Pellegrin, place Amélie-Rabat-Léon, 33076 Bordeaux, France
| | - H Begueret
- Service d'anatomopathologie, CHU Bordeaux, hôpital Haut-Lévêque, 5, avenue de Magellan, 33604 Pessac, France
| | - C Fieschi
- Département d'immunologie, université de Paris, AP-HP, France; INSERM U1126, centre Hayem, hôpital Saint-Louis, Paris, France
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van Stigt AC, Dik WA, Kamphuis LSJ, Smits BM, van Montfrans JM, van Hagen PM, Dalm VASH, IJspeert H. What Works When Treating Granulomatous Disease in Genetically Undefined CVID? A Systematic Review. Front Immunol 2021; 11:606389. [PMID: 33391274 PMCID: PMC7773704 DOI: 10.3389/fimmu.2020.606389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
Background Granulomatous disease is reported in at least 8–20% of patients with common variable immunodeficiency (CVID). Granulomatous disease mainly affects the lungs, and is associated with significantly higher morbidity and mortality. In half of patients with granulomatous disease, extrapulmonary manifestations are found, affecting e.g. skin, liver, and lymph nodes. In literature various therapies have been reported, with varying effects on remission of granulomas and related clinical symptoms. However, consensus recommendations for optimal management of extrapulmonary granulomatous disease are lacking. Objective To present a literature overview of the efficacy of currently described therapies for extrapulmonary granulomatous disease in CVID (CVID+EGD), compared to known treatment regimens for pulmonary granulomatous disease in CVID (CVID+PGD). Methods The following databases were searched: Embase, Medline (Ovid), Web-of-Science Core Collection, Cochrane Central, and Google Scholar. Inclusion criteria were 1) CVID patients with granulomatous disease, 2) treatment for granulomatous disease reported, and 3) outcome of treatment reported. Patient characteristics, localization of granuloma, treatment, and association with remission of granulomatous disease were extracted from articles. Results We identified 64 articles presenting 95 CVID patients with granulomatous disease, wherein 117 different treatment courses were described. Steroid monotherapy was most frequently described in CVID+EGD (21 out of 53 treatment courses) and resulted in remission in 85.7% of cases. In CVID+PGD steroid monotherapy was described in 15 out of 64 treatment courses, and was associated with remission in 66.7% of cases. Infliximab was reported in CVID+EGD in six out of 53 treatment courses and was mostly used in granulomatous disease affecting the skin (four out of six cases). All patients (n = 9) treated with anti-TNF-α therapies (infliximab and etanercept) showed remission of extrapulmonary granulomatous disease. Rituximab with or without azathioprine was rarely used for CVID+EGD, but frequently used in CVID+PGD where it was associated with remission of granulomatous disease in 94.4% (17 of 18 treatment courses). Conclusion Although the number of CVID+EGD patients was limited, data indicate that steroid monotherapy often results in remission, and that anti-TNF-α treatment is effective for granulomatous disease affecting the skin. Also, rituximab with or without azathioprine was mainly described in CVID+PGD, and only in few cases of CVID+EGD.
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Affiliation(s)
- Astrid C van Stigt
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Lieke S J Kamphuis
- Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pulmonary Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Bas M Smits
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre (UMC), Utrecht, Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Centre (UMC), Utrecht, Netherlands
| | - P Martin van Hagen
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Virgil A S H Dalm
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine, Division of Clinical Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hanna IJspeert
- Laboratory Medical Immunology, Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands.,Academic Center for Rare Immunological Diseases (RIDC), Erasmus University Medical Center, Rotterdam, Netherlands
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12
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Maglione PJ. Chronic Lung Disease in Primary Antibody Deficiency: Diagnosis and Management. Immunol Allergy Clin North Am 2020; 40:437-459. [PMID: 32654691 DOI: 10.1016/j.iac.2020.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic lung disease is a complication of primary antibody deficiency (PAD) associated with significant morbidity and mortality. Manifestations of lung disease in PAD are numerous. Thoughtful application of diagnostic approaches is imperative to accurately identify the form of disease. Much of the treatment used is adapted from immunocompetent populations. Recent genomic and translational medicine advances have led to specific treatments. As chronic lung disease has continued to affect patients with PAD, we hope that continued advancements in our understanding of pulmonary pathology will ultimately lead to effective methods that alleviate impact on quality of life and survival.
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Affiliation(s)
- Paul J Maglione
- Pulmonary Center, Boston University School of Medicine, 72 East Concord Street, R304, Boston, MA 02118, USA.
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13
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Agarwal S, Cunningham-Rundles C. Gastrointestinal Manifestations and Complications of Primary Immunodeficiency Disorders. Immunol Allergy Clin North Am 2019; 39:81-94. [PMID: 30466774 DOI: 10.1016/j.iac.2018.08.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastrointestinal (GI) involvement can be the presenting disease manifestation in patients with primary immunodeficiency disorders (PIDs). Infections and noninfectious diarrhea are frequent manifestations; however, malignancy and inflammatory and autoimmune-related GI diseases are also described. GI symptoms and disease seen in association with PIDs can mimic other diseases but are often resistant to conventional treatments owing to alternate disease mechanisms. Despite the advances in treatments for these conditions, therapy for immunodeficiency-related GI disease is often empiric.
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Affiliation(s)
- Shradha Agarwal
- Division of Allergy and Clinical Immunology after the Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1089, New York, NY 10029, USA.
| | - Charlotte Cunningham-Rundles
- Division of Allergy and Clinical Immunology after the Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1089, New York, NY 10029, USA
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14
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Abstract
This article presents the most common gastrointestinal, hepatic, and pancreatic manifestations of the primary immunodeficiency diseases, including the appropriate laboratory testing, endoscopic evaluation, and recommendations for further management.
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Affiliation(s)
| | - Sarah Glover
- UF Health, PO Box 103643, Gainesville, FL 32610, USA.
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15
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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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16
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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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17
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Hasegawa M, Sakai F, Okabayashi A, Sato A, Yokohori N, Katsura H, Asano C, Kamata T, Koh E, Sekine Y, Hiroshima K, Ogura T, Takemura T. Intravenous Immunoglobulin Monotherapy for Granulomatous Lymphocytic Interstitial Lung Disease in Common Variable Immunodeficiency. Intern Med 2017; 56:2899-2902. [PMID: 28924106 PMCID: PMC5709635 DOI: 10.2169/internalmedicine.7757-16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Common variable immunodeficiency (CVID) is a heterogeneous subset of immunodeficiency disorders. Recurrent bacterial infection is the main feature of CVID, but various non-infectious complications can occur. A 42-year-old woman presented with cough and abnormal chest X-ray shadows. Laboratory tests showed remarkable hypogammaglobulinemia. Computed tomography revealed multiple consolidation and nodules on the bilateral lung fields, systemic lymphadenopathy, and splenomegaly. A surgical lung biopsy specimen provided the final diagnosis of lymphoproliferative disease in CVID, which was grouped under the term granulomatous lymphocytic interstitial lung disease. Interestingly, the lung lesions of this case resolved immediately after the initiation of intravenous immunoglobulin monotherapy.
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Affiliation(s)
- Mizue Hasegawa
- Division of Respiratory Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Japan
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Japan
| | - Asako Okabayashi
- Division of Respiratory Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Akitoshi Sato
- Division of Respiratory Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Naoko Yokohori
- Division of Respiratory Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Hideki Katsura
- Division of Respiratory Medicine, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Chihiro Asano
- Division of Hematology, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Toshiko Kamata
- Division of Thoracic Surgery, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Eitetsu Koh
- Division of Thoracic Surgery, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Yasuo Sekine
- Division of Thoracic Surgery, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Kenzo Hiroshima
- Division of Pathology, Tokyo Women's Medical University Yachiyo Medical Center, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Tamiko Takemura
- Department of Pathology, Japanese Red Cross Medical Center, Japan
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18
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Uzunhan Y, Jeny F, Kambouchner M, Didier M, Bouvry D, Nunes H, Bernaudin JF, Valeyre D. The Lung in Dysregulated States of Humoral Immunity. Respiration 2017; 94:389-404. [PMID: 28910817 DOI: 10.1159/000480297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In common variable immunodeficiency, lung manifestations are related to different mechanisms: recurrent pneumonias due to encapsulated bacteria responsible for diffuse bronchiectasis, diffuse infiltrative pneumonia with various patterns, and lymphomas, mostly B cell extranodal non-Hodgkin type. The diagnosis relies on significant serum Ig deficiency and the exclusion of any primary or secondary cause. Histopathology may be needed. Immunoglobulin (IgG) replacement is crucial to prevent infections and bronchiectasis. IgG4-related respiratory disease, often associated with extrapulmonary localizations, presents with solitary nodules or masses, diffuse interstitial lung diseases, bronchiolitis, lymphadenopathy, and pleural or pericardial involvement. Diagnosis relies on international criteria including serum IgG4 dosage and significantly increased IgG4/IgG plasma cells ratio in pathologically suggestive biopsy. Respiratory amyloidosis presents with tracheobronchial, nodular, and cystic or diffuse interstitial lung infiltration. Usually of AL (amyloid light chain) subtype, it may be localized or systemic, primary or secondary to a lymphoproliferative process. Very rare other diseases due to nonamyloid IgG deposits are described. Among the various lung manifestations of dysregulated states of humoral immunity, this article covers only those associated with the common variable immunodeficiency, IgG4-related disease, amyloidosis, and pulmonary light-chain deposition disease. Autoimmune connective-vascular tissue diseases or lymphoproliferative disorders are addressed in other chapters of this issue.
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19
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Prieto Elordui J, Arreba Gonzalez P, Ortiz de Zarate Sagastagoitia J, Deiss Pascual L, Blanco Sampascual S, Baranda Martín A, Calderón García A, Muñoz Villafranca C. Infliximab as treatment of severe enteropathy in a patient with common variable immunodeficiency and cytomegalovirus infection. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:163-164. [PMID: 28476306 DOI: 10.1016/j.gastrohep.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 02/26/2017] [Accepted: 03/02/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Janire Prieto Elordui
- Servicio de Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España.
| | - Paz Arreba Gonzalez
- Servicio de Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
| | | | - Laura Deiss Pascual
- Servicio de Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
| | | | - Amaia Baranda Martín
- Servicio de Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
| | - Angel Calderón García
- Servicio de Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
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20
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Predictors of granulomatous lymphocytic interstitial lung disease in common variable immunodeficiency. Ann Allergy Asthma Immunol 2017; 118:614-620. [PMID: 28254202 DOI: 10.1016/j.anai.2017.01.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/31/2016] [Accepted: 01/05/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND A subset of patients with common variable immunodeficiency (CVID) develop granulomatous lymphocytic interstitial lung disease (GLILD), which is associated with early mortality. OBJECTIVE To determine a set of clinical and/or laboratory parameters that correlate with GLILD. METHODS A retrospective, nested case-control (patients with CVID diagnosed with GLILD compared with patients with CVID without a diagnosis of GLILD) medical record review was undertaken at Mayo Clinic, Rochester, MN. Network and univariate analysis was used to identify clinical and laboratory parameters at the time of diagnosis that are associated with GLILD. RESULTS Twenty-six cases with radiologic evidence of GLILD were included in this study. Eighteen cases (69%) cases had coexistent splenomegaly with lower IgA levels (P = .04) compared with the controls. Patients with low IgA levels (<13 mg/dL) also had percentage expansion of low CD21 B cells (CD21low >5%) (P = .007). Univariate analysis revealed that splenomegaly (odds ratio [OR], 17.3; 95% confidence interval [CI], 3.9-74.5), history of immune thrombocytopenic purpura (ITP) or autoimmune hemolytic anemia (AIHA) (OR, 4.8; 95% CI, 1.1-20.2), low IgA level (OR, 3.6; 95% CI, 1.2-11.9), and percentage expansion of CD21low (OR, 5.8; 95% CI, 1.6-24.7) were independently associated with GLILD. Logistic regression analysis revealed that splenomegaly, history of ITP or AIHA, low IgA level, and percentage expansion of CD21low B cells are highly sensitive in predicting presence of GLILD (area under the receiver operating curve of 0.86). CONCLUSION Presence of splenomegaly, history of ITP or AIHA, low serum IgA level, and percentage expansion of CD21low B cells may be useful to identify a group of patients at high risk for development of GLILD.
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Humoral primary immunodeficiency diseases: clinical overview and chest high-resolution computed tomography (HRCT) features in the adult population. Clin Radiol 2017; 72:534-542. [PMID: 28433201 DOI: 10.1016/j.crad.2017.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/10/2017] [Accepted: 03/21/2017] [Indexed: 12/27/2022]
Abstract
Humoral primary immunodeficiency diseases (hPIDs) are a heterogeneous group of hereditary disorders resulting in abnormal susceptibility to infections of the sinopulmonary tract. Some of these conditions (e.g., common variable immunodeficiency disorders [CVID]) imply a number of non-infectious thoracic complications such as non-infectious airway disorders, diffuse lung parenchymal diseases, and neoplasms. Chest high-resolution computed tomography (HRCT) is a key imaging tool to characterise and quantify the extent of underlying thoracic involvement, as well as to direct and monitor treatment. The aims of this review are to provide a brief clinical overview of hPIDs and describe the related chest HRCT imaging features in the adult population, with a special focus on CVID and its complications.
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22
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Enhanced formation of giant cells in common variable immunodeficiency: Relation to granulomatous disease. Clin Immunol 2017; 175:1-9. [DOI: 10.1016/j.clim.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 10/17/2016] [Accepted: 11/11/2016] [Indexed: 01/08/2023]
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23
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Schussler E, Beasley MB, Maglione PJ. Lung Disease in Primary Antibody Deficiencies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2016; 4:1039-1052. [PMID: 27836055 PMCID: PMC5129846 DOI: 10.1016/j.jaip.2016.08.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/03/2016] [Accepted: 08/22/2016] [Indexed: 01/08/2023]
Abstract
Primary antibody deficiencies (PADs) are the most common form of primary immunodeficiency and predispose to severe and recurrent pulmonary infections, which can result in chronic lung disease including bronchiectasis. Chronic lung disease is among the most common complications of PAD and a significant source of morbidity and mortality for these patients. However, the development of lung disease in PAD may not be solely the result of recurrent bacterial infection or a consequence of bronchiectasis. Recent characterization of monogenic immune dysregulation disorders and more extensive study of common variable immunodeficiency have demonstrated that interstitial lung disease (ILD) in PAD can result from generalized immune dysregulation and frequently occurs in the absence of pneumonia history or bronchiectasis. This distinction between bronchiectasis and ILD has important consequences in the evaluation and management of lung disease in PAD. For example, treatment of ILD in PAD typically uses immunomodulatory approaches in addition to immunoglobulin replacement and antibiotic prophylaxis, which are the stalwarts of bronchiectasis management in these patients. Although all antibody-deficient patients are at risk of developing bronchiectasis, ILD occurs in some forms of PAD much more commonly than in others, suggesting that distinct but poorly understood immunological factors underlie the development of this complication. Importantly, ILD can have earlier onset and may worsen survival more than bronchiectasis. Further efforts to understand the pathogenesis of lung disease in PAD will provide vital information for the most effective methods of diagnosis, surveillance, and treatment of these patients.
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Affiliation(s)
- Edith Schussler
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mary B Beasley
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paul J Maglione
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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Tashtoush B, Memarpour R, Ramirez J, Bejarano P, Mehta J. Granulomatous-lymphocytic interstitial lung disease as the first manifestation of common variable immunodeficiency. CLINICAL RESPIRATORY JOURNAL 2016; 12:337-343. [PMID: 27243233 DOI: 10.1111/crj.12511] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/18/2016] [Accepted: 05/29/2016] [Indexed: 12/15/2022]
Abstract
Common variable immunodeficiency (CVID) is one of the most common primary immunodeficiencies, which is characterized by reduced serum immunoglobulin levels and B-lymphocyte dysfunction. There are many clinical manifestations of this disease, the most common of which are recurrent respiratory tract infections. Among the most recently recognized autoimmune manifestation of CVID is a disease described as granulomatous-lymphocytic interstitial lung disease (GLILD), where CVID coexists with a small airway lymphoproliferative disorder, mimicking follicular bronchiolitis, or lymphocytic interstitial pneumonitis (LIP) on histology specimens. We herein describe the clinical and radiological features of GLILD in a 55-year-old woman where the diagnosis of CVID was actively pursued and eventually confirmed after her lung biopsy showed characteristic features of GLILD. The patient had dramatic response to treatment with IVIG and corticosteroids for 3 months followed by Mycophenolate mofetil for maintenance therapy.
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Affiliation(s)
- Basheer Tashtoush
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Roya Memarpour
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Jose Ramirez
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Pablo Bejarano
- Department of Pathology, Cleveland Clinic Florida, Weston, Florida
| | - Jinesh Mehta
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, Florida
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25
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Perovic D, Perovic V, Pravica V, Bonaci-Nikolic B, Mijanovic R, Bunjevacki V. Evaluation of cytokine genetic polymorphisms in adult patients with common variable immunodeficiency: A single-center study. Immunol Lett 2016; 176:97-104. [PMID: 27288995 DOI: 10.1016/j.imlet.2016.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/08/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
Common variable immunodeficiency (CVID) is a heterogeneous disease characterized by impaired B-cell differentiation and maturation accompanied with the defective antibody production. Several investigators addressed the possibility that disturbed cytokine production of TNF, IL-6, IFN-γ and IL-10, among a variety of others, may be implicated in CVID. The aim of this study was to test the hypothesis that genetic polymorphisms involving TNF (-308G/A), IFNG (+874 T/A), IL10 (-1082G/A, -819T/C and -592A/C), and IL6 (-174G/C) cytokine genes might contribute to susceptibility to CVID. Thirty five patients with CVID and 250 healthy controls were genotyped for indicated single nucleotide polymorphisms (SNP) in TNF, IL6, IFNG and IL10 using Taqman-based assays. CVID patients had significantly higher frequency of TNF A allele and AA genotype than in healthy subjects (p=0.006; OR=2.27; 95%CI=1.24-4.17 and p=0.038, OR=15.64; 95%CI=1.38-177.20, respectively). In addition, the frequency of GG genotype was significantly higher in healthy controls than in patient group (p=0.019, OR=0.43, 95%CI=0.21-0.89). Genetic analysis of IL6 SNP showed that allele G confers increased risk for CVID (p=0.037, OR=1.78, 95% CI=1.03-3.08) while IFNG allele T was associated with splenomegaly in CVID (p=0.032; OR=2.86; 95% CI=1.08-7.56). We observed no association between genotypes, alleles and haplotypes of IL-10 gene and CVID or its clinical complications. In conclusion, our results indicated association between CVID and cytokine gene polymorphisms -308G/A TNF and -174G/C IL6. In addition, we demonstrated that splenomegaly, one of the most common complications in this disease, is associated with +874T/A IFNG polymorphism. These findings add further support to the notion that cytokines may play significant role in pathogenesis of this primary antibody deficiency. However, further investigation that would involve a larger study group of CVID patients is warranted to confirm our findings.
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Affiliation(s)
- Dijana Perovic
- Institute of Human Genetics, School of Medicine University of Belgrade, Visegradska 26, 11000 Belgrade, Serbia.
| | - Vladimir Perovic
- Institute of Microbiology and Immunology, School of Medicine University of Belgrade, Pasterova 2, 11000 Belgrade, Serbia
| | - Vera Pravica
- Institute of Microbiology and Immunology, School of Medicine University of Belgrade, Pasterova 2, 11000 Belgrade, Serbia
| | - Branka Bonaci-Nikolic
- Department of Internal Medicine, School of Medicine University of Belgrade, Dr Subotica 8, 11000 Belgrade, Serbia; Clinic of Allergy and Immunology, Clinical Center of Serbia, Koste Todorovica 2, 11000 Belgrade, Serbia
| | - Radovan Mijanovic
- Clinic of Allergy and Immunology, Clinical Center of Serbia, Koste Todorovica 2, 11000 Belgrade, Serbia
| | - Vera Bunjevacki
- Institute of Human Genetics, School of Medicine University of Belgrade, Visegradska 26, 11000 Belgrade, Serbia
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Lin W, Beardsley RM, Skalet AH, Wilson DJ, Rosenbaum JT, Lin P. Bilateral Idiopathic Solitary Granuloma of the Uveal Tract: Diagnosis and Treatment. ACTA ACUST UNITED AC 2016; 4. [PMID: 26779545 DOI: 10.4172/2324-8599.1000166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We present a case of sequential bilateral idiopathic solitary granuloma of the uveal tract in a 51 year-old woman, who underwent enucleation in one eye due to complications of this condition, but was then successfully treated in the contralateral eye with anti-tumor necrosis-alpha therapy followed shortly by intraocular steroids and a steroid-releasing implant. Her visual acuity at its worst was 20/200 due to vitreous haze and cystoid macular edema, but then stabilized after successful treatment with a final visual acuity of 20/25 in her only seeing eye at 1 year follow-up. This represents the first known biopsy-proven case of bilateral idiopathic solitary granuloma, which additionally, has responded favorably to treatment.
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Affiliation(s)
| | | | | | | | - James T Rosenbaum
- Devers Eye Institute-Legacy Health System, Portland, OR, USA; Casey Eye Institute-OHSU, Portland, OR, USA
| | - Phoebe Lin
- Casey Eye Institute-OHSU, Portland, OR, USA
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27
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Atteintes respiratoires au cours du déficit immunitaire commun variable de l’adulte. Rev Mal Respir 2015; 32:991-1001. [DOI: 10.1016/j.rmr.2015.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 03/31/2015] [Indexed: 12/11/2022]
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Bonilla FA, Barlan I, Chapel H, Costa-Carvalho BT, Cunningham-Rundles C, de la Morena MT, Espinosa-Rosales FJ, Hammarström L, Nonoyama S, Quinti I, Routes JM, Tang MLK, Warnatz K. International Consensus Document (ICON): Common Variable Immunodeficiency Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 4:38-59. [PMID: 26563668 DOI: 10.1016/j.jaip.2015.07.025] [Citation(s) in RCA: 515] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 06/24/2015] [Accepted: 07/24/2015] [Indexed: 02/06/2023]
Affiliation(s)
| | - Isil Barlan
- Marmara University Pendik Education and Research Hospital, Istanbul, Turkey
| | - Helen Chapel
- John Radcliffe Hospital and University of Oxford, Oxford, United Kingdom
| | | | | | - M Teresa de la Morena
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - John M Routes
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis
| | - Mimi L K Tang
- Royal Children's Hospital and Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
| | - Klaus Warnatz
- University Medical Center Freiburg, Freiburg, Germany
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29
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Baughman RP, Grutters JC. New treatment strategies for pulmonary sarcoidosis: antimetabolites, biological drugs, and other treatment approaches. THE LANCET RESPIRATORY MEDICINE 2015. [DOI: 10.1016/s2213-2600(15)00199-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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30
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Abbott JK, Gelfand EW. Common Variable Immunodeficiency: Diagnosis, Management, and Treatment. Immunol Allergy Clin North Am 2015; 35:637-58. [PMID: 26454311 DOI: 10.1016/j.iac.2015.07.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Common variable immunodeficiency (CVID) refers to a grouping of antibody deficiencies that lack a more specific genetic or phenotypic classification. It is the immunodeficiency classification with the greatest number of constituents, likely because of the numerous ways in which antibody production can be impaired and the frequency in which antibody production becomes impaired in human beings. CVID comprises a heterogeneous group of rare diseases. Consequently, CVID presents a significant challenge for researchers and clinicians. Despite these difficulties, both our understanding of and ability to manage this grouping of complex immune diseases has advanced significantly over the past 60 years.
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Affiliation(s)
- Jordan K Abbott
- Division of Allergy and Immunology, Department of Pediatrics, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - Erwin W Gelfand
- Division of Allergy and Immunology, Department of Pediatrics, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
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31
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Yang S, Vary JC. JAAD Grand Rounds quiz: Multiple papules on the hands of a woman with common variable immunodeficiency. J Am Acad Dermatol 2015; 73:350-2. [PMID: 26183992 DOI: 10.1016/j.jaad.2012.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/29/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Shelley Yang
- Worcester, Massachusetts, and Seattle, Washington
| | - Jay C Vary
- Worcester, Massachusetts, and Seattle, Washington
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32
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Verma N, Grimbacher B, Hurst JR. Lung disease in primary antibody deficiency. THE LANCET RESPIRATORY MEDICINE 2015; 3:651-60. [PMID: 26188881 DOI: 10.1016/s2213-2600(15)00202-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 05/11/2015] [Accepted: 05/11/2015] [Indexed: 12/25/2022]
Abstract
This Review summarises current knowledge on the pulmonary manifestations of primary antibody deficiency (PAD) syndromes in adults. We describe the major PAD syndromes, with a particular focus on common variable immunodeficiency (CVID). Respiratory infection is a common presenting feature of PAD syndromes. Respiratory complications are frequent and responsible for much of the morbidity and mortality associated with these syndromes. Respiratory complications include acute infections, the sequelae of infection (eg, bronchiectasis), non-infectious immune-mediated manifestations (notably the development of granulomatous-lymphocytic interstitial lung disease in CVID), and an increased risk of lymphoma. Although minor abnormalities are detectable in the lungs of most patients with CVID by CT scanning, not all patients develop lung complications. Mechanisms associated with the maintenance of lung health versus lung disease, and the development of bronchiectasis versus immune-mediated complications, are now being dissected. We review the investigation, treatment, and management strategies for PAD syndromes, and include key research questions relating to both infectious and non-infectious complications of PAD in the lung.
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Affiliation(s)
- Nisha Verma
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK
| | - Bodo Grimbacher
- Department of Immunology, Royal Free London NHS Foundation Trust, London, UK; Centre for Chronic Immunodeficiency, Medical Centre, University Hospital Freiburg, Freiburg, Germany
| | - John R Hurst
- UCL Respiratory, University College London, London, UK.
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33
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Plana Pla A, Bassas-Vila J, Roure S, Ferrándiz C. Necrotizing and sarcoidal granulomas in the skin and synovial membrane, associated with common variable immunodeficiency. Clin Exp Dermatol 2014; 40:379-82. [PMID: 25557739 DOI: 10.1111/ced.12543] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2014] [Indexed: 11/28/2022]
Abstract
Common variable immunodeficiency (CVID) is a primary immunodeficiency characterized by hypogammaglobulinaemia, T-cell abnormalities and recurrent bacterial infections. Patients with CVID can present granulomatous lesions on both the skin and other organs. When these lesions are the first sign of the disease, the diagnosis can be very challenging. We report the case of a patient with undiagnosed CVID, who presented with necrotizing and sarcoidal granulomas on the skin and synovial membrane as the first appearance of immunodeficiency.
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Affiliation(s)
- A Plana Pla
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - J Bassas-Vila
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - S Roure
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - C Ferrándiz
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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34
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Franxman TJ, Howe LE, Baker JR. Infliximab for Treatment of Granulomatous Disease in Patients with Common Variable Immunodeficiency. J Clin Immunol 2014; 34:820-7. [DOI: 10.1007/s10875-014-0079-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 07/09/2014] [Indexed: 12/18/2022]
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35
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Varzaneh FN, Keller B, Unger S, Aghamohammadi A, Warnatz K, Rezaei N. Cytokines in common variable immunodeficiency as signs of immune dysregulation and potential therapeutic targets - a review of the current knowledge. J Clin Immunol 2014; 34:524-43. [PMID: 24827633 DOI: 10.1007/s10875-014-0053-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/05/2014] [Indexed: 01/19/2023]
Abstract
Common variable immunodeficiency (CVID) is characterized by low levels of circulating immunoglobulins and compromised specific antibody response leading to frequent infections. Cytokines play an important role in the orchestration of the antibody response. Several previous studies have attempted to identify distinct cytokines responsible for the inflammatory changes and different manifestations of CVID, but there are conflicting results regarding the cytokine profiles in CVID patients. In light of this, an extensive review regarding the level of various cytokines and their potential therapeutic role in CVID patients was performed. This review delineates the contribution of interleukin (IL)-1, IL-2, IL-4, IL-5, IL-6, IL-7, IL-10, IL-12, IL-21, interferons, tumor necrosis factor (TNF)-α, IL-17, APRIL (a proliferation inducing ligand) and BAFF (B cell activating factor) in CVID disease and outline their potential therapeutic implications in these patients.
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Affiliation(s)
- Farnaz Najmi Varzaneh
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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36
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Common variable immunodeficiency-associated granulomatous and interstitial lung disease. Curr Opin Pulm Med 2014; 19:503-9. [PMID: 23880700 DOI: 10.1097/mcp.0b013e3283642c47] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Common variable immunodeficiency (CVID) is the most common primary immunodeficiency characterized by a deficiency of immunoglobulins. Approximately 30% of the patients develop autoimmune and granulomatous disease. Similar to sarcoidosis, granulomatous disease in CVID can potentially affect all organs, but the lung is the most common. Interstitial lung disease (ILD) manifests in 5-15% of CVID patients, and is present already at the initial diagnosis in the majority of patients. The number of published studies addressing ILD in CVID is limited. However, recently, several studies added substantial knowledge to the field and are discussed within this review in the context of the literature. RECENT FINDINGS Histologically, ILD in CVID presents within the known patterns of sarcoid-like granuloma, organizing pneumonia, lymphocytic interstitial pneumonitis and nonspecific interstitial pneumonia. Often, these patterns are concomitantly found in the same patients. Three new articles were published which analyzed high-resolution computed tomography findings and response to treatment. SUMMARY In a considerable number of patients, ILD is stable over years and patients may not need any immunosuppressive treatment. Prednisone treatment is often used as the first-line treatment and studies suggest response to treatment in 50-66% of cases. In progressive disease with lung function impairment, combined immunosuppressive treatment is recommended.
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Pacheco C, Morais A, Rolo R, Ferreira L, Nabiço R, Cunha J. Chronic granulomatous disease associated with common variable immunodeficiency - 2 clinical cases. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:219-22. [PMID: 24462347 DOI: 10.1016/j.rppneu.2013.09.005] [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: 05/13/2013] [Revised: 08/25/2013] [Accepted: 09/09/2013] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Chronic granulomatous disease associated with common variable immunodeficiency (GD-CVID), although well documented, is rare. Granulomatous lesions can affect several organs and are histologically indistinguishable from sarcoidosis. CLINICAL CASES Case 1: A 39-year-old male patient with CVID, asymptomatic although with thrombocytopenia and mediastinal-hilar adenopathies. GD-CVID was diagnosed by bone marrow biopsy. Progressive clinical and radiological improvement was obtained with corticotherapy. Case 2: A 38-year-old male patient with CVID, suffered from asthenia, anorexia, myalgia, lower limbs edemas, and dry cough. He had mediastinal and bilateral hilar adenopathies within which biopsy revealed non-necrotizing granulomatous infiltrate. A spontaneous resolution was detected after 9 months of evolution. CONCLUSION GD-CVID is rare and can mimetize other pathologies, namely, sarcoidosis; it should therefore be publicized and discussed so that it becomes a general clinical knowledge.
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Affiliation(s)
- C Pacheco
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal.
| | - A Morais
- Serviço de Pneumologia, Centro Hospitalar de São João; Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - R Rolo
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal
| | - L Ferreira
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal
| | - R Nabiço
- Serviço de Medicina Interna, Hospital de Braga, Braga, Portugal
| | - J Cunha
- Serviço de Pneumologia, Hospital de Braga, Braga, Portugal
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38
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Detková D, Español T. An update on treatment strategies for common variable immunodeficiency. Expert Rev Clin Immunol 2014; 5:381-90. [DOI: 10.1586/eci.09.22] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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39
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Bergbreiter A, Salzer U. Common variable immunodeficiency: a multifaceted and puzzling disorder. Expert Rev Clin Immunol 2014; 5:167-80. [DOI: 10.1586/1744666x.5.2.167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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40
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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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41
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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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42
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Pavic M, Pasquet F, Fieschi C, Malphettes M, Sève P. Granulomatoses au cours des déficits immunitaires primitifs de l’adulte. Rev Med Interne 2013; 34:154-8. [DOI: 10.1016/j.revmed.2012.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Accepted: 02/14/2012] [Indexed: 12/13/2022]
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43
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Orbital follicular hyperplasia in common variable immune deficiency syndrome. Ophthalmic Plast Reconstr Surg 2013; 29:e160-2. [PMID: 23446300 DOI: 10.1097/iop.0b013e3182873c61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Common variable immune deficiency (CVID) is characterized by reduced serum immune globulins and impaired or absent antibody responses. Patients become more susceptible to infections and to lymphoproliferation and granulomatous inflammation. Ophthalmic manifestations of CVID are rare. The authors describe a case of orbital follicular hyperplasia in a 15-year-old girl with CVID syndrome causing proptosis and exposure keratopathy.
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44
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45
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Granulomatous Disease in CVID: Retrospective Analysis of Clinical Characteristics and Treatment Efficacy in a Cohort of 59 Patients. J Clin Immunol 2012; 33:84-95. [DOI: 10.1007/s10875-012-9778-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022]
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46
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Chase NM, Verbsky JW, Hintermeyer MK, Waukau JK, Tomita-Mitchell A, Casper JT, Singh S, Shahir KS, Tisol WB, Nugent ML, Rao RN, Mackinnon AC, Goodman LR, Simpson PM, Routes JM. Use of combination chemotherapy for treatment of granulomatous and lymphocytic interstitial lung disease (GLILD) in patients with common variable immunodeficiency (CVID). J Clin Immunol 2012; 33:30-9. [PMID: 22930256 DOI: 10.1007/s10875-012-9755-3] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 07/26/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE A subset of patients with common variable immunodeficiency (CVID) develops granulomatous and lymphocytic interstitial lung disease (GLILD), a restrictive lung disease associated with early mortality. The optimal therapy for GLILD is unknown. This study was undertaken to see if rituximab and azathioprine (combination chemotherapy) would improve pulmonary function and/or radiographic abnormalities in patients with CVID and GLILD. METHODS A retrospective chart review of patients with CVID and GLILD who were treated with combination chemotherapy was performed. Complete pulmonary function tests (PFTs) and high-resolution computed tomography (HRCT) scans of the chest were done prior to therapy and >6 months later. HRCT scans of the chest were blinded, randomized, and scored independently (in pairs) by two radiologists. The differences between pre- and post-treatment HRCT scores and PFT parameters were analyzed. RESULTS Seven patients with CVID and GLILD met inclusion criteria. Post-treatment increases were noted in both FEV1 (p=0.034) and FVC (p=0.043). HRCT scans of the chest demonstrated improvement in total score (p=0.018), pulmonary consolidations (p=0.041), ground-glass opacities (p=0.020) nodular opacities (p=0.024), and both the presence and extent of bronchial wall thickening (p=0.014, 0.026 respectively). No significant chemotherapy-related complications occurred. CONCLUSIONS Combination chemotherapy improved pulmonary function and decreased radiographic abnormalities in patients with CVID and GLILD.
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Affiliation(s)
- Nicole M Chase
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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47
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Abstract
The 2 most commonly encountered primary immunodeficiency syndromes in adult practice are antibody deficiency disorders and hereditary angioedema.Immunologic therapy for these disorders has significantly improved patient management. Therapy with immunoglobulin leads to improvement in overall quality of life. With increasing survival rates and decreasing levels of life-threatening infections in patients with primary antibody deficiencies, disease complications are more commonly encountered. Treatment of these complications with monoclonal antibody therapy seems promising and is likely to increase in the future. More recently,several additional agents have become available, including novel drugs targeted at different elements of the disease process.
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MESH Headings
- Adrenergic beta-Antagonists/therapeutic use
- Anemia, Hemolytic, Autoimmune/therapy
- Angioedemas, Hereditary/therapy
- Bradykinin/analogs & derivatives
- Bradykinin/therapeutic use
- Complement C1 Inactivator Proteins/therapeutic use
- Complement C1 Inhibitor Protein/therapeutic use
- Cost-Benefit Analysis
- Delayed Diagnosis
- Disease Transmission, Infectious
- Filtration/methods
- Granuloma/therapy
- Home Infusion Therapy
- Humans
- Hypersensitivity, Delayed
- Hypersensitivity, Immediate
- Immunization, Passive
- Immunoglobulin G/blood
- Immunoglobulins/therapeutic use
- Immunologic Deficiency Syndromes/therapy
- Infections/epidemiology
- Kallikreins/antagonists & inhibitors
- Nanotechnology
- Peptides/therapeutic use
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Quality Control
- Quality of Life
- Recombinant Proteins/therapeutic use
- Self Administration
- Technology, Pharmaceutical
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Affiliation(s)
- Philip Wood
- Department of Clinical Immunology, St James's University Hospital, Beckett Wing, Leeds, Yorkshire LS9 7TF, UK.
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48
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Marashi SM, Raeiszadeh M, Enright V, Tahami F, Workman S, Chee R, Webster AD, Milne RSB, Emery VC. Influence of cytomegalovirus infection on immune cell phenotypes in patients with common variable immunodeficiency. J Allergy Clin Immunol 2012; 129:1349-1356.e3. [PMID: 22444511 DOI: 10.1016/j.jaci.2012.02.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 02/14/2012] [Accepted: 02/14/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND A subset of patients with common variable immunodeficiency (CVID) have debilitating inflammatory complications strongly associated with cytomegalovirus (CMV) infection and a hyperproliferative CMV-specific T-cell response. OBJECTIVES We studied the T-cell response to CMV and the global effect of this virus on immune effector cell populations in patients with CVID. METHODS Antibody staining, peptide stimulation, and proliferation assays were used to profile CMV-specific T-cell function. RESULTS CMV infection drives the CD4/CD8 ratio inversion that is characteristic of CVID. The late effector CD8(+) T-cell subset is expanded in CMV-infected patients with CVID. This expansion is largely attributable to CMV-specific cells and correlates with inflammatory disease; within the CMV-specific population, the frequency of late effector cells correlates inversely with the frequency of cells expressing programmed death 1. Supernatants from proliferating CMV-specific CD8(+) cells from patients with inflammatory disease can confer proliferative potential on cells from patients with noninflammatory CVID and healthy subjects. Blocking experiments showed that this proliferation is mediated in part by IFN-γ and TNF-α. CONCLUSIONS These data strengthen the association of CMV with inflammatory pathology in patients with CVID, explain some of the well-known T-cell abnormalities associated with this condition, and provide a plausible mechanism for the documented therapeutic activity of anti-TNF-α and antiviral chemotherapy in managing CVID-associated inflammatory disease.
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Affiliation(s)
- Sayed Mahdi Marashi
- Medical Research Council Centre for Medical Molecular Virology, Division of Infection and Immunity, Royal Free Campus, University College London Medical School, London, United Kingdom
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49
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Abstract
B-cell defects constitute the majority of primary immunodeficiencies. Although a heterogeneous group of diseases, all are characterized by the reduction in or absence of immunoglobulins and/or specific antimicrobial antibodies. Substitution of immunoglobulin G (IgG) is therefore the mainstay of treatment. While from the late 1970s, the intravenous route of administration was the most common, in the past decades, subcutaneous immunoglobulin replacement therapy has become more popular among patients and physicians. Independently of the optimal route of administration, dosage and IgG trough level remain subjects of debate. Higher IgG trough levels seem to improve the protection against recurrent infections and thus better prevent complications such as bronchiectasis. Some patients, however, achieve protection with IgG trough levels on the lower IgG limit of healthy persons. Therefore, an individual protective IgG trough level needs to be defined for each patient. Use of additional prophylactic antibiotics and immunosuppressive drugs differs amongst specialized immunodeficiency centres and clearly requires future investigation in multi-centre trials. Haematopoietic stem cell transplantation (HSCT) is to date indicated as curative treatment in certain patients with B-cell defects associated with cell deficiencies, for example in two class-switch recombination defects and in selected severe forms of common variable immunodeficiency.
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Affiliation(s)
- Miriam Hoernes
- Division of Immunology, Haematology and BMT, Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, University Children's Hospital Zurich, Zürich, Switzerland
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50
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Granulomatous inflammation in cartilage-hair hypoplasia: Risks and benefits of anti–TNF-α mAbs. J Allergy Clin Immunol 2011; 128:847-53. [DOI: 10.1016/j.jaci.2011.05.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 05/17/2011] [Accepted: 05/17/2011] [Indexed: 11/19/2022]
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