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Fernandes RA, Perez-Andres M, Blanco E, Jara-Acevedo M, Criado I, Almeida J, Botafogo V, Coutinho I, Paiva A, van Dongen JJM, Orfao A, Faria E. Complete Multilineage CD4 Expression Defect Associated With Warts Due to an Inherited Homozygous CD4 Gene Mutation. Front Immunol 2019; 10:2502. [PMID: 31781092 PMCID: PMC6856949 DOI: 10.3389/fimmu.2019.02502] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/07/2019] [Indexed: 12/12/2022] Open
Abstract
Idiopathic T-CD4 lymphocytopenia (ICL) is a rare and heterogeneous syndrome characterized by opportunistic infections due to reduced CD4 T-lymphocytes (<300 cells/μl or <20% T-cells) in the absence of HIV infection and other primary causes of lymphopenia. Molecular testing of ICL has revealed defects in genes not specific to CD4 T-cells, with pleiotropic effects on other cell types. Here we report for the first time an absolute CD4 lymphocytopenia (<0.01 CD4+ T-cells/μl) due to an autosomal recessive CD4 gene mutation that completely abrogates CD4 protein expression on the surface membrane of T-cells, monocytes, and dendritic cells. A 45-year-old female born to consanguineous parents consulted because of exuberant, relapsing, and treatment-refractory warts on her hands and feet since the age of 10 years, in the absence of other recurrent infections or symptoms. Serological studies were negative for severe infections, including HIV 1/2, HTLV-1, and syphilis, but positive for CMV and EBV. Blood analysis showed the absence of CD4+ T-cells (<0.01%) with repeatedly increased counts of B-cells, naïve CD8+ T-lymphocytes, and particularly, CD4/CD8 double-negative (DN) TCRαβ+ TCRγδ- T-cells (30% of T-cells; 400 cells/μl). Flow cytometric staining of CD4 using monoclonal antibodies directed against five different epitopes, located in two different domains of the protein, confirmed no cell surface membrane or intracytoplasmic expression of CD4 on T-cells, monocytes, and dendritic cells but normal soluble CD4 plasma levels. DN T-cells showed a phenotypic and functional profile similar to normal CD4+ T-cells as regards expression of maturation markers, T-helper and T-regulatory chemokine receptors, TCRvβ repertoire, and in vitro cytokine production against polyclonal and antigen-specific stimuli. Sequencing of the CD4 gene revealed a homozygous (splicing) mutation affecting the last bp on intron 7-8, leading to deletion of the juxtamembrane and intracellular domains of the protein and complete abrogation of CD4 expression on the cell membrane. These findings support previous studies in CD4 KO mice suggesting that surrogate DN helper and regulatory T-cells capable of supporting antigen-specific immune responses are produced in the absence of CD4 signaling and point out the need for better understanding the role of CD4 on thymic selection and the immune response.
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Affiliation(s)
- Rosa Anita Fernandes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Martin Perez-Andres
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Elena Blanco
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Maria Jara-Acevedo
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain.,Sequencing DNA Service, NUCLEUS, University of Salamanca, Salamanca, Spain
| | - Ignacio Criado
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Julia Almeida
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Vitor Botafogo
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Ines Coutinho
- Dermatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Artur Paiva
- Flow Cytometry Unit-Clinical Pathology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Ciências Biomédicas Laboratoriais, ESTESC-Coimbra Health School, Instituto Politécnico de Coimbra, Coimbra, Portugal.,Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, Coimbra, Portugal
| | - Jacques J M van Dongen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Alberto Orfao
- Department of Medicine, Cancer Research Centre (IBMCC, USAL-CSIC), Cytometry Service (NUCLEUS), University of Salamanca (USAL), Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Biomedical Research Networking Centre on Cancer-CIBER-CIBERONC (CB16/12/00400), Institute of Health Carlos III, Madrid, Spain
| | - Emilia Faria
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Ahmad DS, Esmadi M, Steinmann WC. Idiopathic CD4 Lymphocytopenia: Spectrum of opportunistic infections, malignancies, and autoimmune diseases. Avicenna J Med 2013; 3:37-47. [PMID: 23930241 PMCID: PMC3734630 DOI: 10.4103/2231-0770.114121] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia (ICL) was first defined in 1992 by the US Centers for Disease Control and Prevention (CDC) as the repeated presence of a CD4+ T lymphocyte count of fewer than 300 cells per cubic millimeter or of less than 20% of total T cells with no evidence of human immunodeficiency virus (HIV) infection and no condition that might cause depressed CD4 counts. Most of our knowledge about ICL comes from scattered case reports. The aim of this study was to collect comprehensive data from the previously published cases to understand the characteristics of this rare condition. We searched the PubMed database and Science Direct for case reports since 1989 for Idiopathic CD4 lymphocytopenia cases. We found 258 cases diagnosed with ICL in 143 published papers. We collected data about age, sex, pathogens, site of infections, CD4 count, CD8 count, CD4:CD8 ratio, presence of HIV risk factors, malignancies, autoimmune diseases and whether the patients survived or died. The mean age at diagnosis of first opportunistic infection (or ICL if no opportunistic infection reported) was 40.7 ± 19.2 years (standard deviation), with a range of 1 to 85. One-sixty (62%) patients were males, 91 (35.2%) were females, and 7 (2.7%) patients were not identified whether males or females. Risk factors for HIV were documented in 36 (13.9%) patients. The mean initial CD4 count was 142.6 ± 103.9/mm3 (standard deviation). The mean initial CD8 count was 295 ± 273.6/mm3 (standard deviation). The mean initial CD4:CD8 ratio was 0.6 ± 0.7 (standard deviation). The mean lowest CD4 count was 115.4 ± 87.1/mm3 (standard deviation). The majority of patients 226 (87.6%) had at least one infection. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Malignancies were reported in 47 (18.1%) patients. Autoimmune diseases were reported in 37 (14.2%) patients.
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Affiliation(s)
- Dina S Ahmad
- Department of Internal Medicine, University of Missouri School of Medicine, Columbia, MO, USA
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