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Suri V, Sinha AK, Priyaranjan M, Patel V. Cerebellar progressive multifocal leucoencephalopathy identified by the shrimp sign. BMJ Case Rep 2024; 17:e258289. [PMID: 38182166 PMCID: PMC10773296 DOI: 10.1136/bcr-2023-258289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
Progressive multifocal leucoencephalopathy (PML) is a demyelinating disease caused by the John Cunningham (JC) virus, which may get reactivated under certain immunosuppressive states such as AIDS, immunomodulatory therapy and haematological malignancies. PML has been reported rarely even in immunocompetent individuals where no immunodeficiency was present. PML characteristically involves periventricular and juxtacortical white matter. Isolated cerebellar or brainstem PML may be seen rarely. We present a case of a man in his 70s who presented with rapidly progressive cerebellar ataxia, ptosis and bipyramidal signs. Investigations excluded a direct viral cerebellar infection, acute disseminated encephalomyelitis, paraneoplastic cerebellar degeneration or any structural cerebellar lesion. MRI PET study revealed the classical shrimp sign which raised the possibility of cerebellar PML, and the same was confirmed by a positive JC virus PCR in the cerebrospinal fluid. Our patient had no known immune-compromising state, but further workup revealed a low CD4 count suggestive of idiopathic CD4 lymphopenia. The case illustrates the importance of the shrimp sign on MRI, the possibility of cerebellar involvement of PML as well as the need to consider a differential diagnosis of PML even in individuals with no obvious immunocompromised state.
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Affiliation(s)
- Vinit Suri
- Neurology, Indraprastha Apollo Hospitals New Delhi, New Delhi, New Delhi, India
| | - Ajay Kumar Sinha
- Neurology, Indraprastha Apollo Hospitals New Delhi, New Delhi, New Delhi, India
| | - Mayank Priyaranjan
- Neurology, Indraprastha Apollo Hospitals New Delhi, New Delhi, New Delhi, India
| | - Vipin Patel
- Neurology, Indraprastha apollo hospital, New Delhi, Delhi, India
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Somboonviboon D, Thongtaeparak W, Suntavaruk P, Nasomsong W. Disseminated coinfection with Mycobacterium Avium complex and Mycobacterium Kansasii in a patient with idiopathic CD4 + lymphocytopenia: A case report. J Infect Chemother 2023; 29:1167-1171. [PMID: 37562711 DOI: 10.1016/j.jiac.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/31/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Simultaneously disseminated coinfection with two species of nontuberculous mycobacteria (NTM) is extremely rare and had been reported only in immunocompromised individuals. Here, we report a 59-year-old Thai man, previously healthy. He presented with a 2-month history of prolonged fever, constitutional symptoms, and hepatosplenomegaly. His chest and abdomen computed tomography illustrated multiple enlarged mediastinal lymph nodes accompanied with multifocal crazy-paving appearance in both lungs and hepatosplenomegaly. Endobronchial ultrasound-guided transbronchial needle aspiration was performed on the mediastinal nodes. The pathologic findings were necrotizing granulomatous lymphadenitis with numerous AFB-positive bacilli. Blood culture subsequently isolated M. intracellulare, while BAL and lymph node culture isolated M. intracellulare and M. kansasii, which confirmed species by multiplex PCR and 16s rRNA sequencing. Idiopathic CD4+ lymphocytopenia (ICL) was diagnosed as the cause of secondary immune deficiency. Intravenous imipenem, amikacin, and azithromycin were administered as an empirical antibiotic regimen for 4 weeks, then substituted to oral rifampicin, clarithromycin, moxifloxacin, and ethambutol as definitive regimen. Unfortunately, it was found that he had died unexpectedly at home after 4 months of treatment, possibly related to this illness. In our view, patients with severe disseminated NTM disease should be evaluated to explore a secondary immune deficiency disorder. An ICL is a rare heterogenous syndrome but should be considered.
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Affiliation(s)
- Dujrath Somboonviboon
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Thailand
| | - Wittaya Thongtaeparak
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Thailand
| | - Papatsiri Suntavaruk
- Division of Infectious Disease, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Thailand
| | - Worapong Nasomsong
- Division of Infectious Disease, Department of Internal Medicine, Phramongkutklao Hospital and College of Medicine, Thailand.
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3
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Ogata R, Kido T, Takeda K, Nemoto K, Heima R, Takao M, Miyashita R, Ozasa M, Tokito T, Okuno D, Ito Y, Yura H, Koga T, Hashimoto K, Takemoto S, Takazono T, Ishimoto H, Sakamoto N, Fukuda K, Sasaki Y, Obase Y, Ishimatsu Y, Yatera K, Izumikawa K, Mukae H. Disseminated Mycobacterium genavense Infection Mimicking Sarcoidosis: A Case Report and Review of Literature on Japanese Patients. Microorganisms 2023; 11:2145. [PMID: 37763989 PMCID: PMC10535052 DOI: 10.3390/microorganisms11092145] [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: 07/27/2023] [Revised: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Sarcoidosis is a systemic inflammatory disease characterized by noncaseating epithelioid cell granulomas. However, certain infections can exhibit similar histological findings. We present a case of a 69-year-old man who was initially diagnosed with sarcoidosis and later was confirmed, through 16S rRNA sequencing, to have disseminated Mycobacterium genavense infection. Acid-fast bacteria were detected in the bone marrow biopsy using Ziehl-Neelsen staining, but routine clinical tests did not provide a definitive diagnosis. The patient tested negative for HIV, anti-interferon-gamma antibodies, and genetic immunodeficiency disorders. He was treated with multiple drugs, including aminoglycosides and macrolides, but showed no improvement in fever and pancytopenia. However, these clinical signs responded favorably to steroid therapy. We reviewed 17 Japanese cases of M. genavense infection. All cases were in males; 7/17 (41%) were HIV-negative; and 12/17 (71%) had a decreased CD4 count. Genetic analysis confirmed M. genavense isolation, and macrolides were used universally. Mycobacterium genavense infection is challenging to identify and mimics other systemic inflammatory diseases such as sarcoidosis. There are no standard treatment protocols. Our case report and Japanese case review contribute to understanding this rare disease.
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Affiliation(s)
- Ryo Ogata
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Takashi Kido
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Kazuaki Takeda
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Kazuki Nemoto
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan, Kitakyusyu 807-8556, Japan; (K.N.); (K.Y.)
| | - Riko Heima
- Clinical Genomics Center, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.H.); (M.T.)
| | - Mami Takao
- Clinical Genomics Center, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.H.); (M.T.)
| | - Ritsuko Miyashita
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Mutsumi Ozasa
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Takatomo Tokito
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Daisuke Okuno
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Yuya Ito
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Hirokazu Yura
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan;
| | - Kunio Hashimoto
- Department of Pediatrics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan;
| | - Shinnosuke Takemoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan;
| | - Hiroshi Ishimoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Kazumasa Fukuda
- Department of Microbiology, University of Occupational and Environmental Health, Japan, Kitakyusyu 807-8556, Japan;
| | - Yuka Sasaki
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, Tokyo 204-8585, Japan;
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
| | - Yuji Ishimatsu
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8520, Japan;
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, University of Occupational and Environmental Health, Japan, Kitakyusyu 807-8556, Japan; (K.N.); (K.Y.)
| | - Koichi Izumikawa
- Department of Infectious Diseases, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan;
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki 852-8501, Japan; (R.O.); (K.T.); (R.M.); (M.O.); (T.T.); (D.O.); (Y.I.); (H.Y.); (S.T.); (T.T.); (H.I.); (N.S.); (Y.O.); (H.M.)
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Kavirayani V, Negi A, Prabhu MM. Acute Cryptococcal Meningitis in a Patient With Idiopathic CD4 Lymphocytopenia: A Rare Clinical Entity. Cureus 2023; 15:e43417. [PMID: 37706126 PMCID: PMC10496933 DOI: 10.7759/cureus.43417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2023] [Indexed: 09/15/2023] Open
Abstract
Cryptococcal meningitis is a known cause of opportunistic infection in immunocompromised patients, especially those with AIDS. Very few cases exist in literature where cryptococcal meningitis is seen in patients without evidence of HIV infection. Here, we describe a case of an elderly woman presenting with clinical features of meningitis. Our patient tested positive for cryptococcal antigen (CRAg) in the CSF and growth of Cryptococcus neoformans was obtained in CSF culture. Further laboratory investigations revealed CD4 lymphocytopenia (233 cells/μl) in the absence of HIV infection. When we checked the CD4 count, beyond a period of six weeks, it was reported to be low, which confirmed our diagnosis of idiopathic CD4 lymphocytopenia (ICL). She was successfully treated with amphotericin B along with flucytosine for two weeks and discharged on maintenance antifungal therapy for eight weeks. This case emphasizes the need to maintain a high index of suspicion and consider the possibility of opportunistic infections even in the absence of HIV infection for timely diagnosis and treatment.
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Affiliation(s)
| | - Arundhati Negi
- Internal Medicine, Kasturba Medical College, Manipal, IND
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Wang Y, Guo J, Yang F, Dong R, Song D, Huang P, Wen L, Xiang G, Wang S, Teng J, Miao W. Predictive effect of the decline in CD4 + T cell levels in blood on infection in patients with severe hemorrhagic stroke and mechanism. Front Neurol 2023; 14:1118282. [PMID: 37360336 PMCID: PMC10288285 DOI: 10.3389/fneur.2023.1118282] [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: 01/16/2023] [Accepted: 05/03/2023] [Indexed: 06/28/2023] Open
Abstract
Objective The purpose of this research was to evaluate the influence of immunity on infection in patients with severe hemorrhagic stroke and explore the mechanism underlying this connection. Methods Clinical data obtained from 126 patients with severe hemorrhagic stroke were retrospectively analyzed, and the factors affecting infection were screened by multivariable logistic regression models. Nomograms, calibration curves, the Hosmer-Lemeshow goodness-of-fit test, and decision curve analysis were used to examine the effectiveness of the models in evaluating infection. The mechanism underlying the reduction in CD4+ T-cell levels in blood was explored by analysis of lymphocyte subsets and cytokines in cerebrospinal fluid (CSF) and blood. Results The results showed that CD4+ T-cell levels of <300/μL was an independent risk factor for early infection. The models for multivariable logistic regression involving the CD4+ T-cell levels and other influencing factors had good applicability and effectiveness in evaluating early infection. CD4+ T-cell levels decreased in blood but increased in CSF. Similarly, interleukin (IL)-6 and IL-8 levels in CSF had a significant increase, generating a substantial concentration gradient between the CSF and the blood. Conclusion Reduced blood CD4+ T-cell counts among patients who had severe hemorrhagic stroke increased the risk of early infection. CSF IL-6 and IL-8 may be involved in inducing the migration of CD4+ T cells into the CSF and decreasing blood CD4+ T-cell levels.
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Affiliation(s)
- Yating Wang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Junshuang Guo
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Immunology, School of Basic Medical Science, Central South University, Changsha, Hunan, China
| | - Fan Yang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ruirui Dong
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dandan Song
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Peipei Huang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lijun Wen
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Guoliang Xiang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Shuiyu Wang
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Junfang Teng
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wang Miao
- Neuro-Intensive Care Unit of the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Lisco A, Ortega-Villa AM, Mystakelis H, Anderson MV, Mateja A, Laidlaw E, Manion M, Roby G, Higgins J, Kuriakose S, Walkiewicz MA, Similuk M, Leiding JW, Freeman AF, Sheikh V, Sereti I. Reappraisal of Idiopathic CD4 Lymphocytopenia at 30 Years. N Engl J Med 2023; 388:1680-1691. [PMID: 37133586 PMCID: PMC10239023 DOI: 10.1056/nejmoa2202348] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Idiopathic CD4 lymphocytopenia (ICL) is a clinical syndrome that is defined by CD4 lymphopenia of less than 300 cells per cubic millimeter in the absence of any primary or acquired cause of immunodeficiency. Some 30 years after its original identification, ICL has remained a disease of obscure cause, with limited evidence with respect to its prognosis or management, despite diagnostic and therapeutic innovations. METHODS We evaluated the clinical, genetic, immunologic, and prognostic characteristics of 108 patients who were enrolled during an 11-year period. We performed whole-exome and targeted gene sequencing to identify genetic causes of lymphopenia. We also performed longitudinal linear mixed-model analyses of T-cell count trajectories and evaluated predictors of clinical events, the response to immunization against coronavirus disease 2019 (Covid-19), and mortality. RESULTS After the exclusion of patients with genetic and acquired causes of CD4 lymphopenia, the study population included 91 patients with ICL during 374 person-years of follow-up. The median CD4+ T-cell count among the patients was 80 cells per cubic millimeter. The most prevalent opportunistic infections were diseases related to human papillomavirus (in 29%), cryptococcosis (in 24%), molluscum contagiosum (in 9%), and nontuberculous mycobacterial diseases (in 5%). A reduced CD4 count (<100 cells per cubic millimeter), as compared with a CD4 count of 101 to 300 cells, was associated with a higher risk of opportunistic infection (odds ratio, 5.3; 95% confidence interval [CI], 2.8 to 10.7) and invasive cancer (odds ratio, 2.1; 95% CI, 1.1 to 4.3) and a lower risk of autoimmunity (odds ratio, 0.5; 95% CI, 0.2 to 0.9). The risk of death was similar to that in the age- and sex-adjusted general population, but the prevalence of cancer was higher. CONCLUSIONS Among the study patients, ICL continued to be associated with increased susceptibility to viral, encapsulated fungal, and mycobacterial diseases, as well as with a reduced response to novel antigens and an increased risk of cancer. (Funded by the National Institute of Allergy and Infectious Diseases and the National Cancer Institute; ClinicalTrials.gov number, NCT00867269.).
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Affiliation(s)
- Andrea Lisco
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Ana M Ortega-Villa
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Harry Mystakelis
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Megan V Anderson
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Allyson Mateja
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Elizabeth Laidlaw
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Maura Manion
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Gregg Roby
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Jeanette Higgins
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Safia Kuriakose
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Magdalena A Walkiewicz
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Morgan Similuk
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Jennifer W Leiding
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Alexandra F Freeman
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Virginia Sheikh
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
| | - Irini Sereti
- From the Laboratory of Immunoregulation (A.L., H.M., M.V.A., E.L., M.M., G.R., V.S., I.S.), Biostatistics Research Branch, Division of Clinical Research (A.M.O.-V.), Centralized Sequencing Program, Division of Intramural Research (M.A.W., M.S.), and the Laboratory of Clinical Immunology and Microbiology (A.F.F.), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, the Clinical Monitoring Research Program Directorate (A.M.), Leidos Biomedical Research (J.H.), and the Clinical Research Directorate (S.K.), Frederick National Laboratory for Cancer Research, Frederick, and the Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University, Baltimore (J.W.L.) - all in Maryland
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7
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Ha R, Keynan Y, Rueda ZV. Increased susceptibility to pneumonia due to tumour necrosis factor inhibition and prospective immune system rescue via immunotherapy. Front Cell Infect Microbiol 2022; 12:980868. [PMID: 36159650 PMCID: PMC9489861 DOI: 10.3389/fcimb.2022.980868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/15/2022] [Indexed: 11/22/2022] Open
Abstract
Immunomodulators such as tumour necrosis factor (TNF) inhibitors are used to treat autoimmune conditions by reducing the magnitude of the innate immune response. Dampened innate responses pose an increased risk of new infections by opportunistic pathogens and reactivation of pre-existing latent infections. The alteration in immune response predisposes to increased severity of infections. TNF inhibitors are used to treat autoimmune conditions such as rheumatoid arthritis, juvenile arthritis, psoriatic arthritis, transplant recipients, and inflammatory bowel disease. The efficacies of immunomodulators are shown to be varied, even among those that target the same pathways. Monoclonal antibody-based TNF inhibitors have been shown to induce stronger immunosuppression when compared to their receptor-based counterparts. The variability in activity also translates to differences in risk for infection, moreover, parallel, or sequential use of immunosuppressive drugs and corticosteroids makes it difficult to accurately attribute the risk of infection to a single immunomodulatory drug. Among recipients of TNF inhibitors, Mycobacterium tuberculosis has been shown to be responsible for 12.5-59% of all infections; Pneumocystis jirovecii has been responsible for 20% of all non-viral infections; and Legionella pneumophila infections occur at 13-21 times the rate of the general population. This review will outline the mechanism of immune modulation caused by TNF inhibitors and how they predispose to infection with a focus on Mycobacterium tuberculosis, Legionella pneumophila, and Pneumocystis jirovecii. This review will then explore and evaluate how other immunomodulators and host-directed treatments influence these infections and the severity of the resulting infection to mitigate or treat TNF inhibitor-associated infections alongside antibiotics.
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Affiliation(s)
- Ryan Ha
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
| | - Yoav Keynan
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
- Department of Community-Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Facultad de Medicina, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Zulma Vanessa Rueda
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
- Facultad de Medicina, Universidad Pontificia Bolivariana, Medellin, Colombia
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8
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Alveolar Proteinosis Secondary to M. tuberculosis, in a Patient with Transient CD4 Lymphocytopenia Due to Cryptococcus neoformans Infection: First Case in the Literature. Infect Dis Rep 2022; 14:169-175. [PMID: 35314651 PMCID: PMC8938766 DOI: 10.3390/idr14020021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/27/2022] [Accepted: 03/02/2022] [Indexed: 12/04/2022] Open
Abstract
Transient CD4 lymphocytopenia is defined as the transitory presence of CD4+ T lymphocyte fewer than 300 cells/mm3 or less than 20% of T cells without HIV infection. It can occur due to multiple causes; however, it is rare for it to occur due to opportunistic infections. Few cases have been described in the literature where antimicrobial treatment normalizes the CD4 count, being more frequent in Mycobacterium tuberculosis infections. To date, this phenomenon has not been described in Cryptococcus neoformans infections. This would be the first reported case according to our knowledge, of a patient who normalizes CD4 count after antifungal treatment, later developing alveolar proteinosis due to M. Tuberculosis.
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9
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Pata R, Nway N, Lutaya I, Chen V. Disseminated Histoplasmosis Presenting as Acute Respiratory Distress Syndrome and Disseminated Intravascular Coagulation in an HIV Positive Immigrant from Central America. Cureus 2022; 14:e21942. [PMID: 35273883 PMCID: PMC8901384 DOI: 10.7759/cureus.21942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2022] [Indexed: 11/21/2022] Open
Abstract
Histoplasmosis rarely causes significant illness in immunocompetent patients. In endemic areas such as the Midwestern United States and Central America, most people are infected, but are rarely symptomatic, with variable presentation. The illness is usually self-limited in immunocompetent individuals. However, in immunocompromised patients, Histoplasma capsulatum can disseminate to various organs and should be suspected especially in the endemic areas or if there is a significant travel history involving these areas. We present a case of a 65-year-old male originally from Central America with no known past medical history presenting with Acute Respiratory Distress Syndrome complicated by disseminated intravascular coagulation due to acute histoplasmosis and incidentally found to have HIV/AIDS.
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10
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Samji NS, Verma R, Mohammed SY, Khan F, Ismail MK. Disseminated Histoplasmosis Involving Soft Palate, Duodenum, Sigmoid Colon and Bone Marrow in a Patient With Isolated CD4+ T-Lymphocytopenia. Cureus 2021; 13:e19748. [PMID: 34938625 PMCID: PMC8684889 DOI: 10.7759/cureus.19748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 11/05/2022] Open
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11
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Onwubiko IN, Taneja K, Gupta N, Mukherjee A. Unusual Case of Progressive Multifocal Leukoencephalopathy in a Patient With Sjögren Syndrome. Am J Forensic Med Pathol 2021; 42:186-190. [PMID: 33464755 DOI: 10.1097/paf.0000000000000656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ABSTRACT Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease caused by reactivation of John Cunningham virus affecting typically subcortical and periventricular white matter of immunocompromised hosts (human immunodeficiency virus infection, hematologic malignancies). Cerebral hemispheric white matter is most commonly affected by lytic infections, leading to progressive damage to oligodendrocytes in the central nervous system. Neuroimaging usually highlights scattered foci of white matter hypodensity not attributable to contrast enhancement or mass effect. In contrast, we present an unusual case of PML predominantly affecting cervical spinal cord and brainstem in an immunocompetent host. This is a rare subset of PML case that can occur in association with connective tissue disorders (Sjögren Syndrome in this case), systemic lupus erythematosus being the most common. Progressive multifocal leukoencephalopathy should be considered in the differential diagnosis of spinal cord or brainstem lesions, particularly in the patients with connective tissue disorders.
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12
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Shavit R, Maoz-Segal R, Frizinsky S, Haj-Yahia S, Offengenden I, Machnas-Mayan D, Tunisky Y, Iancovici-Kidon M, Agmon-Levin N. Combined immunodeficiency (CVID and CD4 lymphopenia) is associated with a high risk of malignancy among adults with primary immune deficiency. Clin Exp Immunol 2021; 204:251-257. [PMID: 33497464 DOI: 10.1111/cei.13579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/20/2020] [Accepted: 01/06/2021] [Indexed: 12/16/2022] Open
Abstract
Primary immunodeficiency disorders (PID) are a group of heterogeneous disorders characterized by recurrent infections, autoimmunity, increased lymphoproliferative disorders and other malignancies. PID is classified into cellular or humoral disorders or a combination of both. We evaluated the clinical differences among adult patients with three variants of PID: common variable immunodeficiency (CVID), idiopathic CD4 lymphopenia (ICL) and combined immunodeficiency (CID). We retrospectively compared demographics, immunological characteristics, clinical presentations and outcomes of CVID, CID and ICL patients followed from 2012 to 2018. In our cohort, we identified 44 adult patients diagnosed with CVID (22), CID (11) and ICL (11). Malignancy was associated with CID, as seven of 11 patients in this group were diagnosed with malignancy compared to CVID (three of 22) or ICL (two of 11) (P = 0·002 and 0·03, respectively). Malignancies were also linked to male gender [odds ratio (OR) = 5, 95% confidence interval (CI) = 1·12-22·18) P = 0·0342] and a low ratio of CD4/CD8 < 0·8 (OR = 5·1, 95% CI = 1·22-21·28, P = 0·025). Among CID and ICL, two of 11 patients died in each group, while no death was documented among CVID group (P = 0·04). Autoimmune manifestations did not differ between groups. Similarly, the rate of infections was similar between groups, although infectious agents vary. CID is associated with a high risk of malignancy compare to CVID or ICL. Among adults with PID, male gender, low CD4 and a CD4/CD8 ratio of < 0·8 may serve as risk factors of concomitant malignancy. Surveillance of lymphocyte subpopulations should be considered for all adults.
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Affiliation(s)
- R Shavit
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - R Maoz-Segal
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - S Frizinsky
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - S Haj-Yahia
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - I Offengenden
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - D Machnas-Mayan
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - Y Tunisky
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - M Iancovici-Kidon
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | - N Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
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13
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Perez-Diez A, Wong CS, Liu X, Mystakelis H, Song J, Lu Y, Sheikh V, Bourgeois JS, Lisco A, Laidlaw E, Cudrici C, Zhu C, Li QZ, Freeman AF, Williamson PR, Anderson M, Roby G, Tsang JS, Siegel R, Sereti I. Prevalence and pathogenicity of autoantibodies in patients with idiopathic CD4 lymphopenia. J Clin Invest 2021; 130:5326-5337. [PMID: 32634122 DOI: 10.1172/jci136254] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 06/24/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUNDIdiopathic CD4 lymphopenia (ICL) is defined by persistently low CD4+ cell counts (<300 cells/μL) in the absence of a causal infection or immune deficiency and can manifest with opportunistic infections. Approximately 30% of ICL patients develop autoimmune disease. The prevalence and breadth of their autoantibodies, however, and their potential contribution to pathogenesis of ICL remain unclear.METHODSWe hybridized 34 and 51 ICL patients' sera to a 9,000-human-proteome array and to a 128-known-autoantigen array, respectively. Using a flow-based method, we characterized the presence of anti-lymphocyte Abs in the whole cohort of 72 patients, as well as the Ab functional capability of inducing Ab-dependent cell-mediated cytotoxicity (ADCC), complement deposition, and complement-dependent cytotoxicity (CDC). We tested ex vivo the activation of the classical complement pathway on ICL CD4+ T cells.RESULTSAll ICL patients had a multitude of autoantibodies mostly directed against private (not shared) targets and unrelated quantitatively or qualitatively to the patients' autoimmune disease status. The targets included lymphocyte intracellular and membrane antigens, confirmed by the detection by flow of IgM and IgG (mostly IgG1 and IgG4) anti-CD4+ cell Abs in 50% of the patients, with half of these cases triggering lysis of CD4+ T cells. We also detected in vivo classical complement activation on CD4+ T cells in 14% of the whole cohort.CONCLUSIONOur data demonstrate that a high prevalence of autoantibodies in ICL, some of which are specific for CD4+ T cells, may contribute to pathogenesis, and may represent a potentially novel therapeutic target.TRIAL REGISTRATIONClinicalTrials.gov NCT00867269.FUNDINGNIAID and National Institute of Arthritis and Musculoskeletal and Skin Diseases of the NIH.
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Affiliation(s)
| | - Chun-Shu Wong
- HIV Pathogenesis Section, Laboratory of Immunoregulation, and
| | - Xiangdong Liu
- HIV Pathogenesis Section, Laboratory of Immunoregulation, and
| | | | - Jian Song
- Multiscale Systems Biology Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases (NIAID), and
| | - Yong Lu
- Multiscale Systems Biology Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases (NIAID), and
| | - Virginia Sheikh
- HIV Pathogenesis Section, Laboratory of Immunoregulation, and
| | | | - Andrea Lisco
- HIV Pathogenesis Section, Laboratory of Immunoregulation, and
| | | | - Cornelia Cudrici
- Immunoregulation Section, Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland, USA
| | | | - Quan-Zhen Li
- Microarray Core Facility and.,Department of Immunology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Peter R Williamson
- Translational Mycology Section, Laboratory of Clinical and Molecular Immunology, NIAID, and
| | - Megan Anderson
- HIV Pathogenesis Section, Laboratory of Immunoregulation, and
| | - Gregg Roby
- HIV Pathogenesis Section, Laboratory of Immunoregulation, and
| | - John S Tsang
- Multiscale Systems Biology Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases (NIAID), and.,Trans-NIH Center for Human Immunology, NIH, Bethesda, Maryland, USA
| | - Richard Siegel
- Immunoregulation Section, Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland, USA
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, and
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14
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Cudrici CD, Boulougoura A, Sheikh V, Freeman A, Sortino O, Katz JD, Sereti I, Siegel RM. Characterization of autoantibodies, immunophenotype and autoimmune disease in a prospective cohort of patients with idiopathic CD4 lymphocytopenia. Clin Immunol 2021; 224:108664. [PMID: 33422677 DOI: 10.1016/j.clim.2021.108664] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Characterize autoantibodies and autoimmune diseases in a prospective cohort of patients with Idiopathic CD4 Lymphocytopenia (ICL) a rare immunodeficiency characterized by an absolute CD4+ T count of <300 cells/μl in the absence of HIV or HTLV infection. METHODS Single-Center prospective study of 67 patients conducted over an 11-year period. Rheumatologic evaluation and measurement of autoantibodies were systematically conducted, and flow cytometry of immune cell subsets was performed in a subset of patients. RESULTS 54% of referred patients had clinical evidence of autoimmunity, with 34% having at least one autoimmune disease, most commonly autoimmune thyroid disease. 19%, had autoantibodies or incomplete features of autoimmune disease. Patients with autoimmune disease had more elevated serum immunoglobulins, and more effector memory T cells than those without autoimmunity. CONCLUSIONS Evidence of autoimmunity, including autoimmune diseases, is more prevalent in ICL than the general population, and should be considered part of this syndrome.
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Affiliation(s)
- Cornelia D Cudrici
- Immunoregulation Section, Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Intramural Research Program, National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Afroditi Boulougoura
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, USA
| | - Virginia Sheikh
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, USA
| | | | - Ornella Sortino
- Clinical Research Directorate, Frederick, National Laboratory for Cancer Research sponsored by the National Cancer Institute, USA
| | - James D Katz
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health Clinical Center, USA
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, USA.
| | - Richard M Siegel
- Immunoregulation Section, Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Intramural Research Program, National Institutes of Health (NIH), Bethesda, MD 20892, USA.
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15
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Le Hingrat Q, Sereti I, Landay AL, Pandrea I, Apetrei C. The Hitchhiker Guide to CD4 + T-Cell Depletion in Lentiviral Infection. A Critical Review of the Dynamics of the CD4 + T Cells in SIV and HIV Infection. Front Immunol 2021; 12:695674. [PMID: 34367156 PMCID: PMC8336601 DOI: 10.3389/fimmu.2021.695674] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/09/2021] [Indexed: 01/02/2023] Open
Abstract
CD4+ T-cell depletion is pathognomonic for AIDS in both HIV and simian immunodeficiency virus (SIV) infections. It occurs early, is massive at mucosal sites, and is not entirely reverted by antiretroviral therapy (ART), particularly if initiated when T-cell functions are compromised. HIV/SIV infect and kill activated CCR5-expressing memory and effector CD4+ T-cells from the intestinal lamina propria. Acute CD4+ T-cell depletion is substantial in progressive, nonprogressive and controlled infections. Clinical outcome is predicted by the mucosal CD4+ T-cell recovery during chronic infection, with no recovery occurring in rapid progressors, and partial, transient recovery, the degree of which depends on the virus control, in normal and long-term progressors. The nonprogressive infection of African nonhuman primate SIV hosts is characterized by partial mucosal CD4+ T-cell restoration, despite high viral replication. Complete, albeit very slow, recovery of mucosal CD4+ T-cells occurs in controllers. Early ART does not prevent acute mucosal CD4+ T-cell depletion, yet it greatly improves their restoration, sometimes to preinfection levels. Comparative studies of the different models of SIV infection support a critical role of immune activation/inflammation (IA/INFL), in addition to viral replication, in CD4+ T-cell depletion, with immune restoration occurring only when these parameters are kept at bay. CD4+ T-cell depletion is persistent, and the recovery is very slow, even when both the virus and IA/INFL are completely controlled. Nevertheless, partial mucosal CD4+ T-cell recovery is sufficient for a healthy life in natural hosts. Cell death and loss of CD4+ T-cell subsets critical for gut health contribute to mucosal inflammation and enteropathy, which weaken the mucosal barrier, leading to microbial translocation, a major driver of IA/INFL. In turn, IA/INFL trigger CD4+ T-cells to become either viral targets or apoptotic, fueling their loss. CD4+ T-cell depletion also drives opportunistic infections, cancers, and comorbidities. It is thus critical to preserve CD4+ T cells (through early ART) during HIV/SIV infection. Even in early-treated subjects, residual IA/INFL can persist, preventing/delaying CD4+ T-cell restoration. New therapeutic strategies limiting mucosal pathology, microbial translocation and IA/INFL, to improve CD4+ T-cell recovery and the overall HIV prognosis are needed, and SIV models are extensively used to this goal.
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Affiliation(s)
- Quentin Le Hingrat
- Division of Infectious Diseases, DOM, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Alan L Landay
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Ivona Pandrea
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Infectious Diseases and Immunology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Cristian Apetrei
- Division of Infectious Diseases, DOM, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Infectious Diseases and Immunology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
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16
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Sortino O, Dias J, Anderson M, Laidlaw E, Leeansyah E, Lisco A, Sheikh V, Sandberg JK, Sereti I. Preserved Mucosal-Associated Invariant T-Cell Numbers and Function in Idiopathic CD4 Lymphocytopenia. J Infect Dis 2020; 224:715-725. [PMID: 34398238 DOI: 10.1093/infdis/jiaa782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/18/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Mucosal-associated invariant T (MAIT) cells constitute a subset of unconventional, MR1-restricted T cells involved in antimicrobial responses as well as inflammatory, allergic, and autoimmune diseases. Chronic infection and inflammatory disorders as well as immunodeficiencies are often associated with decline and/or dysfunction of MAIT cells. METHODS We investigated the MAIT cells in patients with idiopathic CD4+ lymphocytopenia (ICL), a syndrome characterized by consistently low CD4 T-cell counts (<300 cell/µL) in the absence of HIV infection or other known immunodeficiency, and by susceptibility to certain opportunistic infections. RESULTS The numbers, phenotype, and function of MAIT cells in peripheral blood were preserved in ICL patients compared to healthy controls. Administration of interleukin-7 (IL-7) to ICL patients expanded the CD8+ MAIT-cell subset, with maintained responsiveness and effector functions after IL-7 treatment. CONCLUSIONS ICL patients maintain normal levels and function of MAIT cells, preserving some antibacterial responses despite the deficiency in CD4+ T cells. CLINICAL TRIALS REGISTRATION NCT00867269.
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Affiliation(s)
- Ornella Sortino
- Clinical Research Directorate/Clinical Monitoring Leidos Research Program, Leidos Biomedical Research, Inc., National Cancer Institute Campus at Frederick, Frederick, Maryland, USA
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Joana Dias
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Megan Anderson
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth Laidlaw
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Edwin Leeansyah
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Shenzhen, China
| | - Andrea Lisco
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Virginia Sheikh
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Johan K Sandberg
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Arsanios DM, Quintero-Muñoz E, Echeverry Diaz T, Muñoz Castaño J, Bohórquez J, Mesa C, Estupiñan MF, Cabezas D, Barragan AF. Criptococosis y linfocitopenia T CD4 idiopática: Reporte de un caso. INFECTIO 2020. [DOI: 10.22354/in.v25i1.909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
La linfocitopenia T CD4 idiopática (LCI) es un síndrome clínico inusual que se caracteriza por un déficit de células T CD4+ circulantes en ausencia de infección por VIH u otra condición de inmunosupresión. Los pacientes con dicha enfermedad pueden presentarse asintomáticos o con infecciones oportunistas, las más frecuentes son por criptococo, micobacterias o virales como herpes zoster. Presentamos el caso de un hombre de 32 años, sin antecedentes, en quien se descartó infección por retrovirus, con recuento de linfocitos T CD4+ menor a 300 células/m3; se diagnosticó LCI posterior al diagnóstico de criptococomas cerebrales mediante hallazgos imagenológicos los cuales fueron congruentes con estudios microbiológicos.
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A Review on Bovine Mastitis with Special Focus on CD4 as a Potential Candidate Gene for Mastitis Resistance – A Review. ANNALS OF ANIMAL SCIENCE 2020. [DOI: 10.2478/aoas-2020-0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Mastitis is аn inflammation оf thе mammary gland, caused by the invasion and duplication оf Escherichia coli (E. coli), Staphylococcus uberis (S. uberis) аnd Staphylococcus aureus (S. aureus) аnd а wide variety оf оthеr microorganisms thrоugh teat оr damaged nipple, decreasing potential milk production іn thе affected quarter оf mammary gland. Economic, animal productivity, international trade and animal welfare issues associated with mastitis play an important role in the agricultural industry. Therefore, worldwide dairy cattle breeding programmes are trying to breed cows wіth improved resistance tо mastitis. Mastitis can’t be eliminated but can be reduced to a low level. It can be achieved by breeding strategies, reducing the exposure to pathogen and increasing the resistance to intramammary infection. Numerous therapeutic, prophylactic аnd management techniques аrе uѕеd аѕ control and reduce the mastitis. However, а widely proposed strategy marker assisted selection uѕіng candidate gene approach which іѕ based оn improving thе host genetics. One of them is cluster of differentiation 4 (CD4) gene, which is а glycoprotein located оn receptors оf immune cells. CD4 exhibit аn essential role іn a variety of inflammation related conditions іn mаnу species. Therefore, CD4 as a candidate gene for resistance to mastitis has received considerable attention. The review is based on a study of CD4 in association with improving resistance to mastitis and it may be helpful in formulating breeding programmes and marker assisted selection to lower the mastitis.
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19
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Lee SW, Choi D, Heo M, Shin EC, Park SH, Kim SJ, Oh YK, Lee BH, Yang SH, Sung YC, Lee H. hIL-7-hyFc, A Long-Acting IL-7, Increased Absolute Lymphocyte Count in Healthy Subjects. Clin Transl Sci 2020; 13:1161-1169. [PMID: 32339447 PMCID: PMC7719369 DOI: 10.1111/cts.12800] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/26/2020] [Indexed: 11/29/2022] Open
Abstract
A low lymphocyte count puts immune-compromised patients at risk of mortality. hIL-7-hyFc is a homodimeric interleukin-7 (IL-7), a potent T-cell amplifier, fused to the hybridizing IgD/IgG4 immunoglobulin domain. We performed a randomized, double-blind, placebo-controlled, dose-escalation, phase I study to assess the pharmacokinetic, pharmacodynamic, safety, tolerability, and immunogenicity profiles of hIL-7-hyFc administered s.c. and i.m. to healthy volunteers. Thirty subjects randomly received hIL-7-hyFc or its matching placebo in an 8:2 ratio at 20, 60 μg/kg s.c., or 60 μg/kg i.m. The hIL-7-hyFc was slowly absorbed and its terminal half-life was 63.26 hours after i.m. administration. The hIL-7-hyFc increased absolute lymphocyte count, mostly in T-cells, which peaked 3 weeks after administration and then lasted for several additional weeks. The hIL-7-hyFc was well-tolerated after a single s.c. and i.m. administration. Injection site reaction was the most common treatment-emergent adverse event, which resolved spontaneously without treatment. The hIL-7-hyFc can be developed into a beneficial treatment option for patients with compromised T-cell immunity. This trial was registered at www.clinicaltrials.gov as #NCT02860715.
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Affiliation(s)
- Sang Won Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea.,Department of Clinical Pharmacology and Therapeutics, Hanyang University Seoul Hospital, Seoul, Korea
| | | | - MinKyu Heo
- Genexine, Inc., Seongnam-si, Gyeonggi-do, Korea
| | - Eui-Cheol Shin
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea.,Biomedical Science and Engineering Interdisciplinary Program, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Su-Hyung Park
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea.,Biomedical Science and Engineering Interdisciplinary Program, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - So Jeong Kim
- Biomedical Science and Engineering Interdisciplinary Program, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | | | | | | | | | - Howard Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea.,Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
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20
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Vijayakumar S, Viswanathan S, Aghoram R. Idiopathic CD4 Lymphocytopenia: Current Insights. Immunotargets Ther 2020; 9:79-93. [PMID: 32548074 PMCID: PMC7239889 DOI: 10.2147/itt.s214139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia is a condition characterized by low CD4 counts. It is rare and most of the information about this illness comes from case reports. Presentation is usually in the 4th decade of life with opportunistic infections, autoimmune disease or neoplasia. The pathophysiology of this condition is not well understood. Management revolves around treatment of the presenting condition and close follow-up of these patients. This review presents a narrative summary of the current literature on idiopathic CD4 lymphocytopenia.
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Affiliation(s)
| | - Stalin Viswanathan
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
| | - Rajeswari Aghoram
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
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21
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Ghosh K. Idiopathic CD4+ T lymphocytopenia: Still a long way to understand the disease. J Postgrad Med 2020; 66:65-66. [PMID: 32270778 PMCID: PMC7239403 DOI: 10.4103/jpgm.jpgm_595_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- K Ghosh
- Former Director Institute of Immunohaematology (ICMR), Mumbai, Maharashtra, India
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22
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Farmer JR, DeLelys M. Flow Cytometry as a Diagnostic Tool in Primary and Secondary Immune Deficiencies. Clin Lab Med 2019; 39:591-607. [PMID: 31668272 DOI: 10.1016/j.cll.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Flow cytometry is an incredibly powerful diagnostic tool in the evaluation of primary and secondary immune deficiencies. Assay design and setup involves a methodological consideration of specimen collection, marker and fluorochrome selection, antibody titration, instrumentation, compensation, gating, reference range development, and cross validation. Commonly used analyses for lymphocytes are the lymphocyte subset, T-cell subset, B-cell and T-cell naive/memory, double-negative T-cell, and plasmablast panels. Flow cytometry has direct clinical applicability to the workup of severe forms of primary immune deficiency disorders and is used diagnostically and for therapeutic monitoring in the context of secondary immune deficiency disorders.
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Affiliation(s)
- Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, COX 201, MGH, 55 Fruit Street, Boston, MA 02114, USA; Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA.
| | - Michelle DeLelys
- Cellular Therapeutics and Transplantation/Flow Cytometry, Department of Pathology, Massachusetts General Hospital, WRN 506, MGH, 55 Fruit Street, Boston, MA 02114, USA; Cellular Therapeutics and Transplantation/Flow Cytometry, Department of Cancer Center, Massachusetts General Hospital, WRN 506, MGH, 55 Fruit Street, Boston, MA 02114, USA
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23
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Pulmonary Cryptococcus infections as a manifestation of idiopathic CD4 lymphocytopenia: case report and literature review. BMC Infect Dis 2019; 19:862. [PMID: 31623573 PMCID: PMC6798450 DOI: 10.1186/s12879-019-4453-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/10/2019] [Indexed: 01/15/2023] Open
Abstract
Background Idiopathic CD4 lymphocytopenia (ICL) is a rare clinical disease with relative CD4 deficiency in the absence of HIV infection. The pathogenicity of ICL is poorly understood with an unclear incidence rate in the general population. Sequelae of ICL includes AIDS-defining infections, which most commonly includes Cryptococcus neoformans. Typically, C. neoformans infections present with CNS involvement but rarely with extra-CNS manifestations. Here, we present a rare case of ICL with exclusively primary pulmonary cryptococcus and a review of the literature. Case presentation A 56-year-old female presented to our tertiary care hospital requiring a right hip open reduction intervention. The patient became febrile during admission, prompting a work-up that included a chest X-ray showing a peripheral pulmonary solitary nodule. Transthoracic biopsy revealed encapsulated yeast forms in keeping with C. neoformans. CD4 counts, repeated at least one month apart, were < 200 cells/mm3, with negative HIV testing. Flow cytometry and genetic testing were completed to elucidate the etiology of the immune deficiency, both of which were unremarkable. She was subsequently treated with 12 months of posaconazole with clinical resolution. Conclusions Our patient highlights a rare clinical disease, which a review of literature revealed only five cases in the literature with exclusive pulmonary Cryptococcus in ICL/ This case demonstrates the strong clinical acumen required to properly diagnose and ultimately manage the patient.
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Perez-Diez A, Liu X, Sheikh V, Roby G, Stroncek DF, Sereti I. Humanized mouse models reveal an immunologic classification of idiopathic CD4 lymphocytopenia subtypes. JCI Insight 2019; 4:127802. [PMID: 31341106 DOI: 10.1172/jci.insight.127802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/05/2019] [Indexed: 12/21/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia (ICL) is a clinically heterogeneous immunodeficiency disorder defined by low numbers of circulating CD4+ T cells and increased susceptibility to opportunistic infections. CD8+ T cells, NK, and/or B cells may also be deficient in some patients. To delineate possible pathogenic cellular mechanisms in ICL, we compared immune system development and function in NOD-RAGKO-γcKO (NRG) mice transplanted with hematopoietic stem cells from patients with ICL or healthy controls. CD34+ hematopoietic stem cells from healthy controls and patients with ICL reconstituted NRG mice equally well. In contrast, PBMC transfers into NRG mice identified 2 ICL engraftment phenotypes, reconstituting and nonreconstituting (NR), based on the absence or presence of donor lymphopenia. For patients in the NR group, the distribution of lymphocyte subsets was similar in the peripheral blood of both the patient and the corresponding humanized mice. The NR-ICL group could be further divided into individuals whose CD3+ T cells had defects in proliferation or survival. Thus, ICL cellular pathogenesis might be classified by humanized mouse models into 3 distinct subtypes: (a) T cell extrinsic, (b) T cell intrinsic affecting proliferation, and (c) T cell intrinsic affecting survival. Humanized mouse models of ICL help to delineate etiology and ultimately to guide development of individualized therapeutic strategies.
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Affiliation(s)
- Ainhoa Perez-Diez
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - Xiangdong Liu
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - Virginia Sheikh
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - Gregg Roby
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
| | - David F Stroncek
- Department of Transfusion Medicine, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Irini Sereti
- HIV Pathogenesis Section, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, and
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García-Moreno J, Melendo-Pérez S, Martín-Gómez MT, Frick MA, Balcells-Ramírez J, Pujol-Jover M, Martín-Nalda A, Mendoza-Palomar N, Soler-Palacín P. Pneumocystis jirovecii pneumonia in children. A retrospective study in a single center over three decades. Enferm Infecc Microbiol Clin 2019; 38:111-118. [PMID: 31272810 DOI: 10.1016/j.eimc.2019.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Pneumocystis jirovecii pneumonia (PJP) is a life-threatening condition in immunocompromised children. Our aim is to analyze the epidemiologic and clinical characteristics of PJP cases in our setting, describing the prognosis and related risk factors. METHODS Retrospective study including all pediatric patients (≤18 years) with PJP admitted to our hospital (January 1989-December 2016). Case definition: patient with acute pneumonitis and P.jirovecii detection in bronchoalveolar lavage or tracheal aspirate using methenamine silver or direct antibody fluorescence staining, or Real-Time Polymerase Chain Reaction. RESULTS Twenty-five cases (0.9 cases/year) were identified. Median age was 2.2 years (interquartile range: 0.5-12.3), 64% were male, and 12% were receiving appropriate antimicrobial prophylaxis. Cytomegalovirus coinfection was detected in 26% cases. The most common underlying diseases were primary immunodeficiencies (36%) and 16% were human immunodeficiency virus (HIV)-infected children. Eighteen were admitted to the pediatric intensive care unit (PICU) and overall 30-day mortality was 20% (31.25% in HIV non-infected vs 0% in HIV-infected patients; OR: 0.33, 95% CI: 0.02-7.24, p=0.55). Clinical outcome was worse in girls and those patients requiring adjuvant steroid therapy. HIV non-infected patients, higher initial LDH, younger age and shorter time elapsed between diagnosis of PJP and the underlying disease were identified as risk factors to be admitted to the PICU (p=0.05, p=0.026, p=0.04 and p=0.001 respectively). CONCLUSION Accompanying the widespread use of combined antiretroviral therapy, PJP has been diagnosed almost exclusively in HIV non-infected children at our institution. Moreover, significant higher morbidity rates associated with PJP are seen in this group of patients.
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Affiliation(s)
- Jorge García-Moreno
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Red de Investigación Translacional en Infectología Pediátrica (RITIP), Spain
| | - Susana Melendo-Pérez
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Red de Investigación Translacional en Infectología Pediátrica (RITIP), Spain
| | - María Teresa Martín-Gómez
- Department of Microbiology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marie Antoinette Frick
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Red de Investigación Translacional en Infectología Pediátrica (RITIP), Spain
| | - Joan Balcells-Ramírez
- Pediatric Intensive Care Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Montserrat Pujol-Jover
- Pediatric Intensive Care Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrea Martín-Nalda
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Red de Investigación Translacional en Infectología Pediátrica (RITIP), Spain
| | - Natalia Mendoza-Palomar
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Red de Investigación Translacional en Infectología Pediátrica (RITIP), Spain
| | - Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Red de Investigación Translacional en Infectología Pediátrica (RITIP), Spain.
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26
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Sullivan NL, Eberhardt CS, Wieland A, Vora KA, Pulendran B, Ahmed R. Understanding the immunology of the Zostavax shingles vaccine. Curr Opin Immunol 2019; 59:25-30. [PMID: 30970291 DOI: 10.1016/j.coi.2019.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/17/2022]
Abstract
Zostavax is a live-attenuated varicella zoster virus (VZV) vaccine recommended for use in adults >50 years of age to prevent shingles. The main risk factor for the development of shingles is age, which correlates with decreasing cell-mediated immunity. These data suggest a predominant role of T cell immunity in controlling VZV latency. However, other components of the immune system may also contribute. In this review, we will discuss how the immune system responds to Zostavax, focusing on recent studies examining innate immunity, transcriptomics, metabolomics, cellular, and humoral immunity.
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Affiliation(s)
- Nicole L Sullivan
- MRL, Department of Infectious Diseases and Vaccines, Merck & Co., Inc., Kenilworth, New Jersey, USA.
| | - Christiane S Eberhardt
- Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA; Center for Vaccinology and Neonatal Immunology, Department of Pediatrics and Pathology-Immunology, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Switzerland
| | - Andreas Wieland
- Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
| | - Kalpit A Vora
- MRL, Department of Infectious Diseases and Vaccines, Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Bali Pulendran
- Institute for Immunity, Transplantation and Infection, Department of Pathology, Department of Microbiology and Immunology, Stanford University, Stanford, CA 94305, USA
| | - Rafi Ahmed
- Emory Vaccine Center and Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
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Kano Y, Inoue H, Sakurai K, Yoshida M, Miura Y, Nakamichi K, Saijo M, Yuasa H. [Idiopathic CD4-positive lymphocytopenia-associated progressive multifocal leukoencephalopathy confirmed by brain biopsy following negative results of repeated CSF-JC-virus tests: a case report]. Rinsho Shinkeigaku 2018; 58:750-755. [PMID: 30487366 DOI: 10.5692/clinicalneurol.cn-001227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 75-year-old man presented with dysarthria and left facial paralysis. Brain diffusion-weighted MRI revealed a high-signal intensity in the right precentral gyrus, and he was hospitalized under the diagnosis of cerebral infarction. His symptoms worsened and brain MRI findings were consistent with progressive multifocal leukoencephalopathy (PML). Cerebrospinal fluid (CSF) JC virus (JCV) was undetectable in the DNA polymerase chain reaction (PCR) test four times, but brain biopsy revealed typical PML histopathology. He had no human immunodeficiency virus infection and history of immunosuppressive treatment, but he was found to have CD4+ lymphocytopenia. He was treated with mefloquine and mirtazapine, and died 29 months after symptoms onset. In cases whose repeated DNA PCR results are negative for CSF JCV, brain biopsy may be useful for the diagnosis of PML.
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Affiliation(s)
- Yuya Kano
- Department of Neurology, Tosei General Hospital
| | - Hiroyasu Inoue
- Department of Neurology, Nagoya City East Medical Center
| | - Keita Sakurai
- Department of Radiology, Teikyo University School of Medicine
| | - Mari Yoshida
- Medical Science of Aging, Aichi Medical University
| | - Yoshiharu Miura
- Department of Neurology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital
| | - Kazuo Nakamichi
- Department of Virology 1, National Institute of Infectious Diseases
| | - Masayuki Saijo
- Department of Virology 1, National Institute of Infectious Diseases
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28
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Idiopathic CD4 lymphocytopenia presenting with progressive disseminated histoplasmosis. Med J Armed Forces India 2018; 74:280-283. [PMID: 30093774 DOI: 10.1016/j.mjafi.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 02/12/2017] [Indexed: 11/22/2022] Open
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29
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Hassoun A, Mehrotra N. Disseminated cryptococcosis in HIV negative patient. BMJ Case Rep 2018; 2018:bcr-2017-223500. [PMID: 29754135 DOI: 10.1136/bcr-2017-223500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 52-year-old white diabetic male with 4-weeks history of persistent cough followed by headache, drenching night sweats, low-grade fever, worsening photophobia, nausea and vomiting was presented. Examination was significant for photophobia and diminution of vision. His spinal fluid and blood cultures were positive for Cryptococcus neoformans Intravenous fluconazole were given for 2 weeks followed by oral fluconazole. There was significant improvement in systemic and ocular symptoms. HIV serology was negative, but his CD4 counts were low with inverted CD4:CD8 ratio.
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Affiliation(s)
- Ali Hassoun
- Department of Infectious Diseases, Alabama Infectious Diseases Center, Huntsville, Alabama, USA
| | - Neha Mehrotra
- Department of Infectious Diseases, Alabama Infectious Diseases Center, Huntsville, Alabama, USA
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Aghoram R, Narayan SK. Progressive multifocal leukoencephalopathy in idiopathic CD4+ lymphocytopenia. J Neurovirol 2018; 24:526-528. [PMID: 29687403 DOI: 10.1007/s13365-018-0638-0] [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] [Received: 10/06/2017] [Revised: 03/19/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
Progressive multifocal leukoencephalopathy is a central nervous system demyelinating disease caused by infection with John Cunningham virus. It affects predominantly the subcortical white matter, producing progressive neurological deficits and large confluent white matter lesions on imaging. It is usually seen in immunodeficient individuals, such as those suffering from acquired immunodeficiency syndrome, those on treatment with monoclonal antibodies, and those following therapeutic bone marrow suppression. Here, we report a rare case of progressive multifocal leukoencephalopathy in an apparently immunocompetent adult, who was found to have idiopathic CD4 lymphocytopenia upon further investigation.
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Affiliation(s)
- Rajeswari Aghoram
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), SS Block, D. Nagar, Pondicherry, 605006, India.
| | - Sunil K Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), SS Block, D. Nagar, Pondicherry, 605006, India
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31
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Behl A, Vohra P, Bali V. HIV negative aids-idiopathic CD4 lyphocytopenia. JOURNAL OF INDIAN ACADEMY OF ORAL MEDICINE AND RADIOLOGY 2018. [DOI: 10.4103/jiaomr.jiaomr_103_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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32
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Primary Immune Deficiencies in the Adult: A Previously Underrecognized Common Condition. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 4:1101-1107. [PMID: 27836059 DOI: 10.1016/j.jaip.2016.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 12/21/2022]
Abstract
The large majority of classified primary immune deficiency (PID) diseases present in childhood. Yet, most patients with PID are adults, with a large proportion experiencing onset of symptoms beyond their childhood years. Most of these are diagnosed predominantly with antibody defects, but cellular and other disorders are increasingly being identified in older patients as well. Moreover, advances in clinical immunology are allowing pediatric patients, even those with severe disease, to reach adulthood. Because of differences in the physiology and pathophysiology of children and adults, the presentation, diagnosis, and management of a complex chronic disease could differ significantly between these patient populations and therefore require modifications in approach.
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Yarmohammadi H, Cunningham-Rundles C. Idiopathic CD4 lymphocytopenia: Pathogenesis, etiologies, clinical presentations and treatment strategies. Ann Allergy Asthma Immunol 2017; 119:374-378. [PMID: 28958376 DOI: 10.1016/j.anai.2017.07.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/16/2017] [Accepted: 07/19/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Idiopathic CD4 lymphocytopenia (ICL) is a rare condition characterized by an unexplained deficit of circulating CD4 T cells leading to increased risk of serious opportunistic infections. The pathogenesis, etiology, clinical presentation, and best treatment options remain unclear. OBJECTIVE To describe the clinical presentation, treatment strategies, and outcome of patients with ICL seen in a single referral center. METHODS In a retrospective study, from January 1993 to January 2014, the demographic characteristics, clinical presentation, and treatments of patients diagnosed with ICL were reviewed. RESULTS Twenty-four patients (14 female [58%] and 10 male [42%]) were evaluated. The mean age was 45 ± 17.6 years (range 7-76 years). Mean CD4 and CD8 T-cell counts at the time of diagnosis were 119 ± 84/mm3 (range 4-294/mm3) and 219 ± 258/mm3 (range 7-630/mm3), respectively. Seventeen patients (71%) had opportunistic infections, 4 (17%) had malignancies, and 3 (13%) had unexplained demyelinating disease and neurologic problems. Most patients had normal levels of immunoglobulins. Thirteen patients had abnormally low to absent response to phytohemagglutinin, concanavalin A, and antigens (candida and tetanus). Three patients had resolution of warts and 1 had mycobacterial lung infection on interleukin-2 with increases in CD4 count. The 11 patients on trimethoprim and sulfamethoxazole had no further hospital admissions for infections. CONCLUSION The pathogenesis of ICL remains unclear. Although only some patients are healthy, most patients present with opportunistic infections. There is no known standard treatment aside from prophylactic antibiotics.
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Affiliation(s)
- Hale Yarmohammadi
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Charlotte Cunningham-Rundles
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Panackal AA, Rosen LB, Uzel G, Davis MJ, Hu G, Adeyemo A, Tekola-Ayele F, Lisco A, Diachok C, Kim JD, Shaw D, Sereti I, Stoddard J, Niemela J, Rosenzweig SD, Bennett JE, Williamson PR. Susceptibility to Cryptococcal Meningoencephalitis Associated With Idiopathic CD4 + Lymphopenia and Secondary Germline or Acquired Defects. Open Forum Infect Dis 2017. [PMID: 28638843 DOI: 10.1093/ofid/ofx082] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Idiopathic CD4+ lymphopenia (ICL) predisposes to opportunistic infections (OIs) but can often remain asymptomatic and does not have a strong association with monogenic mutations. Likewise, cryptococcal meningoencephalitis, the most common OI in ICL, is not strongly associated with monogenic mutations. In this study, we describe 2 patients with ICL plus an additional immune defect: one from an E57K genetic mutation in the nuclear factor-κβ essential modulator, and the other with acquired autoantibodies to granulocyte-macrophage colony-stimulating factor. Thus, these cases may exemplify a "multi-hit model" in patients with ICL who acquire OIs.
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Affiliation(s)
- Anil A Panackal
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH).,Division of Infectious Diseases, Department of Medicine, F. Hebert School of Medicine, Uniformed Services University of the Health Sciences
| | - Lindsey B Rosen
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)
| | - Gulbu Uzel
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)
| | - Michael J Davis
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)
| | - Guowu Hu
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)
| | - Adebowale Adeyemo
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, NIH
| | - Fasil Tekola-Ayele
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland
| | | | - Christopher Diachok
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)
| | - Jonathan D Kim
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)
| | - Dawn Shaw
- Leidos Biomedical Research, Inc., Frederick, Maryland
| | | | - Jennifer Stoddard
- Immunology Service, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, Maryland
| | - Julie Niemela
- Immunology Service, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, Maryland
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, Maryland
| | - John E Bennett
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH).,Division of Infectious Diseases, Department of Medicine, F. Hebert School of Medicine, Uniformed Services University of the Health Sciences
| | - Peter R Williamson
- Laboratory of Clinical Infectious Diseases, Division of Intramural Research (DIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)
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35
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Niknam N, Malhotra P, Kim A, Koenig S. Disseminated histoplasmosis presenting as diabetic keto-acidosis in an immunocompetent patient. BMJ Case Rep 2017; 2017:bcr-2016-217915. [PMID: 28062431 DOI: 10.1136/bcr-2016-217915] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Histoplasma capsulatum causes a spectrum of manifestations from asymptomatic to fatal disseminated disease. Disseminated histoplasmosis is mostly seen in endemic areas among immunocompromised patients such as those with AIDS. Here, we present a patient living in a non-endemic area with previously undiagnosed diabetes mellitus, who presented with septic shock and diabetic ketoacidosis (DKA), and was ultimately diagnosed with disseminated histoplasmosis. The patient rapidly recovered on administration of intravenous liposomal amphotericin followed by oral itraconazole. Uncontrolled diabetes may be a risk factor for disseminated or severe histoplasmosis in otherwise immunocompetent patients.
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Affiliation(s)
- Negin Niknam
- Department of Infectious Diseases, North Shore University Hospital, Manhasset, New York, USA
| | - Prashant Malhotra
- Department of Infectious Diseases, North Shore University Hospital, Manhasset, New York, USA
| | - Angela Kim
- North Shore University Hospital, Manhasset, New York, USA
| | - Seth Koenig
- Long Island Jewish Medical Center, New Hyde Park, New York, USA
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36
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Lum SH, Bonney D, Cheesman E, Wrignt NB, Hughes S, Wynn R. Successful Curative Therapy With Rituximab and Allogeneic Haematopoietic Stem Cell Transplantation for MALT Lymphoma Associated With STK4-Mutated CD4+ Lymphocytopenia. Pediatr Blood Cancer 2016; 63:1657-9. [PMID: 27163767 DOI: 10.1002/pbc.26048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/20/2016] [Accepted: 04/10/2016] [Indexed: 12/19/2022]
Abstract
Idiopathic CD4+ lymphocytopenia and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) are rare diseases in children. We report the first case of a child with STK4-mutated CD4+ lymphocytopenia who developed Epstein-Barr virus associated MALT lymphoma arising in the salivary gland. The child achieved complete remission with rituximab, and her immunodeficiency was cured by haematopoietic stem cell transplantation. The child remained well 24 months post transplantation.
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Affiliation(s)
- Su Han Lum
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, UK
| | - Denise Bonney
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, UK
| | - Edmund Cheesman
- Diagnostic Paediatric Histopathology Service, Royal Manchester Children's Hospital, Manchester, UK
| | - Neville B Wrignt
- Department of Radiology, Royal Manchester Children's Hospital, Manchester, UK
| | - Stephen Hughes
- Department of Paediatric Allergy and Immunology, Royal Manchester Children's Hospital, Manchester, UK
| | - Robert Wynn
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, UK
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37
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Puri V, Duggal AK, Chaudhry N. Idiopathic CD4 lymphocytopenia with sensorimotor polyneuropathy. Ann Indian Acad Neurol 2016; 19:381-4. [PMID: 27570393 PMCID: PMC4980964 DOI: 10.4103/0972-2327.165470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A, 21-years-old, male, presented with acute onset, gradually progressive, predominantly distal, symmetrical weakness of both upper and lower limbs with arreflexia. He had impaired sensations in glove and stocking distribution with distal gradient. He was found to have absolute CD4 + cell count of 188 cells/μL, absolute CD8 cell count, 532 cells/μL and CD4: CD8 ratio of 0.35. Electrophysiology revealed reduced to absent CMAP amplitude as well as SNAPs in various nerves of upper and lower limbs, along with normal conduction velocity and normal F wave latencies. Pattern evoked visual potentials were prolonged, on both sides, P100 being 130 ms, on right and 108 ms, on left side. In the follow up of 2 years, he showed spontaneous but gradual clinical improvement but his electrophysiological parameters as well as CD 4+ cells count did not show any significant improvement.
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Affiliation(s)
- Vinod Puri
- Department of Neurology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Ashish Kumar Duggal
- Department of Neurology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Neera Chaudhry
- Department of Neurology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
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38
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Vögelin M, Biedermann L, Frei P, Vavricka SR, Scharl S, Zeitz J, Sulz MC, Fried M, Rogler G, Scharl M. The Impact of Azathioprine-Associated Lymphopenia on the Onset of Opportunistic Infections in Patients with Inflammatory Bowel Disease. PLoS One 2016; 11:e0155218. [PMID: 27214202 PMCID: PMC4877071 DOI: 10.1371/journal.pone.0155218] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/26/2016] [Indexed: 12/18/2022] Open
Abstract
Background Thiopurines are known to cause lymphopenia (<1,500 lymphocytes/μl). As severe lymphopenia (<500C/μl) is associated with opportunistic infections, we investigated severity of thiopurine-related lymphopenia and development of opportunistic infections in our tertiary referral centre. Methods We retrospectively screened medical records of 1,070 IBD patients and identified 100 individuals that developed a total of 161 episodes of lymphopenia during thiopurine treatment between 2002 and 2014. Occurrence of opportunistic infections was documented. A control group consisted of IBD patients receiving thiopurines but without developing lymphopenia. Results Of a total of 161 episodes of lymphopenia, 23% were severe (<500C/μl). In this subgroup, thiopurine dosing was modified in 64% (dosage reduction: 32%, medication discontinued: 32%). We identified 9 cases (5.5%) of opportunistic infections, of which only two occurred during severe lymphopenia. One opportunistic infection (4.5%) was identified in the control group. No association was found between opportunistic infections and severity of lymphopenia. All patients who suffered from opportunistic infections were receiving additional immunosuppressive medication. Conclusion Our patients treated with thiopurines rarely developed severe lymphopenia and opportunistic infections did not occur more often than in the control group. A careful monitoring of lymphocytes and prophylactic adjustment of thiopurine therapy might contribute to this low incidence.
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Affiliation(s)
- Marius Vögelin
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luc Biedermann
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pascal Frei
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephan R. Vavricka
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Sylvie Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Zeitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael C. Sulz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Michael Fried
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
| | - Gerhard Rogler
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
| | - Michael Scharl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Stadtspital Triemli, Zurich, Switzerland
- * E-mail:
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39
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Sheikh V, Porter BO, DerSimonian R, Kovacs SB, Thompson WL, Perez-Diez A, Freeman AF, Roby G, Mican J, Pau A, Rupert A, Adelsberger J, Higgins J, Bourgeois JS, Jensen SMR, Morcock DR, Burbelo PD, Osnos L, Maric I, Natarajan V, Croughs T, Yao MD, Estes JD, Sereti I. Administration of interleukin-7 increases CD4 T cells in idiopathic CD4 lymphocytopenia. Blood 2016; 127:977-88. [PMID: 26675348 PMCID: PMC4768432 DOI: 10.1182/blood-2015-05-645077] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 12/07/2015] [Indexed: 01/08/2023] Open
Abstract
Idiopathic CD4 lymphopenia (ICL) is a rare syndrome defined by low CD4 T-cell counts (<300/µL) without evidence of HIV infection or other known cause of immunodeficiency. ICL confers an increased risk of opportunistic infections and has no established treatment. Interleukin-7 (IL-7) is fundamental for thymopoiesis, T-cell homeostasis, and survival of mature T cells, which provides a rationale for its potential use as an immunotherapeutic agent for ICL. We performed an open-label phase 1/2A dose-escalation trial of 3 subcutaneous doses of recombinant human IL-7 (rhIL-7) per week in patients with ICL who were at risk of disease progression. The primary objectives of the study were to assess safety and the immunomodulatory effects of rhIL-7 in ICL patients. Injection site reactions were the most frequently reported adverse events. One patient experienced a hypersensitivity reaction and developed non-neutralizing anti-IL-7 antibodies. Patients with autoimmune diseases that required systemic therapy at screening were excluded from the study; however, 1 participant developed systemic lupus erythematosus while on study and was excluded from further rhIL-7 dosing. Quantitatively, rhIL-7 led to an increase in the number of circulating CD4 and CD8 T cells and tissue-resident CD3 T cells in the gut mucosa and bone marrow. Functionally, these T cells were capable of producing cytokines after mitogenic stimulation. rhIL-7 was well tolerated at biologically active doses and may represent a promising therapeutic intervention in ICL. This trial was registered at www.clinicaltrials.gov as #NCT00839436.
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Affiliation(s)
- Virginia Sheikh
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Brian O Porter
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Rebecca DerSimonian
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Stephen B Kovacs
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - William L Thompson
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Ainhoa Perez-Diez
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Alexandra F Freeman
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Gregg Roby
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - JoAnn Mican
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Alice Pau
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Adam Rupert
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Joseph Adelsberger
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Jeanette Higgins
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Jeffrey S Bourgeois
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Stig M R Jensen
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - David R Morcock
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, MD
| | - Peter D Burbelo
- Dental Clinical Research Core, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD
| | - Leah Osnos
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Irina Maric
- Hematology Section, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD; and
| | - Ven Natarajan
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Therese Croughs
- Cytheris Inc., Subsidiary of Cytheris S.A., Issy les Moulineaux, France
| | - Michael D Yao
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
| | - Jacob D Estes
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, Inc., Frederick, MD
| | - Irini Sereti
- National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH), Bethesda, MD
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Sikri V, Kaur H, Jain A. A rare case of idiopathic cluster of differentiation 4(+) T-cell lymphocytopenia presenting with disseminated tubercular infection. Indian J Crit Care Med 2015; 19:621-3. [PMID: 26628830 PMCID: PMC4637965 DOI: 10.4103/0972-5229.167054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Idiopathic cluster of differentiation 4+ (CD4+) T-cell lymphocytopenia is a rare heterogeneous clinical syndrome characterized by low absolute CD4 counts on two different occasions without any evidence of other known cause of immunodeficiency including human immunodeficiency virus (HIV), infections or drugs associated with fall in CD4+ count. Also referred to as severe unexplained HIV seronegative immune suppression by the World Health Organization, it was first described by Centers for Disease Control in 1992 in patients with opportunistic infections who were negative for HIV but had low CD4 counts. Patients typically present with opportunistic infections, malignancies, or autoimmune disorders. There have been case reports on opportunistic infections such as cryptococcal meningitis or non-Mycobacterium tuberculosis infections in these patients. However, no case of disseminated M. tuberculosis has been reported as such in Indian literature. We present a case of disseminated tuberculosis with low CD4 counts without any evidence of HIV infection.
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Affiliation(s)
- Vikas Sikri
- Department of Pulmonary Medicine, Fortis Hospital, Ludhiana, Punjab, India
| | - Harpreet Kaur
- Department of Internal Medicine, Fortis Hospital, Ludhiana, Punjab, India
| | - Alok Jain
- Department of Neurology, Fortis Hospital, Ludhiana, Punjab, India
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41
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Cenderello G, De Maria A. Discordant responses to cART in HIV-1 patients in the era of high potency antiretroviral drugs: clinical evaluation, classification, management prospects. Expert Rev Anti Infect Ther 2015; 14:29-40. [PMID: 26513236 DOI: 10.1586/14787210.2016.1106937] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The goal of antiretroviral treatment (ART) in HIV-1 patients is immune reconstitution following control of viral replication. CD4+ cell number/proportions are a crude but essential correlate of immune reconstitution. Despite suppression of HIV replication, a fraction of ART-treated patients still fails to fully reconstitute CD4+ T cell numbers (immunological nonresponders, INRs). New drugs, regimens and treatment strategies led to increased efficacy, lower side effects and higher virological success rates in clinical practice. The multitude of described immune defects and clinical events accompanying INR opposed to the marginal effect of antiretroviral intensification or immunotherapy trials underline the need for continuing efforts at understanding the mechanisms that underlie INR. Here, we reassess INR definition, frequency, and the achievements of active clinical and translational research suggesting a shared definition for insufficient, partial and complete CD4+ cell number recovery thus improving homogeneity in patient selection and mechanism identification.
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Affiliation(s)
| | - Andrea De Maria
- b Department of Health Sciences , University of Genova , Genoa 16132 , Italy.,c Clinica Malattie Infettive, IRCCS A.O.U. S. Martino - IST Genova , Istituto Nazionale per la Ricerca sul Cancro , Genoa , Italy
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42
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Romano RC, Soape MM, Thirumala S, Ghandour E. Disseminated histoplasmosis mimicking metastatic disease of the colon and omentum: Report of a case and literature review. Arab J Gastroenterol 2015. [DOI: 10.1016/j.ajg.2015.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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43
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Sharma D, Singh N, Kaushal S, Jain S. Isolated cutaneous cryptococcosis in clinically unsuspected idiopathic CD4 lymphocytopenia. J Cytol 2015; 31:230-2. [PMID: 25745296 PMCID: PMC4349021 DOI: 10.4103/0970-9371.151143] [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] [Indexed: 11/23/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia first defined in 1992 by the U.S. Centers for Disease Control and Prevention, as the repeated presence of a CD4+ T-lymphocyte count of fewer than 300 cells/cumm or of <20% of total T-cells with no evidence of human immunodeficiency virus (HIV) infection and therapy that might cause depressed CD4 T-cells. Most of the cases present with systemic opportunistic infections. We report a case without risk factors or laboratory evidence of HIV infection, presenting with cutaneous cryptococcal infection, diagnosed on cytology.
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Affiliation(s)
- Divya Sharma
- Department of Pathology, Maulana Azad Medical College and Associated LNJP Hospital, New Delhi, India
| | - Neha Singh
- Department of Pathology, Maulana Azad Medical College and Associated LNJP Hospital, New Delhi, India
| | - Seema Kaushal
- Department of Pathology, Maulana Azad Medical College and Associated LNJP Hospital, New Delhi, India
| | - Shyama Jain
- Department of Pathology, Maulana Azad Medical College and Associated LNJP Hospital, New Delhi, India
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DUSP4-mediated accelerated T-cell senescence in idiopathic CD4 lymphopenia. Blood 2015; 125:2507-18. [PMID: 25733583 DOI: 10.1182/blood-2014-08-598565] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 02/19/2015] [Indexed: 11/20/2022] Open
Abstract
Idiopathic CD4 lymphopenia (ICL) is a rare heterogeneous immunological syndrome of unclear etiology. ICL predisposes patients to severe opportunistic infections and frequently leads to poor vaccination effectiveness. Chronic immune activation, expansion of memory T cells, and impaired T-cell receptor (TCR) signaling have been reported in ICL, but the mechanistic and causative links remain unclear. We show that late-differentiated T cells in 20 patients with ICL displayed defective TCR responses and aging markers similar to those found in T cells from elderly subjects. Intrinsic T-cell defects were caused by increased expression of dual-specific phosphatase 4 (DUSP4). Normalization of DUSP4 expression using a specific siRNA improved CD4(+) T-cell activity in ICL, as this restored TCR-induced extracellular signal-regulated kinase activation and increased the expression of the costimulatory molecules CD27 and CD40L. Conversely, repeated TCR stimulation led to defective signaling and DUSP4 overexpression in control CD4(+) T cells. This was associated with gradual acquisition of a memory phenotype and was curtailed by DUSP4 silencing. These findings identify a premature T-cell senescence in ICL that might be caused by chronic T-cell activation and a consequential DUSP4-dependent dampening of TCR signaling.
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45
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Chumpitazi BFF, Flori P, Kern JB, Brenier-Pinchart MP, Larrat S, Minet C, Bouillet L, Maubon D, Pelloux H. Severe Pneumocystis jirovecii pneumonia in an idiopathic CD4 + lymphocytopenia patient: case report and review of the literature. JMM Case Rep 2014; 1:e003434. [PMID: 28663813 PMCID: PMC5415924 DOI: 10.1099/jmmcr.0.t00017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/10/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION When diagnosing Pneumocystis jirovecii pneumonia (PJP), the clinical suspicion must be confirmed by laboratory tests. PJP is rarely described in patients with idiopathic CD4+ lymphocytopenia (ICL), a rare T-cell deficiency of unknown origin with persistently low levels of CD4+ T-cells (<300 µl-1 or <20 % of total lymphocytes) but repeated negative human immunodeficiency virus (HIV) tests. We retrospectively analysed a case of an ICL patient with severe PJP associated with multiple opportunistic infections (OIs). We also reviewed the literature since 1986. CASE PRESENTATION A laboratory-confirmed case of PJP associated with invasive candidiasis and cytomegalovirus infection was reported in an ICL patient. Despite early treatment, the patient died of respiratory failure under polymicrobial pneumonia. According to the literature, the mortality rate of ICL patients is 10.4 % (33/316). In ICL patients, the risk of OI is 83.2 % (263/316), with viral infections being the most prevalent (58.2 %, 184/316), followed by fungal infections (52.2 %, 165/316) and mycobacterial infections (15.5 %, 49/316). Dysimmunity is reported in 15.5 % (49/316) of ICL patients. Among the fungal infections, cryptococcal infections are the most prevalent (24.1 %, 76/316), followed by candidiasis (15.5 %, 49/316) and PJP (7.9 %, 25/316). CONCLUSIONS The high risk of OIs underlines the importance of more vigorous preventative actions in hospitals. The response to therapy and the detection of early relapse of PJP may be monitored by several laboratory tests including quantitative PCR. It is essential to treat the ICL and to follow the guidelines concerning therapy and prophylaxis of OIs as given to HIV patients.
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Affiliation(s)
- Bernabé F F Chumpitazi
- Laboratory of Parasitology - Mycology, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France
| | - Pierre Flori
- Laboratory of Parasitology - Mycology, University Hospital of Saint Etienne, Saint Etienne, Av Albert Raimond, F-42055 Saint Etienne, France.,Jean Monnet University, Saint Etienne, France
| | - Jean-Baptiste Kern
- Laboratory of Parasitology - Mycology, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France
| | - Marie-Pierre Brenier-Pinchart
- Laboratory of Parasitology - Mycology, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France.,Université de Grenoble Alpes, Grenoble, France
| | - Sylvie Larrat
- Laboratory of Virology, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France.,Université de Grenoble Alpes, Grenoble, France
| | - Clémence Minet
- Intensive Care Unit, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France
| | - Laurence Bouillet
- Internal Medicine, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France.,Université de Grenoble Alpes, Grenoble, France
| | - Danièle Maubon
- Laboratory of Parasitology - Mycology, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France.,Université de Grenoble Alpes, Grenoble, France
| | - Hervé Pelloux
- Laboratory of Parasitology - Mycology, Grenoble University Hospital, CS 10217, F-38043 Grenoble, France.,Université de Grenoble Alpes, Grenoble, France
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Denu RA, Rush PS, Ahrens SE, Westergaard RP. Idiopathic CD4 lymphocytopenia with giant cell arteritis and pulmonary mucormycosis. Med Mycol Case Rep 2014; 6:73-5. [PMID: 25473601 PMCID: PMC4246401 DOI: 10.1016/j.mmcr.2014.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 10/27/2014] [Indexed: 10/30/2022] Open
Abstract
Idiopathic CD4 lymphocytopenia (ICL) is characterized by a low CD4+ lymphocyte count in the absence of HIV or other underlying etiologies. We report a case of a 57-year old man with ICL and giant cell arteritis (GCA) who developed pulmonary mucormycosis, which, to our knowledge, is the first report of these occurring in a patient with ICL. Abnormally low total lymphocyte or CD4+ cell counts occurring in patients with autoimmune disorders should alert clinicians to the possibility of ICL. Immunosuppressive treatment should be used with caution in this context.
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Affiliation(s)
- Ryan A Denu
- Medical Scientist Training Program, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Patrick S Rush
- Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Sarah E Ahrens
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA ; Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Combined immunodeficiency evolving into predominant CD4+ lymphopenia caused by somatic chimerism in JAK3. J Clin Immunol 2014; 34:941-53. [PMID: 25205547 PMCID: PMC4220108 DOI: 10.1007/s10875-014-0088-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/13/2014] [Indexed: 12/21/2022]
Abstract
Purpose Idiopathic CD4 lymphopenia constitutes a heterogeneous group of immunodeficiencies with characteristically low CD4+ T-cell counts with largely unknown genetic etiology. We here sought to determine the underlying molecular cause in an index family with two patients suffering from combined immunodeficiency that evolved into predominant CD4+ lymphopenia. The more severely affected index patient also presented with selective antibody deficiency against bacterial polysaccharide antigens. Methods For the genetic analysis, we used combined homozygosity mapping and exome sequencing. Functional assays included immunoblot analysis, flow cytometry and TCR Vβ spectratyping. Results A novel homozygous missense mutation was revealed in the kinase domain of JAK3 (c.T3196C, p.Cys1066Arg). Further analysis showed revertant chimerism in CD8+ T-cells in both patients. The additional presence of revertant CD4+ T-cells was associated with a milder clinical and immunological phenotype in the second patient, although the role somatic chimerism plays in amelioration of disease phenotype is uncertain, as presence of revertant cells had no effect on residual CD4 cell JAK3 signaling function. Residual activity of JAK3-dependent STAT3 and STAT5 signaling was also found in immortalized B-cell lines indicating a hypomorphic nature of the described mutation which likely contributes to the milder clinical phenotype. Conclusions We here present the first case of revertant mosaicism in JAK3 deficiency, manifesting as combined immunodeficiency evolving into predominant CD4+ lymphopenia. Revertant chimerism or hypomorphic mutations in genes typically associated with more severe T-cell deficiency should be considered when assessing patients with milder forms of combined immunodeficiencies. Electronic supplementary material The online version of this article (doi:10.1007/s10875-014-0088-2) contains supplementary material, which is available to authorized users.
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Régent A, Autran B, Carcelain G, Cheynier R, Terrier B, Charmeteau-De Muylder B, Krivitzky A, Oksenhendler E, Costedoat-Chalumeau N, Hubert P, Lortholary O, Dupin N, Debré P, Guillevin L, Mouthon L. Idiopathic CD4 lymphocytopenia: clinical and immunologic characteristics and follow-up of 40 patients. Medicine (Baltimore) 2014; 93:61-72. [PMID: 24646462 PMCID: PMC4616307 DOI: 10.1097/md.0000000000000017] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Idiopathic CD4 T lymphocytopenia (ICL) is a rare and severe condition with limited available data. We conducted a French multicenter study to analyze the clinical and immunologic characteristics of a cohort of patients with ICL according to the Centers for Disease Control criteria.We recruited 40 patients (24 female) of mean age 44.2 ± 12.2 (19-70) years. Patients underwent T-lymphocyte phenotyping and lymphoproliferation assay at diagnosis, and experiments related to thymic function and interferon (IFN)-γ release by natural killer (NK) cell were performed. Mean follow-up was 6.9 ± 6.7 (0.14-24.3) years. Infectious, autoimmune, and neoplastic events were recorded, as were outcomes of interleukin 2 therapy.In all, 25 patients had opportunistic infections (12 with human papillomavirus infection), 14 had autoimmune symptoms, 5 had malignancies, and 8 had mild or no symptoms. At the time of diagnosis, the mean cell counts were as follows: mean CD4 cell count: 127/mm (range, 4-294); mean CD8: 236/mm (range, 1-1293); mean CD19: 113/mm (range, 3-547); and mean NK cell count: 122/mm (range, 5-416). Most patients had deficiency in CD8, CD19, and/or NK cells. Cytotoxic function of NK cells was normal, and patients with infections had a significantly lower NK cell count than those without (p = 0.01). Patients with autoimmune manifestations had increased CD8 T-cell count. Proliferation of thymic precursors, as assessed by T-cell rearrangement excision circles, was increased. Six patients died (15%). CD4 T-cell count <150/mm and NK cell count <100/mm were predictors of death.In conclusion, ICL is a heterogeneous disorder often associated with deficiencies in CD8, CD19, and/or NK cells. Long-term prognosis may be related to initial CD4 and NK cell deficiency.
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Affiliation(s)
- Alexis Régent
- From the Université Paris Descartes and Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Cochin, Service de Médecine Interne, Paris (AR, BT, LG, LM); Institut Cochin, U016, CNRS, UMR8104, Université Paris Descartes, Sorbonne Paris Cité 22, Paris (AR, RC, BC-DM, LM); UPMC, Université Paris 6 and INSERM, UMR945, AP-HP, Hôpital Pitié-Salpêtrière, Laboratoire d'Immunologie Cellulaire et Tissulaire, Paris (BA, GC, PH, PD); Université Paris 13 and AP-HP, Département de Médecine Interne, Hôpital Avicenne, Bobigny (AK); Université Paris Diderot and AP-HP, Département d'Immunologie Clinique, Hôpital Saint-Louis, Paris (EO); UPMC, Université Paris 6 and AP-HP, Hôpital Pitié-Salpêtrière, Service de Médecine Interne, Paris (NC-C); Université Paris Descartes and AP-HP, Service de Maladies Infectieuses, Hôpital Necker-Enfants Malades, Paris (OL); and Université Paris Descartes and AP-HP, Service de Dermatologie, Hôpital Cochin, Paris (ND); France
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Legarth RA, Christensen M, Calum H, Katzenstein TL, Helweg-Larsen J. Cryptococcal rib osteomyelitis as primary and only symptom of idiopathic CD4 penia. Med Mycol Case Rep 2014; 4:16-8. [PMID: 24624326 DOI: 10.1016/j.mmcr.2014.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 01/20/2014] [Accepted: 02/14/2014] [Indexed: 01/27/2023] Open
Abstract
A 59-year old man with idiopathic CD4 lymphopenia presented with extensive disseminated Cryptococcus neoformans infection including a large rib cryptoccocoma, vertebral spondylitis and pleural empyema. Complete resection of the affected part of the rib was necessary after failure of initial antifungal treatment. The vertebral spondylitis has been successfully managed at 3 years of follow-up by continuous itraconazole treatment and regular MRI combined with leucocyte scintigraphy assessment.
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Affiliation(s)
- Rebecca A Legarth
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
| | - Merete Christensen
- Department of Thoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
| | - Henrik Calum
- Department of Microbiology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
| | - Terese L Katzenstein
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen O, Denmark
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Kikuchi-Fujimoto Disease Associated with Symptomatic CD4 Lymphocytopenia. Case Rep Rheumatol 2014; 2014:768321. [PMID: 25313340 PMCID: PMC4182841 DOI: 10.1155/2014/768321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 09/09/2014] [Indexed: 11/18/2022] Open
Abstract
Kikuchi-Fujimoto disease is a rare benign condition of necrotising histiocytic lymphadenitis with unknown aetiology. We describe here a 30-year-old African American female who presented with fever, generalized rash, cervical lymphadenopathy, and oral candidiasis and was found to have Kikuchi-Fujimoto disease on lymph node biopsy with low CD4 count. The initial presentation was concerning for acute retroviral infection. Her HIV serology and HIV RNA PCR were negative however she had low CD4 count with reversal of CD4/CD8 ratio. Although low CD4 count has been associated with autoimmune disease, it has not been described with Kikuchi-Fujimoto disease. We report the first case of Kikuchi-Fujimoto disease associated with symptomatic CD4 lymphocytopenia.
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